明尼苏达州个人市场改革的影响评估（英）

PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.Research

ReportPREETHI

RAO,

FEDERICO

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CHRISTINE

EIBNERAssessing

theImpact

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IndividualMarket

Reforms

inMinnesotaPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.Formoreinformationonthis

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/pubs/permissions.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.AboutThisReportTheMinnesotaCouncilofHealthPlanswasinterestedinunderstandingthepotentialimpactofeffortsthestatemighttaketoimprovehealthinsuranceenrollmentinthestate.Inthisreport,weusedRAND’sCOMPAREmicrosimulationmodeltoestimatetheimpactofstate-fundedindividualmarketsubsidyenhancements,aswellasthereplacementofMinnesotaCare,thestate’sBasicHealthProgram(BHP)infavorofasimilarly-structuredindividualmarketplan.Foreachpolicyscenario,weestimatedenrollment,premiums,andfederalandstatespending.ThisresearchwasfundedbytheMinnesotaCouncilofHealthPlansandwascarriedoutwithinthePayment,Cost,andCoveragePrograminRANDHealthCare.RANDHealthCare,adivisionoftheRANDCorporation,promoteshealthiersocietiesbyimprovinghealthcaresystemsintheUnitedStatesandothercountries.Wedothisbyprovidinghealthcaredecisionmakers,practitioners,andconsumerswithactionable,rigorous,objectiveevidencetosupporttheirmostcomplexdecisions.Formoreinformation,see/health-care,orcontactRANDHealthCareCommunications1776MainStreetP.O.Box2138SantaMonica,CA90407-2138(310)393-0411,ext.7775RAND_Health-Care@AcknowledgmentsWegratefullyacknowledgethesupportandassistanceofseveralpeopleinwritingthisreport.WethankLucasNesse,DanEndreson,ChelseyOlson,andHannahFairmanfortheirhelpfulinputandfeedback,aswellastheMinnesotaCouncilofHealthPlansforfundingthiswork.WearegratefultoCarterPriceandPetraRasmussenoftheRANDCorporationandJeanAbrahamoftheUniversityofMinnesotafortheirthoughtfulreviewsofthiswork.iiiPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.SummaryStartingin2025,MinnesotacouldexperiencedisruptionsinitshealthinsurancemarketplaceduetothesunsetofenhancedfederaltaxcreditsavailablethroughtheInflationReductionAct(IRA)of2022andtheexpirationofstatefundingforitsreinsuranceprogram.Withreducedtaxcredits,fewerpeoplemightenrollinmarketplaceplans,potentiallyleadingtohigherpremiumsandmarketinstability.Theexpirationofreinsurance,whichpartiallyoffsetsinsurers’claimscostsforpeoplewithhighexpenditures,couldexacerbatetheseissues.Inthisreport,weestimatetheeffectsofimplementingstate-fundedsubsidiestostrengthenMinnesota’smarketplacegiventheseanticipatedchanges.ThepolicyreformsthatweconsiderweredevelopedbytheMinnesotaCouncilofHealthPlansandsharesimilargoalswithlegislationrecentlyproposedbyMinnesotapolicymakers,suchasHF96,abillauthorizingstudyofapublicoptionthatalsoproposedtotemporarilyenhancemarketplacesubsidies.OuranalysisaccountsforuniquefeaturesofMinnesota’shealthinsurancemarket,includingthefactthatMinnesotaiscurrentlyoneofonlytwostatesthatofferaBasicHealthProgram(BHP),aMedicaid-likeplanavailableforpeoplewithincomesbelow200percentoffederalpovertylevel(FPL)whodonotqualifyforMedicaid.Becausethestate’sBHP,calledMinnesotaCare,drawsenrolleeswhowouldotherwisebeeligibleformarketplacecoverage,itshrinksthepoolofmarketplaceenrollees,whichcouldcontributetovolatilityinindividualmarketpremiums.ThisissueisfurthercomplicatedbyaTrump-eradecisiontohaltfederalpaymentofcost-sharingreductions(CSRs),whichreducedeductibles,copays,andothercost-sharingformarketplaceenrolleeswithincomesunder250percentofFPL.BecauseinsurersarerequiredtoprovideCSRsregardlessoffederalfunding,moststateshavedirectedinsurerstoloadthesecostsontosilver-tiermarketplaceplans,whichincludesthebenchmarkplanusedtocalculatefederaltaxcredits.Thisloadinghastheeffectofincreasingthepremiumtaxcreditamount,whichbenefitsconsumers.However,consumersinMinnesotadonotbenefitasmuchfromCSRsilverloadingasconsumersinotherstates,becausemostpeoplewhowouldotherwisebeCSR-eligibleareinsuredthroughtheMinnesotaCare.Furthermore,thefederalgovernmentfundsBHPsatarateof95percentofwhattheywouldhavepaidinAPTCs,absenttheprogram.OneofourscenariosconsidersmovingMinnesotaCareenrolleestoanactuarially-equivalentmarketplaceplan,enablingthestate’smarketplacetotakefulladvantageofthetaxcreditboostprovidedbyCSRsilverloading,andreceivingthe“full”federalAPTCprovision.PolicyScenariosConsideredThepolicyscenariosthatweanalyzeincludestate-fundedenhancementstoCSRs,statefundedenhancementstoadvancepremiumtaxcredits(APTCs),andmovingMinnesotaCareivPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.enrolleesintoanactuarially-equivalentmarketplaceplan.UndertheACA,APTCswereavailableforpeoplewithincomesbetween100and400percentofFPLwithnoalternativesourceofaffordablecoverage.ARPA/IRAenhancedthesetaxcreditsbyreducingtheapplicablepercentagecontributionsandbyextendingthepremiumtaxcreditstopeoplewithincomesover400percentofFPLiftheywouldhavetopaymorethan8.5percentofincometoenrollinabenchmarkplan.Weestimateresultsfor2025,whenthefederalenhancementstoAPTCsremaininplaceandreinsuranceisfunded,andfor2026,aftertheexpirationofreinsurancefundingandfederally-enhancedAPTCs.WedonotaccountforarecentpolicychangeinMinnesotathatwouldenableundocumentedimmigrantstoenrollinMinnesotaCarestartingin2025.Thefivescenarioswemodeledwereasfollows:•

