ACA Rule Foreshadows New Plan Model in 2028
Affordability’s all the buzz, but Trump’s sweeping payment rule emphasizes consumer choice over cost control.
Hello! I’m Julie Appleby, a senior correspondent at KFF Health News. I started covering all things health insurance long before the ACA existed and still do. Send tips to jappleby@kff.org.
The Affordable Care Act — always in a policy tug-of-war as its backers and critics spar over how it should work and who can qualify for coverage — will see wide-ranging changes starting next year. A rule backed by the Trump administration and finalized in mid-May features new plans with 30% higher out-of-pocket costs and others with no set networks of doctors or hospitals.
The administration says its changes will expand consumers’ choices and may carry lower premiums.
But the combined effect of the new provisions could cost $1.3 billion each year to implement, and reduce ACA enrollment by up to an additional 2 million in 2027.
“Even more people will lose coverage as healthcare costs and administrative burdens rise,” said Katie Keith, director of the Center for Health Policy and the Law at the Georgetown University Law Center, who writes frequently about the ACA.
The rule is an annual exercise in which the Centers for Medicare & Medicaid Services sets standards for coverage. This time around, it’s more ambitious than in the past, with changes to how plans are designed, eligibility verification, and adjustments needed to implement congressional legislation, along with technical updates.
One key change is that starting in 2028, some ACA consumers may be able to pick plans that don’t have dedicated networks of doctors and hospitals. Instead, these enrollees would seek out providers willing to accept the amount their insurer will pay toward whatever nonemergency care they need. Regulators say the policy aims to reduce costs by getting consumers to “shop for lower prices and negotiate directly with providers.”
But some experts warn that non-network plans might chip away at ACA safeguards intended to ensure enough medical providers are available in a geographic area or that patients aren’t on the hook financially if their chosen doctors or hospitals charge more than the insurer will reimburse.
Meanwhile, in 2027, insurers that offer at least one bronze plan with a regular out-of-pocket maximum can set higher limits. That means people with some bronze plans could pay up to $15,600 out-of-pocket for individual coverage or $31,200 per family.
Regulators say they need to set these criteria because bronze plans increasingly can’t meet other ACA requirements without increasing those thresholds.
Similar increases in catastrophic plan out-of-pocket maximums take effect in 2028.
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Already this year, on the ACA, my deductibles & copays have gone up significantly. For example, my primary copay was $5, now $50; specialist copay was $8, now $90; generic meds copay was $3, now around $12-16. As someone who is unable to work due to severe illness, these increases hit hard, are paid via credit, which lowers my credit score & increases my credit card apr %. This is the spiral to poverty that these increases are causing, even if I can still, barely, afford my ACA payments (I can’t afford to pay for housing though, so currently live with family).
I'm sure this comment is a bit redundant with my prior comments on this Substack, but, since your post in on the ACA, and the comment is on the so-far-successful Republican actions to weaken the ACA, I will plop it down.
So, it appears that there is, and will continue to be, substantial effort by the administration and the Republicans, to try to counter the evidence, as it comes in, on the pair of major ACA cuts that Democrats unsuccessfully fought to reverse at the end of last year with the shutdown.
There is recent information: both data on the coverage-loss effects (of the part that already happened), and misleading information from the administration on both parts.
Further, it kind of looks like some misleading information that was planned to try to neutralize the news on the now-looking-large coverage losses on the part of the cuts that already happened, is causing difficulty even for the administration and Trump, as some fraud analysis by an organization headed by a very-pro-Trump former Trump administration member, though apparently designed to be a bit of pro-Trump propaganda (with, for example, very propagandistic terminology such as "phantom enrollees"), is still not able to support the intended claim. (Which is that large coverage losses are due almost entirely to the administration's successful reduction of ACA fraud.)
There are some very recent Jonathan Cohn posts on Bulwark on both of these cuts--the one that happened already, and the one coming.. (They are behind a Bulwark Substack paywall, but I have alternative links not behind a paywall to the information. One of those from me, actually.)
(Jonathan Cohn is a health and health-system reporter, and author of "The Ten Year War" (on the ACA), written about 6 years ago, when the war by the Republicans had only been going on for 10 years.)
The serious ACA weakenings are these two, that the Democrats fought, unsuccessfully, with the shutdown at the end of last year, to reverse:
1) ACA on-exchange coverage via 1/1/26 non-extension of the on-exchange expanded subsidies.
(Data on the coverage losses from this are now coming in, the losses look large, and there is evidence of misleading information about this will come from the administration, claiming falsely that the considerable coverage losses are mainly due to fraud reduction by the administration. Detailed in linked Substack posts below.)
