Elena Maslia Marks

@taygoldenstein @RobertDownen_ @HoustonChron @TexasTribune Welcome to Trib.

After seven years (🤯) at the @HoustonChron covering state politics, today is my last day. I’ll be joining the enterprise and investigative reporting team at the @TexasTribune on Tues. It’s bittersweet to leave a newsroom I love, but I’m so beyond excited for this next chapter!

@MSpellingsBPC @BPC_Bipartisan Looking forward to seeing what you do. I have some thoughts.

Rising health care costs are a challenge across the whole economy, and we can’t make real progress for the American people with a piecemeal approach. That’s exactly why BPC recently launched its Health Care Affordability Initiative. We will actively work with policymakers on both sides to identify policies that will address high health care prices at their root and help lower the everyday cost of living. Want to learn more about this new initiative? Read our article below and follow along this week at @BPC_Bipartisan. bipartisanpolicy.org/article/moving…

@evanasmith Agree

he's roy hobbs in the natural -- possibly the best decision i made in thirty years-plus of hiring young journalists. snap him up *now* #wonderboy

@brian_blase The cost of health insurance is based on the cost of healthcare that is expected to be used.

The ACA market is massively oversubsidized even without the expired Covid credits. The subsidies are inflationary (lead to higher health care prices and premiums), extremely distortionary (harm people with employer coverage, incent employers to drop coverage), and costly.

@mattyglesias Many of the supplemental benefits keep seniors healthy and living in their homes/communities, avoiding hospital visits and institutionalization. The non-medical drivers of health, or social determinants of health, are more important than medical care to health outcomes.

🎙️ More than half of Texas women can’t access their preferred birth control method. Why does it matter — and what can be done about it? @ResoundRH’s Gracia Sierra joins @elenamarks on “Texas Briefing” to discuss how insurance status shapes access to contraception. bit.ly/4i9j9Mw

@CharlesTXPolicy The rate/amount of subsidies available decreases if enhanced subsidies go away while cost of plans climb

@elenamarks The subsidies do, in fact, undo the price increases. If the benchmark plan increases by $100, the subsidy increases by $100.

Here's the thing about the ACA, and Larry knows this -- the overwhelming majority of enrollees are subsidized (heavily), and because the subsidies are linked to prices, there's really no chance of a premium death spiral at this point. Let me explain. Larry is getting at a phenomenon in insurance known as adverse selection. The basic premise of adverse selection occurs in insurance when an unfavorable risk pool distribution occurs, and there is information about the risks are known in advance. In simple terms, you don't want to do a group project with the class slacker when all members of the group get the same grade. When you treat all people (healthy and already sick) the same from a premium perspective, healthy people rightly understand that they're getting the short end of the stick, and don't want to participate. Larry's concern thus is that if you let healthy people not participate in the ACA, they won't, and this will make the remaining ACA risk pool sicker, and thus gross premiums will increase. So far, so good. But the ACA also provides substantial subsidies to people, and those subsidies are linked to the price of the product. When gross premiums increase, so do subsidies. What this means is that any individual who is eligible for subsidies is entirely insulated from gross premium increases. In fact, due to some weird quirks, some subsidized enrollees *might* even benefit from gross premium increases. In 2025, 22,413,868 out of 24,319,713 (92%) of enrollees were subsidized. If the enhanced subsidies expire, enrollees over 400% of FPL would lose access to subsidies. In 2025, 2,549,648 enrollees (~10%) reported income over 400% FPL, or is reported as "other/unknown." This means that ~ 90% of current enrollees would likely continue to be eligible for subsidies when the enhancements expire. There simply is not a fact-based case that "letting people bypass the ACA" would lead to a death spiral. It's a fundamental misunderstanding of the ACA market.

@CharlesTXPolicy Even with subsidies, prices will go up for many people who will opt out. Subsidies are like discounts; they mitigate against price hikes but they don’t undo them entirely.

@elenamarks This misunderstands ACA market dynamics. That is how normal, unsubsidzied markets work. Markets where subsidies are linked to price operate differently.

