Bronze plans are terrible. Bronze plans are often the best choice.

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In discussion of the ACA marketplace (and health insurance generally), deductibles are often used as a stand-in for out-of-pocket costs. Now here cometh David Anderson to remind us that a plan's maximum out-of-pocket cost (MOOP) can be just as important -- and that the MOOP often does not particularly correspond to metal level.

The highest allowable MOOP at all metal levels is $8,150 (a travesty by international rich country standards).  Here is David's mapping of the range of MOOP for gold plans in HealthCare.gov states.  Dark green is $2,500 MOOP; dark red is $8,150.

As David points out, bronze plans will be a better deal for anyone who knows they'll hit the out-of-pocket max. As he's pointed out elsewhere (and in passing here), it takes a lot more spending to hit the high max in a gold plan -- say, $30,000 -- than in a bronze plan. That's because once you meet your deductible (likely to be relatively low in a gold plan with high MOOP), a high percentage of ensuing costs will be covered in a gold plan until the MOOP is reached, at which point coverage goes to 100% for ensuing costs (if you stay in network).

Premium vs. deductible: New tools oversimplify

Buying health insurance is hard, we're told. Forced to weigh premium against deductible and other out-of-pocket costs, people will make the wrong choice more often than not.  Decision support tools like total cost estimators can reduce that likelihood.

Maybe, maybe not. It seems to me that a cost estimator has to be pretty sophisticated not to oversimplify the decision.

The new Plan Match tool rolled out this month by DC Health Link, the District's ACA marketplace, is in one way at least more informative than healthcare.gov's Total Cost Estimator. The DC tool, furnished by Consumer Checkbook, provides not only a Yearly Cost Estimate that factors in the user's rating of his health, but also an estimate of "Cost in a Bad Year." The latter total is simply the plan's yearly out-of-pocket maximum plus the annual premium.

I'm not sure that that information doesn't give the wrong impression by leaving out a vast middle.

The tool might actually be more useful in any market other than DC -- which, uniquely, extends Medicaid eligibility to adults with incomes up to 210% of the Federal Poverty Level (FPL).  By so doing, DC eliminates the strong Cost Sharing Reduction (CSR) subsidies that are available in most states* to private plan buyers with incomes up to 200% FPL -- but only to buyers of silver plans. For those up to that income threshold, silver plans' out-of-pocket maximum is capped at $2,250  -- compared  to a $6,850 allowable OOP max for bronze plans. In most ACA markets, the "Cost in a Bad Year" would reflect that yawning gap for buyers under 200% FPL.

Weaker CSR is available, in DC and everywhere else, to buyers with incomes in the 200-250% FPL range. At that income level, the out-of-pocket maximum for silver plans is $5,450. That smaller contrast does come into play in the Cost in a Bad Year estimates.

Who'll stop the hospital billing machine when you're "covered"?

My family gets its health insurance through my wife's employer, a multi-hospital system. Until this year, we have had in-network coverage only. Last fall, somewhat to my surprise, the hospital-insurer agreed to cover in full an operation out-of-network on grounds that no one in-network was qualified to do it. This was a wake-up call for me, and I insisted that this year we pay more for a plan that provides limited out-of-network coverage.While out-of-network coverage has substantial deductibles and limited co-pays, out-of-pocket expenses are capped at about $11,000 per individual. That strikes me as worthwhile catastrophic insurance if one of us gets seriously ill and needs to tap a top specialist outside the network. But our experience with the covered out-of-network operation we already had raises a question in mind about that out-of-pocket maximum -- for myself and for insured patients in general, particularly those buying on the new healthcare exchanges.

Here's the rub: while our insurer informed us that the operation would be covered in full, they were slow to pay some bills and paid some only in part. We then became targets of "balance billing" -- practices affiliated with the hospital where the operation occurred as well as the hospital itself dunning us for unpaid balances, often under threat of siccing a collections agency on us.