Same Drug. Same Hospital. 2,347 Prices.
Hospitals have been required to post their prices since 2021, but prescription drug prices have stayed buried in files almost no patient can read. PatientRightsAdvocate.org's free Hospital Drug Price Finder changes that. It lets anyone compare what hospitals charge health plans and cash-paying patients for the same medication.
The companion analysis from 3 Axis Advisors is startling. At the same hospital, the highest negotiated price for a drug averages 2,347 times the lowest. Some insurers are paying more than four times the manufacturer's list price.
Direct care practices start from the opposite premise: post the price and keep it simple. When you can see the price, you can shop, and a market can finally work.
Sources: www.patientrightsadvocate.org/hospital-drug-prices-report and www.prnewswire.com/news-releases/patientrightsadvocateorg-launches-nationwide-hospital-drug-price-finder-302705265.html
11 Insurers Exit ACA Marketplaces in 2027, Led by 350,000 Cigna Members
Every October, hundreds of thousands of Americans open an envelope from their health insurance company and learn that their plan won't exist on Jan 1.
For 2027, KFF tracks 11 insurance carriers that have announced they are exiting Affordable Care Act Marketplaces in some or all of their states, while only 6 carriers are entering new state marketplaces.
The biggest exit comes from Cigna. After reporting more than 350,000 on-exchange enrollees in the first quarter, Cigna decided to leave the individual market completely for 2027, pulling out of all 11 states where it currently sells plans, both on and off the exchange, to focus on other lines of business. Centene's Ambetter, the largest Marketplace insurer in the country with 3.5 million members across 27 states, is also exiting Delaware and New Hampshire for 2027.
KFF's analysts explain the business calculation plainly. After enhanced federal premium subsidies expired and Marketplace sign-ups fell by more than 1 million people between 2025 and 2026, insurers re-evaluated which states were still profitable enough to stay in. Where the risk pool shrank or tilted toward sicker patients, carriers packed up.
From an insurance executive's desk, exiting 2 states or 11 states is portfolio management.
From a patient's kitchen table, it means starting over.
When your carrier leaves the state, you don't just pick a new logo and a new monthly premium by Dec 31. You inherit a new provider directory, a new prescription formulary, a new prior-authorization department, and a very real chance that the family doctor you have seen for 6 years isn't in the new network.
Oddly enough, even the carriers staying in the market have noticed that patients are exhausted by the friction. For 2027, Centene is marketing condition-specific plans in North Carolina and Ohio with four $0 cardiologist visits a year, and Oscar Health is launching a "RetireEase" plan in 5 states promising set prices for labs and routine services. Insurers are now using $0 visits and posted prices as a headline sales pitch, as long as they haven't pulled out of your county.
Direct primary care gives you that simplicity without tying it to an insurance carrier's annual earnings call.
When you pay your primary care physician a direct monthly membership, your doctor doesn't belong to Cigna, Ambetter, or Oscar. If your insurer exits your state this fall and you have to move your catastrophic coverage to a new carrier on Nov 1, your doctor stays put. Your medical chart stays put. The cell phone number you text when your kid wakes up with a fever stays put.
Insurance companies enter and exit markets every year. Your relationship with your physician shouldn't be on a 12-month lease.
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24% Higher Premiums in Kansas: What 2027 Rate Filings Say About Your State
In our home state of Kansas, individual market insurers filed for an average rate increase of 24.2% for 2027.
Kansas isn't an outlier. Across the country, the median and weighted-average proposed rate increase for 2027 ACA Marketplace plans sits at 15%, according to Louise Norris's state-by-state review at healthinsurance.org.
Look down the state table where rates have already been finalized or proposed: Arizona is up 27.9%, Alabama 25%, New Mexico 24.4%, Montana 22.6%, Washington 22.2%, South Carolina 22.1%, Oregon 21.6%, Georgia 20.7%, and New Jersey 19.8%. Even states at the bottom of the chart, like New York at 6% and Vermont at 3%, are moving in only one direction.
Those percentages land on top of a baseline that already jumped. Between 2025 and 2026, the average full-price Marketplace premium climbed from $619 a month to $741 a month. Add another 15% for 2027, and the typical unsubsidized premium crosses $850 a month, more than $10,000 a year for one person before the deductible is touched.
Why doesn't everyone feel the same shock on Nov 1?
Because 87% of Marketplace enrollees receive federal premium subsidies that rise alongside the local benchmark silver plan. If your income qualifies for a tax credit and you shop carefully near the benchmark, the federal government absorbs most of the rate hike.
The other 13% of on-exchange buyers, along with everyone who buys individual coverage off the exchange where subsidies don't exist, take the full hit on their own bank statement.
Insurers point to the same culprits in almost every state filing: rising hospital prices, specialty prescription drugs including GLP-1 medications, higher labor costs, and a smaller, sicker risk pool as healthy unsubsidized customers drop out. Notice how that feedback loop works. Higher prices chase healthy buyers out of the pool, which leaves a sicker pool, which becomes the justification for next year's 24% filing.
If you pay full price in Kansas, Georgia, Arizona, or any of the 40-plus states facing double-digit increases for 2027, auto-renewing your current plan is the most expensive habit in personal finance.
