Coverage Without Care: The Cruel Math of Health Insurance Open Enrollment

As open enrollment begins, families face skyrocketing premiums, rising deductibles and shrinking coverage as Big Insurance posts record profits.

It is Halloween, which means that open enrollment for the Affordable Care Act (ACA) Marketplace plans starts tomorrow. For families across the country, this annual ritual is a grim exercise in patience, anxiety, and arithmetic: comparing premiums, deductibles, coinsurance, and out-of-pocket (OOP) maximums all while trying to guess what could happen if someone gets sick.

For most people, health insurance next year will likely be more expensive and less protective than ever before. The Trump administration just released a preview of what people will face when they review their health insurance options for next year and its pretty scary: Insurers have increased rates an average of 30% in most states for ACA Marketplace plans. To illustrate what families face, I’ll walk you through my hypothetical thought process if I were beginning the chore of enrolling my family in an ACA Marketplace plan for coverage starting January 1.

We currently get health insurance through my spouse’s employer, but growing up my family relied on ACA Marketplace plans, so I am no stranger to this process. My husband and I have two kids, and I will be using the plans available in Atlanta for this example. Like many – and many more if Congress fails to extend the enhanced premium subsidies – we do not qualify for subsidies and are responsible for paying the entire premium each month out of our pockets.

There are an overwhelming number of plan options so to make sense of it, I will compare one plan in each metal tier: Bronze (with lower premiums but the highest OOP costs); Silver (moderate premiums and OOP costs); and Gold (higher premiums and lower OOP costs).

I’ll compare the Anthem Bronze Pathway Guided Access HMO 7500, the Cigna Connect Silver HMO, and the UnitedHealthcare UHC Advantage Gold HMO plans pictured below:

Premiums: The Cover Charge

The premiums for plans in 2026 are steep. The Bronze plan, which is supposed to have the most “affordable” premiums, would cost my family $1,885.55 every month and $22,626.60 total over the year. This is just the cost to be enrolled in the plan – the cover charge, as I call it. The Silver plan will cost $3,259.06 in premiums per month totaling $39,108.72 for the year, and the Gold plan will cost $3,577.58 per month totaling $42,930.96 for the year. Overall, health insurance premiums on the ACA marketplace are increasing roughly 20% from last year. Insurers claim this increase is due to increased medical costs. However, the seven largest for-profit insurers made over $71 billion in profits in 2024, a $600 million increase from their profits in 2023.

Deductibles: Paying Twice for Coverage

Next, I look at the deductibles for each plan. The deductible is the amount of money my family would have to pay before the coverage (that I am already paying tens of thousands for in premiums) kicks in. For the Bronze plan, we will have to pay $15,000 completely out of pocket for any medical care we need before the health plan starts paying anything. For the Silver plan I would have to pay $14,000 and the Gold plan requires $2,200 of out-of-pocket spending before my plan benefits start. Many health plans exclude preventative care from the deductible.

Using my family’s health needs from last year as a guide, we typically have multiple primary care doctor visits in the winter months since my two kids, like almost any children, get a few viruses or bacterial infections like the flu or strep throat. Those sick visits would cost a bit over $300 each before we hit our deductible. Being a Type 1 diabetic, I require regular appointments with specialists to ensure I am preventing any complications from my disease. These appointments cost close to $400 each time before we hit our deductible.

I will also need to refill our family’s prescriptions including my insulin and durable medical equipment, which cost roughly $2,000 each month before we hit our deductible. When examining these high out-of-pocket costs required by health insurers it’s necessary to keep in mind that last year, the seven largest for-profit insurers took in over $1.5 trillion in revenue. This is money they are supposed to be using to pay for the medical care of people enrolled in their plans. Instead, they take the premiums you send them and hold it hostage until you pay even more money out of your own pockets before distributing crumbs of access to medical care they call “coverage.” And keep this in mind, too: Big insurers and their parent companies – like UnitedHealth, Cigna and Elevance, which owns and operates Anthem plans – have bought thousands of physician practices, clinics and pharmacy benefit managers, so they are now able to collect – and convert to profits – much of the money they force you to spend out of pocket before your coverage kicks in.

Coinsurance and Copays: Paying for medical care a third time

Next, I look at the required payments after we hit our (already too high) deductible if we were to enroll in any of these plans. For a primary care visit, all three plans require a copayment, or set amount my family would pay each time we visit the primary care provider. The Bronze plan copayment for each primary care visit is $50, the silver plan copayment is $5, and the Gold plan is $10.