2) ACA expanded Medicaid via OBBB work requirements and other restrictions going into effect start of 2027
(Misleading information from the administration has also come about the effects of this, being a claim of significant poverty reduction. Detailed also in linked Substack posts below.)
(Note the former, ACA on-exchange, covered, in 2025, roughly 24 million people, and the latter, ACA expanded Medicaid, a separate set of about 20 million people. So, the programs that covered about 44 million people total, at least before the damage, are what are affected.)
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On the first--the lapsed expanded subsidies:
There is information is that the observed coverage drops are high (3 to 5 million of about 24 million covered in 2025), that the information on the numbers of drops seems to be being delayed by the administration, and that misleading claims from the administration that the large drops are due mainly to the administration's successful reduction in fraud are forthcoming.
So, there was a pretty comprehensive look at this from Jonathan Cohn of a few days ago, here:
https://substack.com/@citizencohn/p-201946924 called "The Obamacare 'Phantom' Menace"
(That Cohn post actually mentions little old me, and also my post on mainly the same stuff, in its footnote (3) !)
My post is here, and is free (as an alternative or supplement, or if you can't get behind the Bulwark paywall):
https://normspier828307.substack.com/p/loss-of-aca-coverage-after-republicans
The posts (Jonathan's and mine) are is on the coverage drops now showing up, with a lot of other information on what seems to misleading statements coming from the administration, which are still in process.
A lot of the information in his post and mine overlaps. Some is in one or the other, but not both.
The information in mine, is:
The coverage drops from data gradually rolling in,
The apparent non-release of some data by CMS with the drops,
The leaked-from-CMS information that the administration is planning a response falsely indicating the coverage drops are due to the administration's successful cracking down on fraud
The current, kind of weak, propagandistic response from the Washington Post editorial department using a report from the Paragon Health Institute. (The president himself seems not to have directly made a statement on this yet. It may be that the large coverage drops have taken the administration by surprise, and, as well, the Paragon report really doesn't support any substantial reduction of fraud, even though it is a pretty propagandistic document. It will be interesting to see if the president tries to delay all data release until after the midterms.)
We also both cover some of:
The history of the deception, and lies, and apparently weak research that the Republicans used last year to justify not extending the expanded subsidies.
(Between my post and Jonathan's, many of the same, and some different details are covered. Jonathan probably has a bit of an easier to read, polished style. If you read Jonathan's, and you want to really suck up all the details he has, I suggest clicking on all of his links, and reading all of his footnotes.)
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On the second--on the OBBB damage to mainly expanded Medicaid starting beginning of 2027:
A great Jonathan Cohn post came out a few days before the other Cohn post on these (behind a bulwark Substack paywall :https://www.thebulwark.com/p/donald-trump-incredibly-misleading-downright-outrageous-case-medicaid-cuts-work-requirements .)
It seems the administration has prepared highly questionable research indicating a large coming reduction in poverty due to the work requirements for expanded Medicaid, by them making a lot of people get out of poverty by choosing to work.
Jonathan links to some non-paywalled analysis of the issue by a pair of health economists here, for those interested:
https://donmoynihan.substack.com/p/the-trump-administrations-dubious , for those interested.
Also, on the OBBB damage to expanded Medicaid and the work requirements, there is an earlier Jonathan Cohn post (Bulwark paywalled):
https://substack.com/@citizencohn/p-196250677
focusing very much on the chaos that is likely to come as 51 state+DC Medicaid agencies struggle to manage handling the technical complexity of the coming work and other requirements.
I have my own non-paywalled post that hits some of this:
https://normspier828307.substack.com/p/a-new-aca-defect-created-by-the-one
(As I actually have some experience with the ACA, where, before aging into standard-Medicare-for-Me with my medigap, I had 8 years on the ACA / expanded Medicaid system in Massachusetts. So, the insurance system we have, including the ACA and expanded Medicaid, has such byzantine complexity that without absolute computer geniuses designing the computer systems at each and every Medicaid agency, much will go wrong, and much does.
Thus, in Massachusetts, which is a state that actually wants the ACA to work, in the eight years I used the ACA for coverage, though I did everything correctly, and was always eligible for coverage, I was placed in primal fear for either my health, my finances, or both, no less than five times.
And now, significant complexity has been added by OBBB, for each of the 51 Medicaid agencies, and actually, the federal and state exchanges as well, because expanded Medicaid ineligibility is required for on-exchange ACA eligibility. What a mess!)