Pull up the 2027 rate filings for your state before Nov 1. Compare the total annual cost of the lowest-premium bronze or HSA-eligible plan against what you are paying now. Then put the savings toward a direct primary care doctor who posts a flat monthly fee, answers your texts, and runs blood work and prescriptions at wholesale cost.
The state insurance department approves the carrier's rate filing. You approve your household budget.
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$63,840 and $1 Over: Where 48% of the Marketplace Drop Came From
7% of the enrollees. 48% of the exits.
When KFF examined who walked away from the Affordable Care Act Marketplace after enhanced federal tax credits expired, one group stood out. People earning above 400% of the federal poverty level made up just 7% of Marketplace enrollment in 2025. Yet they accounted for nearly half, 48%, of the total drop in plan selections for 2026.
The reason is a hard math line called the subsidy cliff.
Under the rules that returned in 2026 and remain in place for 2027, premium tax credits don't phase out gradually above 400% of the poverty line. They vanish on the next dollar. For 2027 coverage in the continental United States, that cliff sits at $63,840 for a single person and $132,000 for a household of 4, according to healthinsurance.org.
Earn $63,800, and your benchmark silver premium is capped at 10.22% of your household income. Earn $63,841, and you pay 100% of the sticker price.
And that sticker price has been climbing fast. The average full-price Marketplace premium rose from $619 a month in 2025 to $741 a month in 2026, and insurers have proposed a median 15% increase for 2027. For a self-employed couple in their 50s or a family of 4 just above $132,000, the unsubsidized bill can easily rival a mortgage payment.
Many of the families who stayed on the exchange survived by downgrading. KFF found that bronze plan sign-ups jumped from 30% of Marketplace selections in 2025 to 40% in 2026, growing from 7.3 million to 9.2 million people, while silver sign-ups fell to a record low of 43%. That shift pushed the average Marketplace deductible up 37% in a single year, from $2,759 to $3,786.
If your household income sits near or above that $63,840 single or $132,000 family line as Nov 1 open enrollment begins, two moves belong on your notepad before you renew.
First, check how your modified adjusted gross income is calculated. Contributions to a health savings account or a pre-tax retirement plan reduce your ACA-specific income dollar for dollar. For someone a few thousand dollars over the line, funding an HSA, up to $4,500 for an individual or $9,000 for a family in 2027, can pull household income back under the 400% threshold and restore thousands of dollars in tax credits.
Second, if you are buying an unsubsidized bronze plan with a $3,786 or $7,000 deductible, recognize what you are buying. You are paying cash for your primary care either way. Pairing that high-deductible policy with a direct primary care membership puts your routine visits, wholesale labs, and generic prescriptions on a flat monthly fee, and since January 2026, qualifying DPC memberships up to $150 a month for an individual can be paid directly from an HSA.
A $1 raise shouldn't cost a family $10,000 in health premiums. Run the income math before you pick the plan.
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$140 With Insurance or $25 in Cash: Why Patients Skip Their Plan
"They come to us because our cash price is often lower than what their insurance plan asks them to pay. That tells you something is wrong."
Mark Cuban delivered that line to Texas House lawmakers on Sept 1, explaining why so many customers at Cost Plus Drugs already carry health insurance cards in their wallets.
A study in Annals of Internal Medicine backs him up with 62 million commercial generic prescription claims. Researchers matched employer-sponsored insurance claims against direct-purchase cash prices at Cost Plus Drugs, including a $5.25 shipping fee on every prescription.
Whenever a patient's copay or coinsurance under an employer plan topped $15, the cash price beat the insurance price nearly 80% of the time.
At the higher tiers, the gap turns into a canyon. For generic prescriptions where the insurance plan asked the patient to pay more than $100 out of pocket, the median cost through the plan was $140. The median cash price at Cost Plus was $25. That is an 85% drop, or a median savings of $119 on a single fill, across common medications in cardiology, psychiatry, neurology, urology, and oncology.
How does an insured worker end up paying $140 for a generic pill that sells for $25 in cash?
Three pharmacy benefit managers, CVS Caremark, Cigna's Express Scripts, and UnitedHealth's OptumRx, handle roughly 80% of prescription claims in the United States. Their contracts with employers can run hundreds of pages, packed with rebate definitions, spread pricing, and gag clauses that keep employers from comparing terms. Cuban calls those agreements "contractual terrorism."
At the same time, employer plans have shifted more drug spending onto workers through higher deductibles and coinsurance tiers. Even electronic "real-time benefit check" tools inside doctors' prescribing software caught savings only 39% of the time on those $100-plus generic fills, missing more than half the cases where cash was cheaper.
There is one catch every patient should know before pulling out a debit card. As pharmacist Jennifer Graff told The American Journal of Managed Care, cash purchases outside the plan usually do not count toward your annual deductible or out-of-pocket maximum. Cuban told Texas lawmakers the law should change so patients aren't penalized for saving themselves and their health plan money. Until it does, you have to run the math on whether you are likely to hit your deductible that year.
In our direct primary care clinics at AtlasMD, we skipped the middleman years ago. We dispense generic medications in the office at wholesale prices, often for pennies a pill, and tell patients the exact cash price before the label is printed. If a mail-order pharmacy or a local cash discount beats us, we send the prescription there.
When a $25 bottle of pills costs $140 through the benefit card, the card isn't a discount. It's a tollbooth.
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