Cost Sharing Reductions, Silver Loading, An Old Republican Goof, New Republican Bills and Deceptions, and a Tad More of the Questionable Paragon Health Institute
It’s 12/28/2025. In four days, a load of people who would have had ACA on-exchange plans if the ACA expanded subsidies, which have been in place for 5 years, were extended (as the Democrats proposed well over 6 months ago), but now face premium increases, often to humongo levels, will have no health insurance.
(Humongo example: Laramie County, Wyoming. Zip 82001. Married couple. Both 62 years old. Non smokers both.
Total income $88,000 a year. U.S. citizens both.
If expanded subsidies were extended
An option: BlueSelect Gold Standard without Kid’s Dental ($4000 deductible, $16,400 oop max)
Premium after subsidy: 4748.64/yr =5% of income
Now, without the extension:
Lowest-cost plan: BlueSelect Bronze (skimpy truly catastrophic-only—deductible and out-of-pocket max both: $21,200/year (=24% of income)
Premium (no subsidy available) : $39,904.80/yr (=45% of income))
Recent Legislative Activity:
A Democratic Senate Bill to extend the expanded subsidies for 3 years was voted on a few weeks ago, and, despite 4 Republicans joining in as Yea, the filibuster requirement was not met.
A really ridiculous Republican Crapo-Cassidy Senate bill was also voted on, which did not extend the expanded subsidies or any part thereof, and had other objectionable provisions, and also, would have “funded cost sharing reductions”. This bill also failed to meet the filibuster requirement.
A House Democratic Bill to extend the expanded subsidies for 3 years did not make it to the floor of the House because of being blocked by House Republican Leader Mike Johnson, but will make it to the floor of the House sometime in 2026, because of a “discharge petition” forcing a vote, which included a few Republicans to give the discharge petition a necessary majority.
A Republican House Bill that did not include extending the expanded subsidies, or any part thereof, which did happen to include “funding cost sharing reductions” was passed.
So, What Are Cost Sharing Reductions?
The ACA, for on-exchange plans, has special lower deductibles and out-of-pocket maximums for people with incomes below 250% of the Federal Poverty Level (FPL). (They get those reduced deductibles and out-of-pocket maxes only if they pick a silver plan, so that’s what they’ll almost all wind up picking.)
(This income group works out to people in the 138% FPL to 250% FPL zone in the 40 states that expanded Medicaid, and 100% to 250% of FPL in the 10 Republican states that did not. In expansion states, people below 138% FPL get expanded Medicaid. In non-expansion states, people below 100% get no insurance unless they have it provided by an employer, or until they dip down to being dirt-poor in BOTH income and assets, and get traditional pre-ACA Medicaid.)
To illustrate, going to healthcare.gov, I typed in a 50 year old individual in Laramie County, Wyoming. (For my convenience, I used the same zip as the prior example. The location does not affect the illustration of the cost-sharing-reduction.)
So, if I plug in a single individual, any age, with a $28,170 income (which is about 180% of FPL), I get a second lowest cost silver plan (SLCSP) with a deductible of $900, and an out-of-pocket maximum of $3,400 a year.
If I plug in the same individual with an income of $46,950 (which is 300% of FPL so they get no cost-sharing-reduction) the deductible jumps to $3,500 and the out-of-pocket max jumps to $9,400.
(The premium-before-any-subsidy will be the same in the two cases, but after subsidy, the 180% FPL person will have a lower net premium.)
Funding for Cost Sharing Reductions
The ACA system with the exchanges and all started at the beginning of 2014.
It was the intent of the ACA drafters that the Cost Sharing Reductions would be funded by direct payments to insurers by the Federal Government. (This is separate from the “subsidy” one would see on the exchanges when choosing a plan.)
However, the direct payments to insurers were not explicitly written into the ACA bill.
Now, in one of their continuous attempts to sabotage the ACA, Republicans in Congress decided to challenge the legality of the direct payments, and file cases in the courts. It took a few years, but the courts eventually declared the direct payments illegal. (Sources: Charles Gaba post or alternately . The last source is only for the origination in the Republican lawsuit, in case for some reason you don’t trust Charles. That second post was before the Republicans won the case, which that second post considered unlikely.)
So, in 2017, the courts decided to stop the direct CSR funding.
Whoops! Republicans Goofed:
The Republicans who filed the lawsuit did not think things through, or really, they didn’t discuss the matter with competent experts.
