Attention IA, IL, NC, ND, NE, OK, TX, WI & WY: There's FREE Gold in Them Thar Hills!

Much has been written by myself and others (especially the Kaiser Family Foundation) about the fact that millions of uninsured Americans are eligible for ZERO PREMIUM Bronze ACA healthcare policies.

I say "Zero Premium" instead of "Free" because there's still deductibles and co-pays involved, although all ACA plans also include a long list of free preventative services from physicals and blood screenings to mammograms and immunizations with no deductible or co-pay involved.

If you have a fairly healthy year, you really could go the entire year without paying a dime in healthcare costs while still taking advantage of many of these free services, and also having the peace of mind that in a worst-case scenario, at least you wouldn't go bankrupt. Not perfect, but a lot better than going bare especially since you wouldn't pay a dime in premiums.

However, far less has been written about the zero-premium GOLD plans which are also available to some ACA enrollees around the country. Most of that which has been written about them has been (to my knowledge) written by my friend David Anderson of Balloon Juice.

How is it possible for a Gold plan (which covers around 80% of the average person's healthcare expenses in aggregate and which typically has higher premiums than Bronze or Silver plans while having deductibles averaging less than 1/3 as much as Silver, to cost nothing per month?

Well, that's thanks to the magic of something called Silver Loading (aka the Silver Switcharoo), a policy pricing strategy which was adopted by health insurance carriers & given its blessing by state regulators in response to Donald Trump's failed attempt to destroy the ACA markets by cutting off Cost Sharing Reduction (CSR) reimbursement payments.

It's a long, stupid story, but the bottom line is that as a result of the confusing mess above, millions of people who qualify for ACA subsidies are eligible for enough financial assistance to reduce their net, post-subsidy Bronze premiums to nothing...and a much smaller subset of the population even qualifies for enough APTC (Advance Premium Tax Credits) to bring net Gold premiums down to $0/month as well.

KFF has posted a state-level analysis estimating that a whopping 4.0 million uninsured Americans (27% of all uninsured eligible to enroll in ACA exchange plans) are eligible for $0 premium Bronze plans, ranging from as few as 1,000 in Minnesota to over a million people in Texas (DC doesn't have any uninsured residents eligible, but that's likely because lower-income uninsured folks are eligible for Medicaid up to 215% of the Federal Poverty Line anyway).

How about $0-premium Gold plans, though? I asked Dave Anderson, and he gave me a spreadsheet of the 192 counties across 9 states where a single 40-yr old adult (no kids) is eligible for free Gold plans if they earn up to $18,000/year (appx. 140% FPL). As it happens, most of these counties are located in states which have expanded Medicaid up to 138% FPL anyway (or which are in the process of doing so, such as Oklahoma), but it's still a good starting point. I've highlighted the counties in states which don't have Medicaid expansion, where significantly more people should qualify:

NOTE: It's important to keep in mind that many enrollees earning less than 200% FPL (roughly $25,000/year if you're single or $52,000/year for a famly of four) are probably still better off enrolling in a high-CSR Silver plan than a Gold plan even at $0/mo in premiums due to the signficant reductions in deductibles and other cost sharing...but if you live in the counties below, are in that income range and are looking to pay nothing per month above other considerations, you should strongly consider going for the Gold.

Here's the Free Gold @ $18,000 counties:

