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The marginal rate is 19%.

Okay, but compare that to the rate for buying private insurance with similar coverages, and covering pre-existing conditions. For retiree coverage through my former employer, an HSA compliant plan is $1,100/month for me. I can buy a plan in my state (WA) through ACA with similar max out of pocket costs for $700 - $750/month with no subsidies. If I stay below $105k (or so), I start getting a subsidy, and if I drop down to around 400% of FPL, my premium drops to $75 - $92/month.

So to me, the marginal cost doesn't really matter - it's still significantly cheaper than my other option.

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