@brian_blase @larry_levitt I guess we could dispense with insurance and let everyone pay for what they can afford, with some assistance for low income Americans. How do we deal with the fact that the real benefit of INSURANCE is spreading the costs of low probability high cost events?

@larry_levitt We could give Americans’ health care freedom, protect people with pre-existing conditions, spend a lot less money than Obamacare, and avoid its inflationary premium and price spiral that benefits big insurers and has led to massive amounts of fraud.

You have to read between the lines here to imagine what President Trump is proposing. But, it sounds like it could be a plan for health accounts that could be used for insurance that doesn’t cover pre-existing conditions, which could create a death spiral in ACA plans that do.

@brian_blase ESI is tax subsidized

From CMS: The avg premium after subsidies will be $50 per month for the lowest-cost plan in 2026. This is only a $13 increase from 2025. And it remains $20 less expensive than the monthly premium after subsidies in 2020. Point: underlying Obamacare subsidies are very large.

@brian_blase @larry_levitt Using pretax dollars

@larry_levitt Thanks for asking. I have an Obamacare plan, bought with my ICHRA. My premium next year will be: $32,556. For a plan with a $13,700 deductible. Before Obamacare, my family had a short-term plan that covered more providers, had a lower deductible, and cost one-quarter as much.

We estimate the average ACA enrollee will see their out-of-pocket premium increase by 114%. But, it will vary a lot based on age, income, family size, and zip code. I'd be interested in what you're seeing if you're an ACA enrollee and log on to the marketplace. Please reply here.

Join us for this important webinar. Free but registration required. Barriers to Choice: Insurance and Contraceptive Access in Texas bakerinstitute.org/event/barriers…

@GeBaiDC Ge, I’m in favor of young helping old, as old helped young. We are all in this together and have to figure out how to make it work fairly over the course of a lifetime.

Forcing the Young to Subsidize the Old and Stifling Entrepreneurship —The ACA’s “Intended Consequence”

@KandRMom @WesleyHuntTX In favor with some adjustments

@WesleyHuntTX What is your position on the renewal of the enhanced subsidies?

Good Morning America 🇺🇸

@brian_blase @CPopeHC What is your solution to the problem of access to affordable healthcare?

.@CPopeHC has an important new piece on the staggering fraud in the Obamacare exchanges—centered in South Florida but happening nationwide. Extending Biden’s COVID-era subsidy boosts that fueled this fraud would be patently unserious policymaking. city-journal.org/article/obamac…

Reposting

Exciting new @TexasTribune . Our next CEO will be @sarahadlerhart beginning later this year. Grateful to @SonalRShah for her leadership the last 3 years.

📉 From 2022–24, the share of children without health insurance saw its steepest rise in nearly a decade, per Georgetown University. Texas leads the nation in uninsured kids. 🎙️ On Houston Matters with @HoustonPubMedia, Baker Institute fellow @elenamarks explains what this means: bit.ly/48hLM7F

@johnarnold We shall see….

Estimates for the cost of unnecessary or ineffective healthcare interventions range from 10-30% of total spend. Any serious effort to reduce costs and improve care must address this. The WISeR model proposed by CMS will face pushback, but is an important step forward. Many procedures, tests, and drugs have no clinical benefit, but almost all interventions have risks and side effects. A well-run health system protects patients from unnecessary and even harmful services and protects the taxpayer and patient from unnecessary spending. There’s a place for targeted utilization review that occurs before the unnecessary service is delivered and the claim is paid. Some Medicare Advantage plans arguably overuse prior authorization, creating unnecessary friction for patients and providers. Meanwhile traditional Medicare rarely applies it, paying for all care regardless of benefit. The WISeR model is a small pilot by CMS to add prepayment review aided by a mix of technology and clinicians for select low-value services in 6 states. If anything, I think it moves too cautiously, but CMS is right to be careful to ensure the incentives and guardrails are set properly. While prior auth in MA has left many clinicians and patients uneasy, the WISer model is designed to improve health outcomes and reduce costs without imposing needless burdens on providers. It's a smart reform and deserves support.