2025o

Currentlaw:includesfederally-enhancedAPTCsandreinsuranceo

State-fundedsubsidies:enhancedCSRsforpeoplewithincomesbetween200and250percentofFPL(theonlyCSReligiblepopulationonthemarketplaces,giventheMinnesotaCareBHP)•

2026o

Currentlaw:eliminatesfederallyenhancedsubsidiesandreinsuranceo

Statefundedenhancedsubsidies,including:§

EnhancedCSRsforpeoplewithincomesbetween200and250percentofFPL§

StatefundedAPTCenhancementstoincreasesubsidygenerosityandextendAPTCstopeoplewithincomesabove400percentofFPLo

Statefundedenhancedsubsidies,plusreplacingtheMinnesotaCareBHPwithanactuarially-equivalentmarketplaceplan.Tthisbuildsonthepriorscenarioby:§

Bolsteringstate-fundedCSRenhancementstoensurethatAPTC-eligiblepeoplewithincomesunder250percentofFPLareeligibleforaplanwitha94percentactuarialvalue.§

Addingstate-fundedpremiumtaxcreditstoensurethatAPTC-eligiblepeoplewithincomesunder200percentofFPLhavethesamepremiumsastheywouldhavebeenchargedontheMinnesotaCareBHP.ApproachWeusedtheCOMPAREmicrosimulationmodeltoestimatetheeffectsoftheproposedpoliciesonhealthinsuranceenrollment,premiums,andstatespending.COMPAREisananalytictooldevelopedbytheRANDCorporationtoestimatehowindividuals,families,andbusinesseswillrespondtohealthinsurancepolicychanges.IndividualsinthemodelmakechoicesbyweighingthecostsandbenefitsofavailablehealthinsuranceoptionsandchoosingtheoptionvPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.thatyieldsthehighestvaluetothem.Policychanges,suchasanincreasedtaxcredits,canaffecttheirdecisions.Premiumsinthemodelalsorespondtoenrollmentdecisions,reflectingtheage,healthstatus,anddemographiccompositionofthepopulation.WeadaptedthemodeltoreflectMinnesota’sspecificpolicylandscape,includingMinnesotaCareandthereinsuranceprogram,andtoensurethatweaccuratelyestimatedoutcomesgivencurrentlaw.KeyFindingsEnrollmentFigureS.1showstheprimaryenrollmenteffectsthatweestimatefromtheproposedchanges.•

Undercurrentlaw,individualmarketenrollmentissubstantiallyloweranduninsuranceishigherin2026relativeto2025.ThisreflectstheexpirationofreinsurancefundingandIRApremiumtaxcreditenhancementsthattakesplacein2026.•

Enhancingsubsidiesincreasesindividualmarketenrollmentandreducesuninsuranceinboth2025and2026;effectsarelargerin2026becausethestate-financedsubsidyenhancementsthatwemodeledfor2026aremorecomprehensiverelativetocurrentlawthanin2025.•

MovingtheMinnesotaCarepopulationtothemarketplacereducesuninsurancerelativetotheenhancedCSRandpremiumsubsidyscenarioin2026.ThisreflectsthatthevalueoftheAPTCincreaseswhentheMinnesotaCareBHPisreplacedwithaQHPduetosilverloading,therebyincreasingenrollees’buyingpowerforplansonothermetaltiers.Additionally,becauseproviderpaymentratesarehigherinmarketplaceplansthanintheMinnesotaCareBHP,weassumethatpeoplehaveaslightpreferencefortheactuarially-equivalentmarketplaceplanrelativetothecurrentMinnesotaCareprogram,andarethereforemorelikelytoenroll.viPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.Figure

S.1.

Individual

Market

Enrollment

and

Uninsurance

in

Minnesota

Across

Scenarios,

2025and

2026400,000364,000349,000350,000300,000250,000200,000150,000100,00050,0000111,000111,000295,000277,000272,000232,000263,000109,000226,000206,000109,000133,0000Current

Law,

State

Enhanced

State

EnhancedCurrent

Law,

State

Enhanced2025CSRs,

20252026CSRs

and

APTCs,CRSs

and

APTCs,2026No

BHP,

2026Enrolled

in

Individual

MarketEnrolled

in

BHPUninsuredSource:EstimatesfromCOMPAREmodel.The2025scenariosincludestatefundingforreinsuranceandfederallyenhancedAPTCs,whichbothexpirein2026.PremiumsFigureS.2showstheestimatedstatewideaverage,annualmarketplacepremiumsforasingle,40yearoldnonsmokerinthefivemodeledscenarios.Wefocusonanaveragebronzeplancomparedtothebenchmarksilverplanonthemarketplaces.•

Premiumsaresubstantiallyhigherundercurrentlawin2026thanin2025,reflectingtheeliminationofreinsurance.•

Thesubsidyenhancementsmodeledfor2025increasepremiumsrelativetocurrentlawbecausetheaffectedpopulation—peoplewithincomesbetween200and250percentofFPL—tendstobeslightlymoreexpensivethantheoverallindividualmarketpopulation.However,thiseffectissmall—about$100annually,orlessthan3percentofpremiums.•

Wefindthatthe2026subsidyenhancements,whicharemorecomprehensivethanthe2025enhancements,tendtobringinarelativelyhealthypopulationcomparedtocurrentlaw2026enrollees,decreasingpremiumsrelativetocurrentlawin2026.Inourmodel,viiPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.thesemarginalenrolleestendtohavelowanticipatedhealthcareexpenditures,andthusmayprefernottoenrollininsuranceunlesstheirout-of-pocketpremiumcostsareverylow.•

