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From 2020 to 2021, average monthly premiums decreased in 24 states and increased in another 24 states
Published November 2, 20218 min read
Table of contents
The Affordable Care Act, also called Obamacare or the ACA, guarantees basic health coverage and allows U.S. residents to buy a health insurance plan through either the federal health insurance marketplace or through their state’s own marketplace. For 2021 plans that people purchased at the end of 2020, 36 states used the federal marketplace and 15 states (including the District of Columbia) ran their own state-based exchanges (SBEs).
To get a picture of how health insurance consumers were faring in the age of the coronavirus pandemic, we looked at how each state handles coverage on the Obamacare exchange: how many people are enrolled in a marketplace plan, how much premiums cost in 2021, and how much each state offers in tax credits to make health insurance more affordable.
Overall enrollment in Obamacare plans increased from 11.4 million in 2020 to 12 million in 2021, the first time Obamacare enrollment has increased since 2015 and the first time at least 12 million people bought an exchange plan since the 2016 open enrollment period. Half of all Obamacare enrollments for 2021 came from five states, with the top three states — Florida, California, and Texas — combining for 42% of all signups. Across the country, average premiums decreased by $9 for 2021, with half of states seeing an overall increase and the other half seeing a decrease. And while 2021 premiums range from $400 to $1,000 depending on the state, that doesn’t factor in health insurance subsidies. The advance premium tax credit (APTC) could bring average 2021 premiums to less than $75 in some states.
Enrollment in Obamacare plans increased to $12 million for 2021, the first increase since 2015 open enrollment
Florida, California, and Texas accounted for 42% of all ACA enrollees during 2021 open enrollment
Average monthly premiums fell in 24 states from 2020 to 2021 — to an average of $37 — and increased in 24 states — to an average of $19
Most ACA enrollees receive the advance premium tax credit (APTC), which helps low-income individuals afford insurance by decreasing monthly premiums to as little as 7% of their pre-APTC cost in some states
More than 12 million people selected health insurance plans through Obamacare during the 2021 open enrollment period, which lasted from Nov. 1, 2020, to Dec. 15, 2020, in most states. The increase in enrollment (compared to about 11.4 million for both 2020 and 2019) is notable because Obamacare enrollment had been decreasing every year since President Trump took office and worked to roll back parts of Obamacare. (For example, open enrollment was shortened by two weeks in 2017 and the Trump administration repealed the individual mandate in 2019.) Of the people who bought a marketplace plan for 2021, 79% had also purchased a marketplace plan from the same state for 2020, while 21% were new customers.
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The increase in Obamacare enrollment for 2021 is likely the result of Americans losing their jobs because of COVID-19. Department of Labor statistics show more than 10 million people were receiving unemployment benefits before open enrollment. A majority of people in the U.S. get health insurance from their jobs, so losing a job during the pandemic means losing health coverage. Some people may have kept their previous employer’s insurance through COBRA coverage, but COBRA is unaffordable for most Americans.
Even for people who didn’t completely lose their jobs, buying a marketplace plan may have been necessary. Many people enroll in ACA plans because they do not have access to affordable health insurance, a situation made worse during the pandemic. Workers who didn’t completely lose their jobs still had their hours reduced. Others may have transitioned from full-time work to contractor positions in the gig economy. Then of course there are the millions of people who missed work or incurred medical bills because they or someone they knew had COVID-19.
Increased plan enrollment is also interesting because, for years, the percentage of the population that had health insurance was decreasing. Not only did Obamacare enrollment decrease from 2016 to 2020, but Census data shows the overall number of uninsured Americans also increased from 7.9% in 2017 to 8.5% in 2018 and then to 9.2% in 2019. Perhaps the uptick in 2021 ACA plans is a sign that America is working to reverse its current trajectory and more Americans will get insurance going forward.
During 2021 open enrollment, 36 states used the federal government’s marketplace, healthcare.gov, and 15 states, including the District of Columbia, ran their own state-based exchanges. The federal marketplace accounted for 69% of 2021 ACA enrollments and the state exchanges accounted for 31% of enrollments.
Three states accounted for 42% of all ACA enrollees in 2021: Florida, California, and Texas. Rounding out the top five states using Obamacare plans are North Carolina and Georgia. These five states have 51% of all enrollees. (California is the only state in the top five that runs an SBE.)
Florida, which uses the federal marketplace, had the most ACA enrollees in 2021 — 2.1 million people — and accounted for 18% of all ACA enrollees. The number of enrollees in Florida increased 11% from 2020 (205,375 more people in 2021 than 2020). Based on the Census Bureau’s latest population estimates for Florida, 10% of Florida’s population enrolled in a marketplace plan for 2021.
California had about 1.6 million people enroll through its state exchange in 2021 and accounted for about 14% of all ACA enrollees. The number of enrollees increased 6% from 2020 to 2021.
Texas, using the federal exchange, had about 1.3 million people enroll for a health insurance plan in 2021. That enrollment is 11% of the national ACA enrollment, and Texas saw an increase of 16% from 2020 (175,679 more people in 2021).
