New Analysis Reveals Health Exchange Plans Have Shifted Costs to Sicker Patients
Plans have increased patients’ prescription drug out-of-pocket costs by 36%, on average, since 2021
WASHINGTON, DC - August 12, 2025 - A new analysis published by No Patient Left Behind (NPLB) finds that health exchange plans have increased patients’ prescription drug costs by 36%, on average, since 2021. The average person spent $560.75 out of pocket in 2023, up from $412.64 in 2021. The study also found that over the same period, health exchange plans have shifted costs to sicker patients by raising out-of-pocket maximums, but lowering deductibles and premiums at the same time to give the appearance of more generous insurance coverage.
“People shouldn’t have to have a Ph.D. in plan design to figure out which health exchange plan will get them affordable coverage,” said Peter Rubin, Executive Director of NPLB. “Patients and taxpayers want to know if they pay premiums they will be covered by their health plan when they get sick – that is how insurance is supposed to work.”
With the ACA’s enhanced premium tax credits set to expire, now’s the time to ensure that patients and taxpayers get value out of their premium dollars. Rubin continued that “capping out-of-pocket drug costs for the small percentage of patients whose annual drug costs exceed $2,000 ensures ACA exchange coverage remains meaningful to enrollees who get sick while also preserving significant flexibility for health insurers to invent innovative benefit designs and better care management.”
During the COVID-19 pandemic, the American Rescue Plan Act (ARPA) increased premium subsidies through 2024. As a result, the NPLB analysis found that the number of people with healthcare coverage through the ACA marketplace grew by 79% since 2021. It also found that non-Medicaid expansion states had higher-than-average enrollment growth.
Despite these larger risk pools and additional funding from the government, health exchange plans have disproportionately increased out-of-pocket drug costs for patients seeking care. The analysis, conducted by Magnolia, found that in 2023, 5.6% of enrollees had annual pharmacy out-of-pocket costs greater than $2,000, significantly higher than the $560.75 average. And while cost-sharing reductions provided under the ACA can help patients with these high costs, they are only allowed in Silver-level plans. Many people choose Gold-level plans instead because they think they’ll get better coverage. In reality, the cost-sharing reductions in the Silver-level plans would provide better value.
These contradictory practices undermine the intent of the ACA, which aimed to provide affordable benefits to the uninsured.
Policymakers can address these growing affordability challenges in the ACA marketplace. An out-of-pocket cap of $2,000 – similar to the one enacted in Medicare Part D under the Inflation Reduction Act – would not come at a high cost to the government, but would result in significant savings for the 5.6% of Americans enrolled in ACA exchange plans who pay more than that out of pocket. And giving states the option to expand cost-sharing reductions to Gold-level plans would give more patients access to this assistance rather than force them to do complicated calculations to compare plans during open enrollment season.
Background: How plan out-of-pocket costs limit patient access to prescribed treatments
A previous survey by NPLB and the BREM Foundation to Defeat Breast Cancer found that 48% of U.S. women are unlikely to pursue prescribed treatment if their out-of-pocket costs are over $2,000.
A previous study in the Journal of Clinical Oncology found that prior to Medicare Part D’s out-of-pocket cap, 49% of oral cancer therapy patients abandoned care and 18% of patients had their treatment delayed when their out-of-pocket drug costs exceeded $2000.
About No Patient Left Behind No Patient Left Behind (NPLB) is a coalition of biotechnology innovators, investors, healthcare professionals, and patient advocates working to ensure that patients have access to the medicines they need today and in the future. Through rigorous, independent research and data analysis, NPLB promotes biotech affordability and innovation, advancing common-sense solutions that enable every patient to afford the drugs prescribed by their doctor at low or no out-of-pocket cost — while also preserving the incentives for investment that spur the development of new, life-saving treatments. In tandem with its research efforts, NPLB educates leaders and stakeholders across the biotech ecosystem about thoughtful and balanced policy solutions. Learn more about NPLB’s latest initiatives at www.nopatientleftbehind.org.
About Magnolia Magnolia Market Access specializes in market access, health economics and outcomes research (HEOR), and healthcare policy for biopharma, medical device companies, and trade associations. The company develops strategies across the product lifecycle—from early evidence planning to post-launch support. Its expertise spans evidence generation, value communication, reimbursement strategy, and policy analysis. Leveraging clinical and real-world data, a team of specialists informs decisions, engages stakeholders, and guides clients through complex market and policy environments.