Premiumsdecreaseevenfurtherinthe2026scenariothataddstheMinnesotaCarepopulationtothemarketplaces.However,withoutreinsurancefunding,premiumsdonotreturnto2025levelsinanyofthe2026scenarios.•

Thedifferencebetweenthebenchmarksilverpremiumandthebronzepremiumislargestinthe2026scenariothatreplacestheMinnesotaCareBHPwithaQHP,duetoincreasedsilverloading.BecauseAPTCsarepeggedtothebenchmarksilverpremium,thelargerdifferencebetweenthebronzeandthebenchmarkpremiumimpliesthatAPTCswillcoveragreatershareofthebronzepremium,loweringout-of-pocketpremiumsforsubsidizedenrolleesrelativetootherscenarios.Byasimilarlogic,increasedsilverloadingmeansthatAPTCswillcoveralargershareoftheunloadedgoldandplatinumpremiumsonthemarketplaces,thoughthoseresultsarenotshowninthefigure.Figure

S.2.

Statewide

Average

Individual

Market

Annual

Premiums

for

a

40

Year

Old

NonsmokerAcross

Scenarios,

2025

and

2026$9,000$8,000$8,000$7,200$7,000$6,900$7,000$6,400$6,000$5,600$5,200$5,100$5,000$4,600$4,500$4,000$3,000$2,000$1,000$0Current

Law,2025State

EnhancedCSRs,

2025Current

Law,2026State

Enhanced

State

EnhancedCSRs

and

APTCs,

CRSs

and

APTCs,2026No

BHP,

2026BronzeBenchmark

SilverSource:EstimatesfromCOMPAREmodel.The2025scenariosincludestatefundingforreinsuranceandfederallyenhancedAPTCs,whichbothexpirein2026.viiiPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.State

SpendingFigureS.3showsestimatedspendingbytheMinnesotastategovernmentontheindividualmarketandMinnesotaCarepopulationsacrossthescenarios.•

Currentlawstatespendingonthispopulationishigherin2025thanin2026,reflectingtheeliminationofstatefundsforreinsurancein2026.•

Statespendingincreasesinthescenariosthataddstate-financedsubsidies;thiseffectislargestin2026,whenthesubsidiesarerelativelymoregenerous.•

Thescenariothatincludesbothstate-financedsubsidiesandmovingtheMinnesotaCarepopulationintoanactuarially-equivalentmarketplaceplanincreasesstatespendingrelativetothescenariothatincludessubsidiesalone.Thischangeisdrivenbythefactthatmorepeoplebecomeinsuredinthisscenario.Figure

S.3.

State

Spending

on

Individual

Market

and

MinnesotaCare

BHP

Enrollees

AcrossScenarios

(in

Millions),

2025

and

2026Current

Law,

2025$257.9State

Enhanced

CSRs,

2025$319.5Current

Law,

2026State

Enhanced

CRSs

and

APTCs,

2026$83.3$539.0State

Enhanced

CSRs

and

APTCs,

No

BHP,

2026$578.2$0$100$200$300$400$500$600$700Source:EstimatesfromCOMPAREmodel.The2025scenariosincludestatefundingforreinsuranceandfederallyenhancedAPTCs,whichbothexpirein2026.ixPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.ConclusionWithoutadditionalpolicyaction,ourestimatesindicatethattotalinsurancecoverageandindividualmarketenrollmentinMinnesotawilldeclinesubstantiallyin2026,duetotheeliminationofIRAtaxcreditenhancementsandtheexpirationofreinsurancefunding.Ouranalysisconsidersseveralpolicyoptionsthatthestatecouldimplementtocounteractthischangeinenrollment.Wefindthatusingstatefundstoenhancemarketplacesubsidiescouldsubstantially(butnotcompletely)reversethedropininsurancecoverage.MovingtheMinnesotaCarepopulationintoanactuarially-equivalentmarketplaceplancouldbringinsuranceenrollmentinthestatetonewhighs,duetoincreasedAPTCsrelativetounloadedindividualmarketpremiumsandduetoanassumptionthatconsumers’accesstocarewouldincreaseifproviderswerepaidmarketplacerates.Eachoftheseoptionstoexpandcoveragewouldincreasestatespendingrelativetocurrentlaw.TheenhancedCSRandAPTCsubsidiesthatwemodeledwouldincreaseinsurancecoverageby69,000individualsin2026whileincreasingstatespendingby$456millionrelativetocurrentlaw—anetcostof$7,600pernewlyinsuredindividual,ofwhichthestatepaid$6,600.EnhancingsubsidiesandmovingtheMinnesotaCarepopulationtoanactuarially-equivalentmarketplaceplanwouldincreasecoverageby101,000individualsrelativetocurrentlawwhileincreasingstatespendingby$495million,foranetcostof$7,400pernewlyinsuredindividual,ofwhichthestatecontributed$4,900.xPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.ContentsAboutThisReportiiiSummary

