The Hidden Costs of Zero-Premium Plan Turnover

When automatically moved from a zero-dollar silver plan to one that requires a premium due to plan turnover, do lower-income health insurance marketplace enrollees lose or switch coverage?

As a result of the Patient Protection and Affordable Care Act (ACA), 24.2 million people enrolled in the health insurance marketplaces this year, a record number.1 However, sustaining that coverage can potentially be a major challenge, given the administrative obstacles that they can face.

Why zero-dollar premium plans matter for low-income enrollees

Many lower-income enrollees rely on zero-dollar premium silver plans, which were created via the American Rescue Plan Act (ARPA) and the Inflation Reduction Act (IRA). In order to qualify, an individual must have an income below 150% of the federal poverty level, which represents an annual salary of about $23,475 for an individual or $48,225 for a family of four in 2025. Unfortunately, the plans that qualify for the zero premiums can change year to year, requiring enrollees to either begin paying premiums or switch plans.

Administrative barriers undermine continuous coverage

This zero-premium silver plan turnover results in two administrative burdens when it comes to reenrollment:

  1. Learning costs, which involves individuals understanding and responding to changes in coverage
  2. Compliance costs, which involves either setting up payments or switching plans

Given these factors, previously conducted studies have shown these hurdles have decreased reenrollment. Now, in a new cross-sectional study published in JAMA Health Forum,1 investigators explore how zero-premium silver plan turnover has impacted marketplace coverage in 29 HealthCare.gov states following implementation of ARPA.

Key Takeaways

  • Marketplace enrollment reached a record 24.2 million in 2025, but administrative barriers threaten coverage continuity for low-income enrollees.
  • Zero-premium silver plan turnover led to a 7% drop in automatic reenrollment and forced many enrollees to switch plans or begin paying premiums.
  • If IRA subsidies expire in 2026, coverage losses could worsen due to increased costs and continued administrative burdens.

Using primary data from the Qualified Health Plan Landscape File from HealthCare.gov and the Marketplace Open Enrollment Period (OEP) Public Use Files from the Center for Consumer Information and Oversight, the study authors explored how county-level HealthCare.gov reenrollment rates were impacted by exposure zero-premium silver plan turnover, overall and across insurers, from 2022 through 2024, following expanded ARPA premium subsidy implementation.

It’s important to also note that the captured data represents losses in coverage related to turnover, only when enrollees switched to new insurers, and does not apply to active reenrollment data, since they need to select a plan before the Jan. 15 deadline. Therefore, the investigation focuses on overall and automatic reenrollmenton county years containing insurer-level turnover, including active reenrollment of all country years with any turnover.

To analyze the data, multivariable log-linear fixed-effects regression models were utilized to predict the connection between reenrollment and counties experiencing zero-premium silver plan turnover. The investigators then retransformed their predictions, determining errors using the δ method. The estimates were broken down as percentage changes in reenrollment.

Turnover leads to reduced automatic reenrollment

Overall, the sample consisted of a total of 2,159 counties representing approximately 10 million HealthCare.gov enrollees yearly in 29 states that used the HealthCare.gov platform from 2022 through 2024. From 2021 to 2022, as the American Rescue Plan Act subsidies were enacted, the percentage of enrollees that reside in counties exposed to turnover rose from 10.3% to 93.9%.

These increases continued heading into 2024—the turnover across insurers represented a 7.0% (95% confidence interval, or CI, −12.7 to −1.3) decline in automatic reenrollment. Any turnover was not related to changes in active enrollment, but it was associated with a 13.4% decrease (95% CI, −17.7 to −9.1) in enrollees going with their previous, default plan and a 15.0% increase (95% CI, 11.5-18.5) in enrollees choosing to switch plans.

“We examined how zero-premium silver plan turnover is associated with marketplace enrollment on the federally-facilitated marketplace,” the study authors concluded. “We found that turnover was associated with reduced automatic reenrollment by roughly 7%, and that it nudged some returning enrollees to select a new plan rather than opting to stay in their previous one. Expiration of the IRA subsidies will likely lead to coverage losses due to price increases; our findings suggest further coverage losses may occur for lower-income enrollees as a result of the administrative burdens created by turnover.”

Reference

1. Drake C, Nagy D, Avina S, Ludwinski D, Anderson DM. Coverage Retention and Plan Switching Following Switches From a Zero- to a Positive-Premium Plan. JAMA Health Forum. 2025;6(5):e251424. doi:10.1001/jamahealthforum.2025.1424

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