<P> However, the premium tax credits are mandatory spending, meaning all those eligible under the ACA receive them without Congressional appropriation . These adjust with premium increases to limit after - subsidy premium payments by ACA enrollees to a fixed percentage of income . Based on President Trump's threats to end the CSR payments during early 2017, several insurers and actuarial groups estimated this resulted in a 20 percentage point or more increase in premiums for the 2018 plan year . In other words, premium increases expected to be 10% or less in 2018 became 28--40% instead . </P> <P> The CBO reported in August 2017 (prior to President Trump's decision) that ending the CSR payments might increase ACA premiums by 20 percentage points or more, with a resulting increase of nearly $200 billion in the budget deficit over a decade, as the premium tax credit subsidies would rise along with premium prices . CBO also estimated that initially up to one million fewer would have health insurance coverage, although more might have it in the long - run as the subsidies expand . CBO expected the exchanges to remain stable (i.e., no "death spiral" before or after Trump's action) as the premiums would increase and prices would stabilize at the higher (non-CSR) level . </P> <P> CBO estimated that of the 12 million with private insurance via the ACA exchanges in 2017, about 10 million receive premium tax credit subsidies and will be shielded from premium increases, as their after - subsidy premiums are limited as a percentage of income under the ACA . However, those 2 million who do not receive subsidies face the brunt of the 20% + premium increases, without subsidy assistance . This may adversely impact enrollment in 2018 and beyond . Another 13 million who are covered under the ACA's Medicaid expansion (in the 31 states that chose to expand coverage) should not be directly affected by Trump's action . </P> <P> President Trump's argument that the CSR payments were a "bailout" for insurance companies and therefore should be stopped, actually results in the government paying more to insurance companies ($200 B over a decade) due to increases in the premium tax credit subsidies . </P>

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