ivFiguresandTables

xiiChapter1.Introduction

1Chapter2.PolicyBackground

4MedicaidEligibility4APTCs4CSRPaymentsandSilverLoading5MinnesotaCareBasicHealthProgram

5ReinsuranceProgram

6Chapter3.Methodology

8Minnesota-specificmodelcustomizations

8Microsimulationpolicyscenarios

11Chapter4.Results

13Enrollment13Premiums17StateSpending18SensitivityAnalysis19Chapter5.DiscussionandConclusions

21SummaryofFindings21Discussion

22OtherPolicyConsiderations22Limitations

23Conclusions24AppendixA.COMPAREOverview

26COMPAREModel26AdaptingCOMPAREtoMinnesota28AppendixB.AdditionalTables

30Abbreviations

33References

34xiPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.FiguresandTablesFiguresFigureS.1.IndividualMarketEnrollmentandUninsuranceinMinnesotaAcrossScenarios,2025and2026

viiFigureS.2.StatewideAverageIndividualMarketAnnualPremiumsfora40YearOldNonsmokerAcrossScenarios,2025and2026

viiiFigureS.3.StateSpendingonIndividualMarketandMinnesotaCareBHPEnrolleesAcrossScenarios(inMillions),2025and2026

ixFigure3.1.MinnesotaMedicaidEnrollment,2017-2023

10Figure4.1.InsuranceTransitions

16TablesTable1.1.PolicyScenariosUnderConsideration

3Table2.1.MedicalAssistanceEligibilityinMinnesota

4Table3.1.Policyscenarios

12Table4.1.Enrollment

14Table4.2.AnnualIndividualPremiumsfora40-Year-OldNon-Smoker

17Table4.3.StateandFederalSpending,inMillions

19TableB.1.EnrollmentbyIncomeCategory

30TableB.2.EnrollmentUnderAlternateAssumptions

32TableB.3.PremiumsUnderAlternateAssumptions

32xiiPREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.Chapter1.IntroductionTheAffordableCareAct(ACA)introducedanumberofreformsintendedtoincreaseaccesstohealthinsuranceandhealthcareintheUnitedStates.Thelaw’sMedicaidexpansionextendedMedicaideligibilitytomostindividualswithincomesunder138percentofthefederalpovertylevel(FPL),regardlessofageorparentalstatus,instatesthatchosetoimplementtheprovision.TheACAalsointroducedhealthinsurancemarketplacesineverystate,allowingindividualstopurchasequalifiedhealthplans(QHPs)andreceivesubsidiesfortheirpremiumsand/orcostsharingbasedontheirincome.StateshavesomeflexibilityovertheirMedicaidprogramsandmarketplacesviaoptionalelementsandwaiveroptions.Forexample,Section1331oftheACAallowsstatestocreateandimplementaBasicHealthProgram(BHP),aplanavailabletothosewithincomesbelow200percentofFPLbutwhodonotqualifyforMedicaid.Inaddition,statesmayapplyforSection1332StateInnovationWaiverstowaivecertainrequirementsoftheACA(providedtheymeetspecifiedguardrails).AsaresultoftheACA,healthinsurancecoverageintheUnitedStatesincreasedsubstantially,andoutofpocket(OOP)costshavefallen.However,statepolicymakersandstakeholderscontinuetograpplewithdeterminingtheoptimalpoliciesfortheirresidents.Inthisanalysis,weconsiderpolicyoptionsthatthestateofMinnesotamightconsidertostrengthenthestate’smarketplace,includingreimaginingthestate’scurrentuseofflexibilitiesandwaiversallowedundertheACA.Inadditiontoimplementingastatehealthinsurancemarketplace(MNsure),MinnesotahasexpandedeligibilityforMedicalAssistance(thestate’sMedicaidprogram)toadultswithincomesunder138percentofFPL.Furthermore,MinnesotahasoperatedMinnesotaCare,ahealthinsuranceoptionthatprovideshealthinsurancecoverageatlowornopremiumstoadultswithincomesunder200percentofFPL,withoutaccesstootheraffordablesourcesofcoverage,since1992.MinnesotaCareisnowclassifiedasaBHPunderSection1331oftheACA.Inaddition,Minnesota’sSection1332StateInnovationwaiverapplicationwasapprovedin2017tooperatetheMinnesotaPremiumSecurityPlan,areinsuranceprogram,forfiveyears(2018–2022);in2022,Minnesota’swaiverextensionapplicationwasapprovedfor2023–2027(CMS,2023).Thereinsuranceprogramlowerspremiumsintheindividualmarketbyreimbursinginsurersforindividualclaimsthatexceedathreshold.BoththeMinnesotaCareBHPandreinsuranceprogramsarepartiallyfundedbythefederalgovernment,withfederalpass-throughfundingtiedtothecostofmarketplacesubsidiesthatotherwisewouldhavebeenpaidbythefederalgovernment(CMS,undated;DHS,2019).ThoughtheseoptionalcomponentsoftheACAwereintendedtoallowstatesflexibilitytopursueinnovativehealthinsuranceoptionsandtocustomizecaretothestate’sspecificneeds,someoftheminteractwithoneanothertocauseunintendedoutcomes.Forexample,aBHPpullsindividualsawayfromthemarketplaceinwhichtheyotherwisemighthaveenrolled;this,in1PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.PREPUBLICATIONCOPY.[DATE:JANUARY24,2024]Thisdocumenthasnotbeenedited,proofread,orfinalized.turn,canaffectmarketplacepremiumsandfederalpass-throughdollarsforthereinsuranceprogram.Inaddition,theBHPspecificallyremovesindividualswithincomesunder200percentofFPLfromthemarketplace;thispopulationotherwisewouldhavebeeneligibleforcost-sharingreduction(CSR)subsidies(availabletoAPTC-eligibleindividualswithincomesunder250percentofFPL).FollowingthehaltingoffederalCSRpaymentstoinsurersin2017(LiuandStaman,2017),moststates,includingMinnesota,relyonsomeformofsilverloading,wherebythecostsofCSRsareloadedontoindividualmarketpremiumsinordertodrawhigherfederalAPTCstofundCSRcosts.BecauseofMinnesotaCare,relativelyfewmarketplaceenrolleesinMinnesotaareeligibleforCSRs,andhencetheAPTCboostfromCSRsilverloadingislimited.Furthermore,thefederalgovernment’scontributiontowardtheBHPiscalculatedas95percentofthecostofAPTCsitwouldhavepaidinabsenceoftheprogram.Thismeansthatthestateforgoesfundingitwouldreceiveiftheseindividualswereenrolledinmarketplaceplans.Minnesota’shealthinsurancelandscapeisfurthercomplicatedbythefactthattwoimportantmarketplaceprovisionsareexpectedtoexpireafter2025.First,whileMinnesota’sSection1332waiverextensionapplicationwasapprovedthroughtheyear2027,asofthispublishing,thestatehasonlyapprovedfundingoftheplanthrough2025(SF3472,2022),