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The big questions about the stability of the Affordable Care Act marketplaces have focused on how fast premiums will rise, and how many plans will participate. But an equally important question, and the heart of the matter politically, is: How many people will be affected by the sharp premium increases?

Expand chart

Data: Kaiser Family Foundation analysis of data from Mark Farrah Associates, Healthcare.gov, and KFF Survey of Nongroup Health Insurance Enrollees; Chart: Andrew Witherspoon / Axios

The bottom line: The answer is about 6.7 million Americans who buy coverage in the non-group market in and out of the exchanges, and do not receive premium subsidies. That is a significant number of people, and an urgent policy problem requiring congressional attention and action by the administration, but it's not a system-wide health insurance crisis. The non-group market has always been the most troubled part of the insurance system, and it was far worse before the ACA.

The breakdown:

  • 17.5 million in the non-group insurance market, including:
  • 10.3 million enrolled in the ACA exchanges
  • Approximately 7.2 million buying insurance off the exchanges Most of this group buys ACA-compliant plans About 1.2 million in "grandfathered" plans purchased before the ACA's market reforms took effect

Yes, 17.5 million is a sizeable number, and what happens to their health insurance coverage and costs is important. But, to put it in perspective:

  • 156 million get their primary coverage through an employer, where premiums rose a modest 3% last year for family coverage
  • More than 74 million are covered by Medicaid and CHIP.

According to our new analysis of proposed 2018 premium changes in the exchanges, double-digit increases for benchmark silver plans are quite common, though the range across major cities is large, from a 5% decrease in Providence, R.I. to a 49% increase in Wilmington, Del.

A big reason for these increases is the uncertainty in the market surrounding Trump administration policies, especially whether they will let the $7 billion in cost-sharing reduction (CSR) subsidies flow and whether the individual mandate will be enforced.

Who's getting hit: 84% of the enrollees in the marketplaces – about 8.7 million people – receive premium subsidies under the ACA and are insulated from these premium hikes.

However, roughly 6.7 million people — the ones who buy ACA-compliant plans inside or outside the marketplace and aren't subsidized — will feel the full brunt of premium increases. They'll be hit if the uncertainty is not resolved and the rates do not come down before they are finalized.

In many cases, there is as much as a 20 percentage point swing or more in rates depending on whether the CSRs are paid.

The big picture: Dealing with this uncertainty is an urgent situation, particularly since it may result in some counties having no insurers at all, as well as coverage that is unaffordable for millions of Americans. But it is far from a crisis affecting most Americans and their health insurance.

The media needs to take great care to put this problem in perspective — otherwise they could unduly alarm the public and drive people to support the wrong policy solutions. Already, most Americans wrongly believe that premium increases in the relatively small non-group market affect them. So the headline should be: "Premiums Spike for SOME Americans."

The danger in Congress is that discussion will spread too far beyond the immediate need to stabilize the non-group market, opening up all the old wounds surrounding the ACA and producing stalemate.

Go deeper

Acting Capitol Police chief: Phone logs show Jan. 6 National Guard approval was delayed

Pittman at a congressional tribute for fallen officer Brian Sicknick. Photo: Erin Schaff-Pool/Getty Images

Acting U.S. Capitol Police Chief Yogananda Pittman testified on Thursday that cell phone records show former USCP Chief Steven Sund requested National Guard support from the House sergeant at arms as early as 12:58 p.m. on Jan. 6, but did not receive approval until over an hour later.

Why it matters: Sund and former House Sergeant at Arms Paul Irving clashed at a Senate hearing on Tuesday over a dispute in the timeline for when Capitol Police requested the National Guard during the Capitol insurrection.

Dion Rabouin, author of Markets
3 hours ago - Economy & Business

The digital dollar is now high priority for the Fed

Illustration: Aïda Amer/Axios

The U.S. is starting to get serious about a central-bank-backed digital currency, with recent comments from top officials laying out the strongest support yet.

Driving the news: On Tuesday Fed chair Jerome Powell told Congress that developing a digital dollar is a "high priority project for us," but added that there are "significant technical and policy questions."

Dan Primack, author of Pro Rata
4 hours ago - Economy & Business

Coinbase files to go public via direct listing

Illustration: Sarah Grillo/Axios

Cryptocurrency exchange Coinbase on Thursday filed to go public via a direct listing. It includes a placeholder figure of $1 billion, but that's likely to change.

Why it matters: Coinbase could go public at a higher initial valuation than any other U.S. tech company since Facebook.