Primary care may be skipped under high-deductible ACA plans
Higher deductible bronze-level plans were more popular on the Affordable Care Act (ACA) exchanges in 2018, but customers may not be aware that moving towards this coverage will leave them paying out of pocket for primary care until they hit their deductible—leading some to avoid primary care altogether due to the costs.
As an analysis from the Robert Wood Johnson Foundation (RWJF) explained, the shift was driven by President Donald Trump’s move to eliminate cost-sharing reduction subsidies, or CSRs, for insurers on the ACA’s silver-level plans. Some insurers responded by shifting all of the premium increases needed to avoid financial losses from not receiving CSRs into their silver-level plans. This “silver loading” strategy made bronze-level plans—or even higher cost-sharing “gold” plans—more attractive to exchange customers.
While exchange shoppers eligible for ACA subsidies could be shielded from premium hikes to silver plans, there was a noticeable shift towards bronze plans: their share of the ACA marketplace jumped from 23 to 29 percent, while 34 percent of new enrollees selected bronze plans. Silver plans remained the most popular, but their share of exchange customers fell from 72 percent to 63 percent. The RWJF analysis said this could have “some unintended consequences for individuals and healthcare markets” thanks to the lower cost-sharing in bronze plans.
“Bronze plans not only have the biggest deductibles, but they are also the least likely to have cost-sharing for health services,” the report said.
The differences between bronze and silver level plans could have the biggest impact on utilization of primary care—62.1 percent of bronze plans require customers to reach their deductible before there’s any cost sharing for primary care and that can be a hefty sum, with the median bronze deductible in 2018 hitting $6,400. In contrast, only 23.2 percent of silver plans don’t offer cost-sharing on pre-deductible primary care.
Silver and gold plans more commonly offer a co-pay or co-insurance options for primary care services before the deductible, but only 24 percent of bronze plans offered the same level of cost-sharing. With the average price of a physician office visit exceeding $100, customers on bronze plans may decide to put off primary care to avoid out-of-pocket costs.
These issues would be most pronounced in states with higher shares of bronze plan enrollees on the ACA exchanges and with more plans which don’t cover primary care before the deductible is met. According to the RWJF report, Minnesota is the worst off in this scenario, with 56 percent of consumers enrolled in bronze plans and 67 percent of those plans offering no cost-sharing on primary care pre-deductible.
Restoration of CSR funding appears to be off the table for Congress and CMS declined to address “silver loading” in its final ACA market rule for 2019, leaving the conditions cited by the RWJF study in place for the next open enrollment period. Customers may have extra incentive to seek out bronze-level plans as ACA premiums are again expected to rise by double-digit percentages after the elimination of the individual mandate penalty and efforts to increase the availability of non-ACA-compliant insurance.
John joined TriMed in 2016, focusing on healthcare policy and regulation. After graduating from Columbia College Chicago, he worked at FM News Chicago and Rivet News Radio, and worked on the state government and politics beat for the Illinois Radio Network. Outside of work, you may find him adding to his never-ending graphic novel collection.