  • IOWA: Adair, Adams, Allamakee, Appanoose, Audubon, Boone, Buena Vista, Calhoun, Carroll, Cass, Cherokee, Clarke, Clay, Clinton, Crawford, Davis, Decatur, Des Moines, Dickinson, Emmet, Fayette, Fremont, Greene, Grundy, Guthrie, Hamilton, Hardin, Henry, Howard, Humboldt, Ida, Jasper, Jefferson, Johnson, Keokuk, Kossuth, Lee, Louisa, Lucas, Lyon, Madison, Mahaska, Marion, Marshall, Mills, Monona, Monroe, Montgomery, Muscatine, Obrien, Osceola, Page, Palo Alto, Pocahontas, Poweshiek, Ringgold, Sac, Shelby, Sioux, Story, Tama, Taylor, Union, Van Buren, Wapello, Washington, Wayne, Webster, Winnebago, Winneshiek, Wright
  • ILLINOIS: Boone, Dekalb, Winnebago
  • NORTH CAROLINA: Burke, Caldwell, Catawba
  • NORTH DAKOTA: Benson, Burke, Divide, Eddy, Grand Forks, Griggs, Mckenzie, Mountrail, Nelson, Ramsey, Steele, Walsh
  • NEBRASKA: Buffalo, Butler, Cass, Colfax, Cuming, Fillmore, Hall, Hamilton, Johnson, Kearney, Lancaster, Nance, Nemaha, Nuckolls, Otoe, Pawnee, Saline, Seward, Thayer
  • OKLAHOMA: Alfalfa, Beaver, Blaine, Bryan, Caddo, Carter, Choctaw, Cimarron, Coal, Craig, Custer, Dewey, Ellis, Garvin, Grady, Grant, Harmon, Harper, Haskell, Hughes, Johnston, Kay, Kingfisher, Kiowa, Latimer, Le Flore, Lincoln, Love, Mcclain, Mccurtain, Mcintosh, Major, Marshall, Mayes, Murray, Muskogee, Noble, Nowata, Okfuskee, Okmulgee, Osage, Pawnee, Payne, Pontotoc, Pushmataha, Roger Mills, Seminole, Sequoyah, Stephens, Texas, Tillman, Washington, Washita, Woods, Woodward
  • TEXAS: Lubbock
  • WISCONSIN: Columbia, Jefferson, Rock, Rusk, Walworth
  • WYOMING: (The entire state)

The total population of the counties above is a little over 5.3 million people, but I have no idea how many of them would fall below the $18,000 income threshold.

  • In addition, all 29 counties in Alaska would fall into this category as well, except that the Federal Poverty Level is 25% higher in Alaska than the rest of the country, so the math doesn't work the same...although there are Gold plans available for as little as $3/month or so for Alaskans earning $22,000/year.

Of the 221 total counties listed above, Anderson says that around 190 of them would still have $0 Gold for single adults earning $21,000/year; 74 counties would still be $0 Gold at $24,000/year; 32 counties at $27,000/year and 10 counties--all of them in Oklahoma--still have FREE GOLD PLANS, with just a $500 deductible, available for single adults earning up to $34,750/year (272% FPL):

  • Alfalfa, Bryan, Caddo, Grant, Kay, Marshall, Okfuskee, Seminole, Washita and Woodward Counties, Oklahoma

Note that the total combined population of all 10 of these counties is just 215,000 people, and they'd have to earn less than around $34,750/year to qualify. Then again, the average per capita income of all 10 is just $19,700/year, and the the median household income is less than $40,000, with an average of 2.6 people per household. That means the average income for these 10 counties is just under 200% FPL.

In other words, there's a very good chance that more than half the uninsured residents of these counties (as well as plenty of those already insured) could be eligible for a FREE GOLD PLAN and not even know it.

UPDATE: In fact, it turns out that if you're 64 years old and live in one of those 10 OK counties, you qualify for that same free Gold BCBSOK plan if you earn as much as $51,000/year (400% FPL).

Remember, even if you don't qualify for a FREE Gold plan, a lot more uninsured folks will qualify for one costing just a few dollars per month.

UPDATE: Thanks to Dave Anderson for providing this handy Tableau database which let me list every county where a single adult earning exactly 150% or 200% FPL is eligible for a zero-premium Gold plan. This isn't exactly the same list as above since the income thresholds start a bit higher (150% FPL = $19,140/year for one person; 200% FPL = $25,520/year for one person), but it's pretty close. Note that this only includes the 36 states hosted by HealthCare.Gov; there may be Gold plans available for free in some of the other 14 states not listed as well: