How much more are ~400,000 MASSACHUSETTS ACA enrollees *really* paying this year due to Trump/GOP policies?

IMPORTANT: See the original post in this series for an explanation of the methodology.

Regular readers know that I've been obsessing over the massive increases in both gross as well as net premiums for ACA health insurance policy enrollees being caused by the combination of Congressional Republicans allowing the enhanced federal tax credits to expire as well as other Trump Regime policy changes for well over a year and a half now.

I've written countless analyses of how much both gross and net premiums skyrocketed from 2025 to 2026 across different states, different income levels and various other demographics...and last week it was revealed that over 3 million ACA exchange enrollees had already been priced out of the market as of April, with the number almost certain to climb further throughout the rest of 2026.

As I've repeatedly warned, however, the increases in premium costs (whether gross or net) are only half the story. The other big shoe which is dropping this year is increased out of pocket costs as millions of the ~19.2 million or so remaining enrollees as of April have been forced to downgrade their coverage to avoid (or at least minimize) those massive premium spikes.

In most cases this means moving to plans with higher deductibles, higher co-pays & higher coinsurance costs. In many cases this has also included moving to plasn with worse networks, referral requirements to see specialists and so on.

With that in mind, that's exactly what I've decided to set out to do: Calculate the average year over year increase not just in net premiums (that is, how much more ACA enrollees are having to pay each month) but also the year over year change in average out of pocket costs.

Let's look at MASSACHUSETTS:

• It's important to keep in mind that Massachusetts is one of the states providing additional state subsidies to backfill at least some of the lost federal tax credits this year. In fact, they've had an existing state subsidy program in place for several years now which they dramatically expanded this year. I'll get into the details of this below.

Here's the ACA exchange plan selections during Open Enrollment by household income level this year vs. last.

Enrollment below 100% FPL and over the 400% FPL threshold have dropped significantly, by 23% and 20% respectively; the former is primarily due to the Trump Regime eliminating federal subsidy eligibility to low income legally-residing immigrants who have been U.S. residents for less than 5 years, along with some other categories of documented immigrants, while enrollment over 400% FPL is down due to this population no longer being eligible for any federal tax credits.

Thanks to the beefed-up state subsidies, however, overall plan selections during open enrollment in MA were actually up a bit this year, by around 3.7% or ~14,400 people.

OK, onto the main analysis:

Here's total Open Enrollment plan selections for both 2025 & 2026 broken out by Actuarial Value (AV) category. The first table is based on official metal level tiers, but it's the second table which is critical, since a huge chunk of ACA enrollees are usually enrolled in CSR Silver plans (which include Cost Sharing Reduction assistance). CSR assistance dramatically boosts the AV of Silver plans up to Platinum levels in most cases.

In the end, the average AV, which is the measure of what percentage of total medical costs a plan covers (in aggregate, not individually) has increased a fraction of a percent year over year, from 76.8% to 77.1%...highly unusual for 2026:

IMPORTANT: I only have detailed CSR category enrollment data for the 30 states hosted via the federal ACA exchange, HealthCare.Gov. Unfortunately, the Centers for Medicare & Medicaid Services (CMS) only provides total CSR enrollment for most of the 21 state-based exchanges (SBEs).

For these states, which includes Massachusetts, I'm instead relying on rough estimates based on the percent of enrollees in the 100 - 150%, 150 - 200% and 200 - 250% FPL income brackets who selected Silver plans each year, which can be found in the 2025 & 2026 OEP State, Metal Level, and Enrollment Status Public Use Files (ZIP) from CMS.

These percentages, when converted into raw numbers, correspond fairly closely to the actual CSR category breakouts for FFM states (+ or - 5%), so they should be close enough for my purposes. I've also come up with rough estimates for the AI/AN CSR category based on comparisons of the percent of AI/AN CSR QHPs selected in FFM states to the percent of AI/AN residents within each state. This is less than 3.3% in every SBE state except for New Mexico.

Again, these are broad estimates only but should be reasonably accurate for this project.

As noted above, Massachusetts is one of the states with their own supplemental subsidy program for ACA exchange enrollees. Officially, the Commonwealth Care Trust Fund was beefed up from around $350 million last year to $600 million this year, which would theoretically work out to an average of something like $75 per enrollee per month in 2025 and $124 per enrollee per month this year.

However, I decided to contact the MA Health Connector directly to get the hard data, and here's what I was told:

Average state premium wrap for ConnectorCare for 2025 was $22 PMPM and the average state wrap for 2026 (through May 2026) was $96 PMPM, a difference of $74 per member per month.

Of note, these figures are just for premium wrap (not the state financed cost sharing subsidies that are a part of ConnectorCare, too) so that may be why the above varies a bit from your back of the envelop math using the figures from press releases and the like, which used total program spending amounts that include both premium and cost sharing supports.

...State-financed cost sharing amounts here:

• CY2025: $63 PMPM
• CY2026: $77 PMPM

Note: I should caveat that these are not final actuals for both of these years - here are some contextual notes from our actuary. In short, you should take these as directional/approximate.

2025 includes actuals based on what we know so far: a couple of carriers haven’t submitted their actual claims for 2025 yet and there will be some changes as a result of the claim audit although we would expect (or hope given the number of years we’ve done the claims audit) those changes to be on the small side at this point.

2026 includes some quick estimates for the 2026 reconciliation – it’s not just advanced payments

So, there you have it: In 2025 it averaged around $22/mo per enrollee in state premium subsidies and $63/mo per enrollee in cost sharing assistance. This year those numbers rose to $96/mo and $77/mo respectively.

It's also important to note that while the ACA requires insurance carriers to maintain at least an 80% Medical Loss Ratio in most states, Massachusetts law is much stricter: They have to average an 88% MLR, which means they can only have a 12% gross margin (on a 3-year rotating average). Anything short of that has to be refunded to the policyholder.

By combining these numbers with the average gross premiums per enrollee I'm able to calculate an estimate of the average total medical expenses each enrollee racks up each year assuming an 88% average Medical Loss Ratio (as I stated in the original post, this can vary widely by carrier and year, so should be considered a very broad average only), which looks like so:

The ~400,000 enrollees who signed up during Open Enrollment would have seen their net premiums skyrocket by more than $1,500 apiece; thanks to the state subsidies being expanded this year, however, the increase is a much lower (but still painful) ~$636/year apiece on average.

Their average out of pocket expenses, meanwhile, would have gone up by around 9% or so without the supplemental Cost Sharing Reduction assistance from the state...but thanks ot it, the average OOP cost for MA exchange enrollees actually dropped slightly this year (by around 1% or $11 apiece).

Combined, that's an average increase in healthcare expenses of roughly $625 per enrollee this year...or a little over 20%.

This is actually the least dramatic overall net increase I've seen so far (I'm about halfway through the states), and pretty much the entire reason for that is the MA ConnectorCare subsidy program.

Meanwhile, based on KFF's net data, average deductibles also went up by ~5% to ~$3,400 for single coverage this year, and the maximum (theoretical) out of pocket cut-off for all ACA enrollees went up by over 15% this years as well, to $10,600 for single coverage.

The bar graph below visualizes this, demonstrating how much of a positive impact the state subsidies (the translucent sections at the top) have had:

Next up: MICHIGAN.