Insurers, with the states’ approval and often urging, starting in 2018, reacted by doing “silver loading”, which means they put all of the cost of those lower cost-sharing-reduction deductibles and o.o.p. maxes into silver plans, and raised silver plan costs a good chunk. (Maybe it wound up being 25% more for silver plans than before.)
And, for people getting the cost-sharing-reductions, (those to 250% FPL), since ACA rules determining the subsidies people get are based on bringing the cost of the second-lowest-cost-silver plan down to a certain income-based percent of income, their prices didn’t go up (at least if they got a subsidy, which most of them would have at that low income).
And for people getting a subsidy with incomes above 250% FPL, if they just selected a non-silver plan: gold, bronze, or platinum, the CSR-direct-payment cutoffs increased the subsidy. (Because it increased the cost of the SLCSP, and kept the non-silver plans at the same price!)
(My standard joke about this is that after this, some Republicans should have been going “Dummkopf! Dummkopf! Dummkopf!!!” to other Republicans, and even the President, Trump, who didn’t appeal the court decision. If younger people don’t know the reference, “Dummkopf! Dummkopf! Dummkopf!!!” is what Colonel Klink would yell at to his subordinate, Sgt. Shultz, when the latter messed up. In a 60s TV show called “Hogan’s Heroes”.)
Silver-Loading: no case really can be made for it, at least if we have a rational government trying to make the ACA work. The silver loading was an accident, that results in lower premiums for many, but was not an intentionally-engineered policy choice. The ACA, with or without silver loading, has a bunch of problems, still, due to initial underfunding and some rules not well-thought-out, which particularly resulted from just the bare-minimum 60 votes available in the Senate at the time of passage, 2010.
So, if we can get the legislative competence and sufficient legislative votes to fix completely the ACA, the unfunded cost-sharing reductions and silver loading should be undone as part of that. (However, with Republicans being what they are, taking us fully backwards whenever they can, it’s not so clear what to do with the CSR direct payments.)
The Two Republican bills voted on recently, as I indicated, do fund Cost Sharing Reductions.
So, we ought to note that this action, if it makes it into law, will drive up after-subsidy premiums for many people—those above 250% FPL getting subsidies. (This is a separate increase from the expiration of the expanded subsidies, which those bills extend no part of. There is a humongo-jump case in that non-extension for people over the returning 400% FPL “subsidy cliff”, which is a much-needed ACA fix that has been in place for 5 years as part of the expanded subsidies, as in my Wyoming example.)
Not only are the Republicans not being forthcoming on this after-subsidy premium increase for many people, but they’re showing themselves to be their usual fully-deceptive selves in the Republican description of their Crapo-Cassidy Senate bill or more detIt’s 12/28/2025. In four days, a load of people who would have had ACA on-exchange plans if the ACA expanded subsidies, which have been in place for 5 years, were extended (as the Democrats proposed well over 6 months ago), but now face premium increases, often to humongo levels, will have no health insurance.
(Humongo example: Laramie County, Wyoming. Zip 82001. Married couple. Both 62 years old. Non smokers both.
Total income $88,000 a year. U.S. citizens both.
If expanded subsidies were extended
An option: BlueSelect Gold Standard without Kid’s Dental ($4000 deductible, $16,400 oop max)
Premium after subsidy: 4748.64/yr =5% of income
Now, without the extension:
Lowest-cost plan: BlueSelect Bronze (skimpy truly catastrophic-only—deductible and out-of-pocket max both: $21,200/year (=24% of income)
Premium (no subsidy available) : $39,904.80/yr (=45% of income))
Recent Legislative Activity:
(A Senate Bill to extend the expanded subsidies for 3 years was voted on a few weeks ago, and, despite 4 Republicans joining in as Yea, the filibuster requirement was not met. A really ridiculous Crapo-Cassidy bill was voted on, which did not extend the expanded subsidies or any part thereof, and had other provisions, and also, would have “funded cost sharing reductions”. Which also failed to beat the filibuster requirement.
A House Bill to extend the expanded subsidies for 3 years did not make it to the floor of the House because of being blocked by House Republican Leader Mike Johnson, but will make it to the floor of the House sometime in 2026, because of a “discharge petition” forcing a vote, which included a few Republicans to give the discharge petition a necessary majority.
A House Bill that did not include extending the expanded subsidies, or any part thereof, which did happen to include “funding cost sharing reductions” was passed.)
So, What Are Cost Sharing Reductions?