North Carolina had the fourth most Obamacare enrollments for 2021 at 536,000, accounting for almost 5% of the country’s total enrollments. The state saw signups increase 6% from 2020, making it one of the biggest users of the federal marketplace.
Georgia saw about 517,000 residents sign up for an ACA plan, also through the federal marketplace. The state’s enrollment was equal to about 4% of national enrollments and represented a nearly 12% increase from Georgia’s 2020 signups.
Based on the states where the fewest number of people purchased ACA plans for 2021, here are the five states that use Obamacare the least, accounting for just 0.8% of all ACA enrollees:
District of Columbia: 16,947 ACA enrollees (3% decrease vs. 2020)
Alaska: 18,184 ACA enrollees (3% increase vs. 2020)
West Virginia: 19,391 ACA enrollees (3% decrease vs. 2020)
North Dakota: 22,709 ACA enrollees (5% increase vs. 2020)
Hawaii: 22,903 ACA enrollees (14% increase vs. 2020)
However, if you control for population, by looking at the number of plans purchased as a percentage of a state’s population, the list changes. Here are the five states with the fewest ACA enrollees, as a percentage of state population:
New York: 1.1% of state population
West Virginia: 1.1% of state population
Hawaii: 1.6% of state population
Kentucky: 1.7% of state population
Ohio: 1.7% of population
The cost of health insurance plans varies by state, with Vermont having the highest average premium in 2021 at $1,050 and Utah having the lowest average monthly premium at $405. Across the country, 24 states saw their average premiums decrease from 2020 to 2021 and 24 states had higher average premiums in 2021. In the states with lower premiums in 2021, the average premium was $37 lower. Across states with higher premiums in 2021, the premiums rose just $19. (Note that premium data was not available for Idaho or Nevada.)
Here are five states that saw Obamacare premiums increase the most in 2021:
West Virginia: +$46
Here are five states that saw Obamacare premiums decrease the most in 2021:
New Hampshire: -$83
|State*||Average 2021 premium||Change from 2020|
|District of Columbia||$541||+$7|
*Data does not include Idaho or Nevada because premium data wasn’t available.
Marketplace prices also vary based on the metal tier of your plan. The four metal tiers of the Affordable Care Act — bronze, silver, gold, platinum — are based on the average amount of health care expenses that a customer would have to pay versus how much the insurer would pay.
Bronze plans often have low premiums, but you pay more out of pocket if you incur medical expenses. Platinum plans, which aren’t available in all areas, have the highest monthly premiums on average, but your insurer would cover more of your potential medical expenses. There are also catastrophic health plans, which usually have the lowest monthly premiums because they cover little (if anything) beyond the essential health benefits.
|17 or younger||357,404||321,867||80,720|
|18 to 25||271,782||510,120||40,889|
|26 to 34||451,380||676,200||82,295|
|35 to 44||480,218||768,983||90,797|
|45 to 54||565,016||959,589||99,670|
|55 to 64||875,286||1,266,573||155,956|
|65 or older||28,594||97,255||3,573|
Silver plans are the most popular nationally. However, silver plans are only the most popular in about half of all states. Bronze plans were most popular in most other states.
In general, silver plans aren’t the cheapest but they’re the only ones that allow people to receive premium subsidies (explained more in the next section). Most ACA enrollees do receive a subsidy. For anyone who doesn’t qualify for a subsidy, a bronze plan will usually offer the lowest premium. Gold plans are usually the most expensive of these three tiers (though platinum plans are the most expensive overall), and they are also the last popular of the three in most states.
The table below includes data for the 36 states that used the federal ACA exchange in 2021. The 15 states that used state-based exchanges (including the District of Columbia) have different reporting requirements and weren’t included in this table. Platinum plans and catastrophic plans were also omitted because they aren’t available in all counties or states.
People who have a difficult time affording health insurance may qualify for a health insurance subsidy. The most common type of subsidy is the advance premium tax credit (APTC), which functions as a tax credit that you can take throughout the year to lower your monthly premiums. Someone can only claim the APTC if they purchase a silver plan.
In all states — but not in the District of Columbia — the majority of people who enroll in an ACA plan also receive the APTC. However, the value of the APTC varies widely by state, based on two things: the premium of the second-lowest cost silver plan (SLCSP) on the market and the income of the enrollee. The exact premium of a state’s SLCSP depends on the plans available in that state, and Obamacare rules explain that individuals only have to pay a final premium that’s worth a specific percentage of their annual income. For example, a state may decide someone with an income of $35,000 shouldn’t be spending any more than 8% of their income on insurance premiums.
The APTC is generally available for people who have an income within 100% and 400% of the federal poverty level. Individuals with incomes below that level can usually get Medicaid instead. In the table below, you can see the percentage of ACA enrollees in each state that receive the APTC, how much they receive, and the average premium across all enrollees based on the final amount that APTC recipients pay.
|State||Percent of ACA enrollees with APTC||Average premium with APTC||Average final premiums across all enrollees|
|District of Columbia||7.0%||$206||$508|
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