My family routinely requires laboratory testing, such as blood tests, to ensure our children are not exposed to environmental lead or metabolic and lipid panels to ensure my husband’s and my cholesterol and other markers are within range. The Gold plan requires a $10 copay for these tests. The Silver and Bronze plans require a coinsurance payment. Coinsurance means we pay a percentage of whatever the total cost of the medical service is. In our case, these lab tests cost roughly $1,200. The Silver and Bronze plan both require a 50% coinsurance payment meaning we would be on the hook for $600 each time we need blood work done after our insurance “benefits” are applied.

For prescriptions, all three plans require copayments for preferred brand drugs and coinsurance payments for non-preferred brand medications. It is very difficult, if not impossible to determine which drugs are preferred vs. non-preferred before filling a prescription so here I will estimate that half of my family’s prescriptions are preferred brands and half are non-preferred.

For the Bronze plan, our monthly prescriptions would require a $125 copayment for a 90-day supply of each preferred brand prescription and a 40% coinsurance payment for each non-preferred brand prescription totaling roughly $450 per month. For the Silver plan, our monthly prescriptions would require a $45 copayment for a 30-day supply of each preferred brand prescription and a 45% coinsurance payment for each non-preferred brand prescription totaling roughly $500 per month. And for the Gold plan, our monthly prescriptions would require a $50 copayment for a 30-day supply of each preferred brand prescription and a 30% coinsurance payment for each non-preferred brand prescription totaling roughly $350 per month. This is alongside the$48.5 billion that the health insurers that own the three largest pharmacy benefit managers, (UnitedHealth, Cigna and CVS/Aetna), made in profits in 2024.

Despite our best efforts, as most parents with small children know, a visit to the emergency room is not surprising at least once per year. In the last year we had to make two emergency room visits, one for croup and one for a head injury. (Luckily everyone turned out ok!) Using that as a baseline for what to expect this year, with these plans if we need to use the emergency room we would have to pay 50% of the cost of the visit on the Bronze plan, 50% on the Silver plan, and 20% on the Gold plan amounting to $1,200 for Bronze, $1,200 for Silver, and $480 for Gold for each emergency room visit.

The costs outlined above are only for a relatively normal year with no huge medical procedures needed or non-annual occurrences like pregnancy and child birth. If I were having a baby in the coming year and wanted to compare the cost of the childbirth based on my previous bills I would have to pay a 50% coinsurance for the Bronze and Silver plans totaling $34,687.50 and a 20% coinsurance for the Gold plan totaling $13,875.

This cost would likely make my family reach our out-of-pocket maximum for the year in the Bronze and Silver plans, $21,200 and $19,850 respectively. The Gold plan has an out-of-pocket maximum of $14,400. This is the highest amount you will have to pay out-of-pocket and after your insurance plan pays all costs for in-network services. The out-of-pocket max has risen by $7,500 (55%) over the last ten years while insurers’ profits have risen along with it. And that’s just for in-network care. You could be on the hook for considerably more if you go out of your insurer’s network for care.

The Bigger Picture

The ACA was built on the promise of a public–private partnership that assumed competition would drive value. Instead, consolidation (big insurers buying their smaller competitors or merging with each other) and vertical integration (insurers buying physician practices, PBMs, etc.) have resulted in huge increases in insurers’ revenues and profits. As the for-profit insurers that dominate the industry –and that have bought big chunks of the supply chain, from physician groups to pharmacy benefit managers, while remaining beholden to Wall Street shareholders – families pay more for coverage and get less value for their money, and increasingly less actual care. More and more Americans skip visits to the doctor and walk away from the pharmacy counter without their medications because of unaffordable out-of-pocket requirements.

The ACA and the subsidies that make premiums more affordable were monumental steps forward for millions of American families and individuals. In fact, they were the only reason I was able to get health insurance as a young adult, and I might not be here without them. But a decade in, it’s clear we’re in desperate need of the next step in health reform. Many Americans don’t have the time or the understanding of how health insurance works to figure out what is best for them and their families. They are forced to gamble with their lives and their finances, year in and year out, in ways that nobody else on the planet has to do, just for the sake of allowing Big Insurance to get even bigger and more profitable.

The enhanced premium subsidies being debated in Congress right now are a lifeline for so many of us and must continue in the short term, but they don’t fix the underlying problem: Private insurers extract value rather than control costs or provide access to necessary and affordable care. Decades of experience show that when profits rule health insurance, families face financial ruin no matter which plan they pick during open enrollment.

Rachel Madley, PhD, is Director of Policy and Advocacy at the Center for Health & Democracy. She previously worked for Congresswoman Pramila Jayapal. She received her PhD from Columbia University and has written for publications including The New York Times.