Risk Shifting Disguised as Affordability: Inside CMS’ 2027 Marketplace Proposal
CMS’ new proposed Marketplace rule doubles down on risky plans that are lower-premium but come with sky-high deductibles and significant consumer exposure.
Authors: Ellen Montz and Tara Straw
Editors: Patti Boozang and Amanda Eisenberg
Editor’s Note: The 80 Million will continue to explain the ways in which Congress and the Trump administration are chipping away at the ACA Marketplace coverage and access gains through H.R. 1 and other actions. This week, we turn our attention to how the same dynamics are playing out in ACA Marketplaces.
tl;dr
The 2027 proposed Marketplace rule is here, and it shifts risk to consumers under the guise of “affordability.” CMS is promoting lower‑premium plans that come with sky‑high deductibles, higher out‑of‑pocket caps and weaker protections — making coverage less affordable when people actually need care.
Featured policies of the proposed rule, like expansion of catastrophic plan availability, benefit the healthy and wealthy — not working families. Higher cost sharing would expose consumers to steep point-of-service medical bills and threaten to drive up premiums for everyone else in comprehensive plans.
The proposal continues the current backsliding policy trend. By raising out‑of‑pocket limits, encouraging non‑network designs and reviving weak alternatives, the proposals attempt to promote premium affordability by covering less. The real affordability fix remains restoring enhanced premium tax credits (PTC).
The 80 Million Impact
Each year, the Centers for Medicare & Medicaid Services (CMS) issues the Notice of Benefit and Payment Parameters (NBPP), setting the rules for the upcoming ACA Marketplace plan year. The proposed rule for 2027, released Feb. 11, arrives at a moment when consumers are already facing significantly higher premiums following Congress’s failure to extend enhanced PTC.
The proposals continue to undermine ACA affordability and consumer protection gains. They increase financial consumer exposure, promote risky high-deductible plans, and introduce coverage designs that weaken key consumer protections.
Expanding High-Risk Catastrophic Coverage
Catastrophic plans were intended as a limited option under the ACA — primarily for people under 30 or those facing hardship. These plans already carry extremely high deductibles and cover little to nothing beyond preventive services and three primary care visits before the deductible must be met. Individuals are also ineligible for PTC if they enroll. It is not hard to imagine why participation in the catastrophic plan market has historically been anemic, with only 54,000 people participating across the country in 2025.
To boost catastrophic enrollment (but framed as a pro-affordability measure), the proposed rule puts forth an expansion of exemption eligibility to include anyone whose income is less than 100% of the FPL or above 250% of the FPL, which was first established in sub-regulatory guidance late last year (too late in the year to have any market impact for 2026). Under another proposed provision, the maximum out-of-pocket limit (MOOP) for catastrophic coverage in 2027 would rise from $12,000 to roughly $15,400 for an individual — and about twice that for a family.
But who truly benefits? The only people who may see financial benefit are primarily healthier and higher-income individuals who do not qualify for subsidies, can afford large upfront medical bills and are eligible to save money in a tax-advantaged health savings account (HSA).
For most families, the reality of a $15,000–$30,000 deductible is not true protection — it is financial risk.
For someone with a broken bone requiring surgery or an unexpected hospitalization, insurance would not meaningfully help until thousands of dollars have already been paid out of pocket. About half of adults report they could not cover even a $500 unexpected medical bill without debt. Five-figure exposure is simply out of reach for many.
Further, catastrophic plans are separated from the broader Marketplace risk pool. If healthier consumers migrate into these plans — the president’s Council of Economic Advisers said it expects enrollment in catastrophic plans to reach 3 million — premiums for those remaining in comprehensive Marketplace plans would increase.
Raising Out-of-Pocket Costs Across the Marketplace
The annual limit on out-of-pocket costs is one of the ACA’s most important consumer protections. It ensures that even in the worst health event, costs are capped. The proposed NBPP would increase that limit for bronze and catastrophic plans through formula changes that may push the bounds of CMS’ statutory authority.
This comes on top of earlier rule changes that already resulted in double-digit increases to enrollees’ required share of premiums and out-of-pocket limits in 2026 and 2027 — the first double-digit increases since its start in 2014. Apart from the Marketplace effects, that change also raised the MOOP for people in private insurance coverage.
With the enhanced PTC expired and higher monthly premiums, consumers may gravitate toward lower-premium bronze or catastrophic plans. But those plans carry deductibles nearing $7,500 or more for bronze coverage, and significantly higher for catastrophic coverage. Lower premiums accompanied by rising deductibles do not solve affordability. They simply shift costs to the point of care.
Introducing “Non-Network” Plan Designs
The 2027 proposal also outlines a framework for “non-network” Marketplace plans. Under this approach:
Insurers would not contract with specific in-network providers
Instead, plans would set a predetermined payment amount for each service
If providers charge more, the enrollee will pay the difference — effectively balance billing
The ACA’s MOOP protections apply to in-network covered services. If there is no clear network, it raises serious questions about whether those limits would meaningfully apply anymore. While the details of this proposal are limited and the proposed rule outlines potential guardrails, it raises serious concerns about the continued efficacy of ACA consumer protections, the ability of consumers to understand the risks of these plans, and the impact on the value of the PTC for enrollees in markets with these types of plans.
Encouraging Skimpier Alternatives
Meanwhile, the Trump administration announced a non-enforcement policy on rules for short-term, limited duration insurance (STLDI), which has none of the ACA’s insurance protections, including no limits on out-of-pocket costs. STLDI can discriminate against people based on their health or gender, avoid the ACA’s requirement to cover preventive services at no cost, and eliminate coverage for specific medical conditions or specialties based on health status.
As premiums rise, consumers may be drawn to lower-cost alternatives that lack ACA protections. That dynamic mirrors pre-ACA markets, where affordability came at the expense of security.
The Bottom Line
The ACA reduced financial risk by capping out-of-pocket costs, prohibiting discrimination based on health status and subsidizing premiums so coverage was affordable for working families.
The 2027 proposed NBPP weakens each of those gains:
It increases maximum out-of-pocket limits
It promotes high-deductible catastrophic coverage
It introduces coverage designs that may bypass meaningful consumer protections
It risks destabilizing the broader Marketplace risk pool
Consumers want affordable premiums — and predictable, meaningful coverage when they get sick. Lowering premiums by raising deductibles and expanding skimpier plans is not affordability reform. It is risk-shifting.
The straightforward path to improving affordability remains restoring the enhanced PTC that expired at the end of 2025. Without that, higher-cost exposure disguised as “lower premiums” simply rolls back more than a decade of progress.