While sorting through her mail in June, Andrea Lewis, manager of a small, family-owned jewelry store in Gallia County, found a letter from her Affordable Care Act Marketplace insurance provider, CareSource.
A feeling of nausea settled in her stomach as she read the letter, which said that CareSource would no longer offer any Ohio insurance plans on the ACA Marketplace for 2027. The decision was "driven by rising healthcare costs and ongoing shifts in the ACA Marketplace," according to a statement from a CareSource spokesperson.
Now, Lewis is faced with her own decision: Go without insurance and pay out of pocket for her medical expenses, quit her job of 27 years and take disability, or find a position with health coverage.
"I love my job. It's
basically been my whole career," Lewis said, "but I feel like I don't have any good options left."
With CareSource dropping ACA Marketplace plans in Ohio, that leaves 10 health insurance companies in Ohio, which are proposing an average premium increase of over 14%.
Rising health care costs combined with the loss of enhanced premium subsidies means Ohioans, employers and even insurance providers are dropping their coverage or plans. In response, more employers are dropping traditional health plans with rising premiums and putting in place a model that allows them to reimburse employees for individual insurance premiums.
As people drop coverage, the insurance pool gets sicker
Roughly 161,000 Ohioans lost Obamacare coverage since February 2025, and about 62% of them dropped that coverage within three months after subsidies expired.
The majority tend to be relatively healthy compared to the people who keep their ACA Marketplace coverage, said Brian O'Rourke, health care policy analyst for Health Policy Institute of Ohio.
"We're seeing a destabilization of the marketplace," he said. "We've seen, in their proposed rate increases, insurers point to that as a problem. Knowing that the people who remain on the marketplace are probably going to have higher health needs, be more expensive to cover, and because of that, they need to raise the premiums even more."
Geoff Bartsh, senior vice president of markets for Oscar Health, said some providers that focus more on the ACA Marketplace are more flexible with helping their consumers afford the costs. Others aren't.
In some cases, insurance providers like CareSource pull out of certain markets altogether because they expect even higher costs, O'Rourke said. While Ohio has a large number of insurance carriers, people like Lewis may still be forced to find a new plan.
But doing so may not be easy.
In 2023, Lewis was diagnosed with a rare condition from a car crash over a decade ago. Ohio, like many states, has a two-year statute of limitations on injuries from a car crash. If she can't find insurance coverage for 2027, Lewis has to pay out of pocket for the specialist she sees at Ohio State University.
Three days a week, she wakes up at 5:30 a.m. to research insurance plans before she goes to work at 9. In Gallia County, there are four remaining ACA Marketplace providers. None will cover her provider, Lewis said. And she didn't pass the assessment a PPO insurer does to determine an applicant's risk because of her pre-existing condition.
"It's basically a part-time side hustle trying to get insured," she said. "I love my job and I want to work. I'm trying to work. I'm trying to do the right thing, be productive in society – and can't even buy insurance."
While Lewis's experience is not unique, employers and employees like her are adapting to higher premiums by adopting a relatively new and unknown individual reimbursement model.
Employers consider reimbursement plans to offset premium costs
Born from a 2017 executive order during the first Trump Administration, Individual Coverage Health Reimbursement Arrangements, or ICHRAs, allow employers to reimburse employees for individual health insurance premiums instead of providing a traditional group plan and paying those premiums. On Sept. 3, federal policymakers rebranded ICHRA to Custom Health Option and Individual Care Expense, or CHOICE Arrangements.
CHOICE Arrangements are a way for employers to provide pre-tax money to their employees, which they can then use to buy individual, ACA-compliant plans that best fit their needs, said Andrew Reeves, vice president of ICHRA strategy for Oscar Health.
Businesses can set a budget for employee health contributions
Employers design a budget depending on how many employees they have. Then, they set an equitable contribution amount based on 10 employee "classes," such as full-time, part-time, salaried and others. Contributions may also vary based on the employee's age and number of children.
Under the ACA, employers also have to meet an affordability threshold, which requires them to offer a contribution that makes premiums affordable for employees.
Employees can pick individual plans based on needs, affordability
Employees who use the benefit can then enroll in an individual plan and pay their premiums using the employer contribution. While the model was at first more popular with small employers, the most recent growth in ICHRA enrollment is largely from bigger businesses, Reeves said.
"What's really happened over time is, it has become more or as equally about choice and letting people find what they need for their families in a cost-effective way," Reeves said.
As of Jan. 1, there were an estimated 500,000 to 800,000 ICHRA members across the country, with an expected growth to over 1 million by January 2027, according to a report from Oscar Health and Remodel Health, an ICHRA administrator.
In Ohio, ICHRA enrollment grew by 159%, with more than 19% of that growth happening in Hamilton County. According to the HRA Council, a nonpartisan advocacy organization for employee health coverage, Ohio has the second highest number of total employees eligible for an ICHRA or a qualified small employer reimbursement plan in the country.
Kelly Brothers Roofing, which mostly serves Ohio, Indiana and Kentucky, adopted ICHRA in spring 2025 after its traditional group plan through Anthem increased its 2024 rate by more than 15%, said Joseph Harper, the company's president and chief financial officer.
While most of the employees who used the group health plan worked in the office rather than the field, the company's adoption of ICHRA resulted in a 12% increase in field workers being insured. And it decreased costs for Kelly Brothers Roofing by 18%.
"Kelly Brothers is going to pay for this, for God's sake. Please take advantage of it," Harper said. "Even if you want to take a higher deductible plan where most of the premium is paid by Kelly Brothers, for goodness sakes, take advantage of that, please."
Sarah Goodwin, the finance director at Vineyard Cincinnati, a church and nonprofit organization that adopted ICHRA in August 2025, likes the flexibility of the model, both as an employer and an employee − especially after the nonprofit's group health plan provider gave a renewal rate increase of 31%.
"The increase that they were proposing was just way outside anything that we could do," she said.
Goodwin estimates that she is paying roughly one-fifth of what she'd be paying on a Marketplace plan without ICHRA.
But the reimbursement model is far from perfect.
Like Lewis, Goodwin has a specialist who is not in network with the plan she chose through ICHRA, meaning she has to pay out of pocket or find a new provider. She hopes the ICHRA network will expand its list of providers.
CHOICE Arrangements can be an alternative for businesses struggling to pay for the rising premiums of traditional group plans, and they offer more individual flexibility, Reeves said.
"They're actually saying to the employee, 'Hey, here's money from me. I care about you. I care about your family, and now go get the thing that you want and need in the market that you're in.'"
This article originally appeared on Cincinnati Enquirer: Health care costs are rising. Here's how employers are adapting.