The ACA, for on-exchange plans, has special lower deductibles and out-of-pocket maximums for people with incomes below 250% of the Federal Poverty Level (FPL). (They get those reduced deductibles and out-of-pocket maxes only if they pick a silver plan, so that’s what they’ll all wind up picking.)
(This income group works out to people in the 138% FPL to 250% FPL zone in the 40 states that expanded Medicaid, and 100% to 250% of FPL in the 10 Republican states that did not. In expansion states, people below 138% FPL get expanded Medicaid. In non-expansion states, people below 100% get no insurance unless they have it provided by an employer, or until they dip down to being dirt-poor in BOTH income and assets, and get traditional Medicaid.)
To illustrate, going to healthcare.gov, a typed in a 50 year old individual in Laramie County, Wyoming. (For my convenience, I used the same zip as the prior example. The location does not affect the Cost Sharing Reduction Illustration.)
So, if I plug in a single individual, any age, with a $28,170 income (which is about 180% of FPL), I get a second lowest cost silver plan (SLCSP) with a deductible of $900, and an out-of-pocket maximum of $3,400 a year.
If I plug in the same individual with an income of $46,950 (which is 300% of FPL) the deductible jumps to $3,500 and the out-of-pocket max jumps to $9,400.
(The premium-before-any-subsidy will be the same in the two cases, but after subsidy, the 180% FPL person will have a lower premium.)
Funding for Cost Sharing Reductions
The ACA exchanges started at the beginning of 2014.
It was the intent of the ACA drafters that the Cost Sharing Reductions would be funded by direct payments to insurers by the Federal Government. (This is separate from the “subsidy” one would see on the exchanges when choosing a plan.)
However, the direct payments were not explicitly written into the ACA bill.
Now, in one of their continuous attempts to sabotage the ACA, Republicans in Congress decided to challenge the legality of the direct payments, and file cases in the courts. It took a few years, but the courts eventually declared the direct payments illegal. (Sources: Charles Gaba post or alternately . The last source is only for the origination in the Republican lawsuit, in case for some reason you don’t trust Charles. That second post was before the Republicans won the case, which that second post considered unlikely.)
So, in 2017, the courts decided to stop the direct CSR funding.
Whoops! Republicans Learn they Goofed!
The Republicans who filed the lawsuit did not think things through, or really, they didn’t discuss the matter with competent experts.
Insurers, with the states approval and often urging, starting in 2018, reacted by doing “silver loading”, which means they put all of the cost of those lower cost-sharing-reduction premiums into silver plans, and raised silver plan costs a good chunk. (Maybe it wound up being 25% more for silver plans than before.)
And, for people getting the cost-sharing-reductions, (those to 250% FPL), since ACA rules determining the subsidies people get are based on bringing the cost of the second-lowest-cost-silver plan down to a certain income-based percent of income, their prices didn’t go up (at least if they got a subsidy, which most of them would have at that low income).
And for people getting a subsidy with incomes above 250% FPL, if they just selected a non-silver plan: gold, bronze, or platinum, the CSR-direct-payment cutoffs increased the subsidy. (Because it increased the cost of the SLCSP, and kept the other plans at the same price!)
(My standard joke about this is that after this, some Republicans should have been going “Dummkopf! Dummkopf! Dummkopf!!!” to other Republicans, and even the President, Trump, who didn’t appeal the court decision. If younger people don’t know the reference, “Dummkopf! Dummkopf! Dummkopf!!!” is what Colonel Klink would yell at to his subordinate, Sgt. Shultz, when the latter massed up. In a 60s TV show called “Hogan’s heros”.)
Silver-Loading: no case really can be made for it, at least if we have a rational government trying to make the ACA work. The silver loading was an accident, that results in lower premiums for many, but was not thought up. The ACA, with or without silver loading, has a bunch of problems due to initial underfunding and some rules not well-thought-out, which particularly resulted from just the minimum 60 votes available in the Senate at the time.
So, if we can get the legislative competence and sufficient legislative votes to fix completely the ACA, the unfunded cost-sharing reductions and silver loading should be undone. (However, with Republicans being what they are, taking us fully backwards, it’s not so clear.)
The Two Republican bills mentioned above do fund Cost Sharing Reductions, as I indicated.
So, we ought to note that this action will drive up after-subsidy premiums for many people—those above 250% FPL getting subsidies. (This is separate from the expiration of the expanded subsidies, which those bills extend no part of. There is a humongo-jump case in that of for people over the returning 400% FPL “subsidy cliff”, which is a much-needed ACA fix that has been in place for 5 years as part of the expanded subsidies.)
