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As Charles Gaba's chart shows, four states stand out in reduced cost-sharing in ACA markets, led by New Mexico, featured in the presentation below. https://t.co/IESuBgdVYd Two of those four have achieved this success through aligned premiums by enforcing the ACA's single risk pool guidelines, neighbors New Mexico and Texas. https://t.co/J7XKPoaHkq New York has implemented a "Basic Health Plan" for lower income enrollees and has a large proportion of residents in this program. Wyoming is effectively like Texas and New Mexico, but as a state without "effective rate review", enforcement originates from the federal government. This is perhaps interesting because the federal government is deliberately deferential to state review and the Biden administration removed federal regulatory language clarifying that "plan level adjustments should follow single risk pool guidelines & should not reflect the enrollees specific to the plan or metal level", seemingly licensing the continued misalignment of premiums in state-regulated marketplaces. https://t.co/O63OEL5EAN The other two states in the presentation are New Jersey and California. New Jersey is considering legislation to align premiums with the single risk pool guidelines (explained well in presentation but not overly explicit in the bill language) in similar fashion to Texas, which would lead to enrollee migration from silver to gold plans. California is not aligning premiums and is arguably doing the opposite by using state taxpayer dollars to boost the actuarial value of silver plans to gold level; this will result in a larger concentration of enrollees selecting silver plans, as silver plans will be priced lower than gold but offer equal benefits. At a high level, there are two different ways states can increase the proportion of ACA enrollees in "high value plans" (Mr. Gaba's "Gold or Better" is a reasonable break point). One is strictly enforcing federal law, and the other is leveraging state budgets to increase the actuarial value (as experienced by enrollees) of "low value plans". The presentation is interesting because it is framed as states' interests being aligned and perhaps it is with respect to the impact on ACA consumers, but the radically different approaches of achieving the same means warrant more attention (and questions) in my mind.