Not only are the Republicans not being forthcoming on this after-subsidy premium increase for many people, but they’re showing themselves to be their usual fully-deceptive selves in the Republican description of their Crapo-Cassidy Senate bill or more detailed description.
That second link says:
The bill also directly lowers premiums by 11 percent in 2027 and beyond by providing cost-sharing reduction (CSR) payments.
No mention of increasing the after-subsidy-premiums for people over 250% FPL.
And, no mention that for most people under 250% FPL, the after-subsidy-premium is unchanged!
(Tricksters! Tricksters! Tricksters. By not specifying “before-subsidy” or “after-subsidy”!)
A Technicality On the Above: Interaction With Abortion in Many States
I learned from a Charles Gaba Post that, at least the House Bill (that’s the bill that passed) would only fund cost-sharing-reductions on ACA plans that don’t fund abortions. So, since about 1/4 of plans are in states that require that abortion funding, undo the undoing of silver loading in those states!
This complexity is taken into account on the CBO report on the passed House Bill on the last page. You can see that’s where the 11% number comes from in the Republican Description of the Senate bill. (However, I admit a puzzling thing. I haven’t read the Senate Bill text. The short description does not indicate keeping the not funding Cost Sharing Reductions in states where abortion is required in ACA plans. (If CSRs are funded in all states, then I would think the gross (pre-any-subsidy) silver plan premiums would drop about 4/3*11% = about 14%. Hmmm? Whatever.)
Dr. Brian Blase and his Paragon Health Institute Again (They Appeared in Several Prior Posts of Mine):
I will emphasize that, at this point, there is every appearance that the main, or only, advisor to the Republicans is Dr. Brian Blase and his Paragon Health Institute.
So, for example, if you go back to the description of the Senate Bill description of Republican Crapo-Cassidy Senate bill, there is a link to Paragon that you get when you click on “4 percent of the premium increase in 2026” which link gets you to this Paragon page , which has the statement, in big letters, “Obamacare 2026 Premiums Largely Unaffected by Expiration of Biden’s COVID Credits”
I just caught something about this above statement. I need to check, but I think the statement, if you look at the supporting graph, the number they are referring to is pre-any-subsidy premium. Which is not the relevant thing for the couple in Wyoming with an income of $88,000 a year, with premium jumping from $5000 a year to $40,000 a year! The premium change they’re talking about may be higher adverse selection from dropping the expanded subsidies, making healthier people leave the insurance pool! Not the relevant cost-increase for people who now can’t afford health insurance!
Prior Problems with Dr. Brian Blase and Paragon:
I will continue to be extremely ethical, and not accuse Dr. Blase and his Paragon Institute of either gross incompetence, gross propagandistic deception, or both. (In particular, where I think there’s a big problem of gross error or gross deception, I’ll continue to wait for others to double check me.)
1)But a graphic prepared by Paragon used by both Senator Thune and Mike Johnson as a reason not to extend the expanded subsidies, looks highly-suspicious to me, largely over an issue of not counting the cost-sharing-reductions, which I posted in in my prior post: prior post deceptive graphic.
2)Within my two posts #1 #2 are some impugnings of Paragon. (The latter has a few be major organizations, like KFF and the American Hospitals association. One such impugning minces no words:
From the American Hospital Association:
“It is therefore imperative that policymakers understand that Paragon developed these allegations using inaccurate data, dubious assumptions, and an apparent lack of understanding of how health insurance actually works.” .
which is within the first paragraph here.)
3)And, as well, Sen. Blumenthal, at a committee meeting, gets some issues with Paragon research into the public record here (video).
4)And, separately, Jonathan Cohn, wonky guy who wrote at least one book about the ACA, has some impugning here (which is behind a bulwark paywall).
Deception, Lies, Incompetence from the Republicans:
Apparently all mixed together. How can we possibly separate the three and tell what are the deceptions? What are the lies? What is the sheer incompetence?
Perhaps mixed in, there are some Republicans trying to fool other Republicans, on a topic which is very complex (due to things like “adverse selection” and other tricky concepts that can take time for even a somewhat-quantitative person to get their head around, let alone a typical lawyer-member-of-Congress).
The lies and (arguably extremely-wild deceptions in some cases—Vance and Mike Johnson), not picked up well enough by generalist reporters in the press to call them on it, is most conspicuous in that talking point that the shutdown was to provide healthcare for illegal immigrants. (Explored by me here , with references to the truth, and the lies and deceptions not only from Trump, but Vance and Mike Johnson, as well!)
Then the other cases.
(As Fox News, and similar sources, substantially-successfully keep oodles of people with poor or no critical-thinking-skills in darkness.)
That second link says:
‘The bill also directly lowers premiums by 11 percent in 2027 and beyond by providing cost-sharing reduction (CSR) payments.“
No mention of increasing the after-subsidy-premiums for people over 250% FPL.
And, no mention that for most people under 250% FPL, the after-subsidy-premium is unchanged!
(Tricksters! Tricksters! Tricksters.)
A Technicality On the Above: Interaction With Abortion in Many States
I learned from a Charles Gaba Post that, at least the House Bill (that’s the bill that passed) would only fund cost-sharing-reductions on ACA plans that don’t fund abortions. So, since about 1/4 of plans are in states that require that funding, undo the undoing of silver loading in those states!
This complexity is taken into account on the CBO report on the passed House Bill on the last page. You can see that’s where the 11% number comes from in the Republican Description of the Senate bill. (However, I admit a puzzling thing. I haven’t read the Senate Bill text. The short description does not indicate keeping the not funding Cost Sharing Reductions in states where abortion is required in ACA plans. (If it is not kept in all states, then I would think the gross silver plan premiums would drop about 4/3*11% = about 14%. Hmmm? Whatever.)
Dr. Brian Blase and his Paragon Health Institute Again:
I will emphasize that, at this point, there is every appearance that the main, or only, advisor to the Republicans is Dr. Brian Blase and his Paragon Health Institute.
So, for example, if you go back to the description of the Senate Bill description of Republican Crapo-Cassidy Senate bill, there is a link to Paragon that you get when you click on “4 percent of the premium increase in 2026” which link gets you to this Paragon page , which has the statement, in big letters, “Obamacare 2026 Premiums Largely Unaffected by Expiration of Biden’s COVID Credits”
I just caught something about this above statement. I need to check, but I think the statement, if you look at the supporting graph, the number they are referring to is pre-any-subsidy premium. Which is not the relevant thing for the couple in Wyoming with an income of $88,000 a year, with premium jumping from $5000 a year to $40,000 a year! The premium change they’re talking about may be higher adverse selection from dropping the expanded subsidies, making healthier people leave the insurance pool!
Prior Problems with Dr. Brian Blase and Paragon:
I will continue to be extremely ethical, and not accuse Dr. Blase and his Paragon Institute of either gross incompetence, gross propagandistic deception, or both. (In particular, where I think there’s a big problem of gross error or gross deception, I’ll wait for others to double check me.)
1)But a graphic prepared by Paragon used by both Senator Thune and Mike Johnson as a reason not to extend the expanded subsidies, looks highly-suspicious to me, largely over an issue of not counting the cost-sharing-reductions, which I posted in in my prior post: prior post deceptive graphic.
2)Within my two posts #1 #2 are some impugnings of Paragon. (The latter has a few be major organizations, like KFF and the American Hospitals association. One such impugning minces no words:
Try this one from the American Hospital Association:
“It is therefore imperative that policymakers understand that Paragon developed these allegations using inaccurate data, dubious assumptions, and an apparent lack of understanding of how health insurance actually works.” .
which is within the first paragraph here.
3)And, as well, Sen. Blumenthal, at a committee meeting, gets some issues with Paragon research into the public record here (video).
4)And, separately, Jonathan Cohn, wonky guy who wrote at least one book about the ACA, has some impugning here (which is behind a bulwark paywall).
Deception, Lies, Incompetence from the Republicans:
Apparently all mixed together. How can we possibly separate the three and tell what are the deceptions? What are the lies? What is the sheer incompetence?
Perhaps mixed in, there are some Republicans trying to fool other Republicans, on a topic which is very complex (due to things like “adverse selection” and other tricky concepts.)
The lies and arguably extreme deceptions, not picked up well enough by reporters in the press, is most conspicuous in that talking point that the shutdown was to provide healthcare for illegal immigrants. (Explored by me here , with references to the truth, and the lies and deceptions not only from Trump, but Vance and Mike Johnson, as well!
Then the numerous other cases.
(As Fox News, and similar sources, substantially-successfully keep oodles of people with poor or no critical-thinking-skills in darkness.)