How prevalent is underinsurance among ACA beneficiaries?

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Big rain, small umbrella

In a New York Times op-ed Aaron Carroll, a physician and highly reliable assessor of data (his Bad Food Bible sifts expertly through a lot of bullshit in dietary research) makes two incontrovertible points about U.S. healthcare:

1. Americans are burdened with uniquely high out-of-pocket costs that induce us to forego need as well as unneeded care.

2. The ACA partly replicated this gaping flaw in our healthcare system, inflicting ridiculously high deductibles and out-of-pocket maximums on a significant number of marketplace enrollees.

But the argument includes what I regard as a slight (and common) distortion of emphasis in his overview of marketplace enrollees' high out-of-pocket costs: 

The average deductible on a silver-level plan on the A.C.A. exchanges rose to $4,500 in 2021. If people tried to buy plans with a lower premium, at a bronze level, the average deductible rose to more than $6,000. Granted, some cost-sharing reductions are available for those who make less than 250 percent of the federal poverty line, but even after accounting for those, the average deductible was more than $3,100 for silver plans.

On HealthCare.gov, CSR takeup rose steadily from 2015 through 2017

One aspect of ACA marketplace enrollment that's intrigued me ever since HHS started producing enrollment statistics is "CSR takeup" -- the percentage of enrollees who are eligible for Cost Sharing Reduction (CSR) subsidies who access the benefit by selecting silver plans, the only level at which CSR is available.

Silver can be expensive for low income enrollees -- a benchmark silver plan costs an enrollee with an income at 200% of the Federal Poverty Level about $125 per month. At the same time, up to 200% FPL, CSR dramatically reduces out-of-pocket costs. (The benefit is much weaker for those in the 200-250% FPL range, and silver plan selection tapers off accordingly among enrollees over 200% FPL.)

One fact that's escaped me until now: CSR takeup rose steadily from 2015 through 2017, at least in the states using the federal exchange, HealthCare.gov (as 37 states did in 2015 and 39 in 2017). That's been somewhat obscured by the fact that the percentage of all enrollees with CSR has not risen. But enrollees' income mix on the federal platform has shifted upward as states on the platform enacted late Medicaid expansion, and as two states that expanded Medicaid early, Hawaii and Kentucky, came on board the federal platform. In 2015, 78% of enrollees were known to have incomes under 251% FPL. In 2017, 74% were below that threshold.

CSR windfall: Will it have bronze or gold cast?

Those of us who have been anticipating the paradoxical effects for subsidized ACA marketplace shoppers of Trump's cutoff of CSR reimbursement have to split our gaze more between shiny objects.

Designed as an add-on benefit, CSR (Cost Sharing Reduction) radically reduces out-of-pocket costs for silver plan enrollees with incomes under 200% of the Federal Poverty Level (and much more modestly for enrollees in the 200-250% FPL range). Until this month, the federal government reimbursed insurers for the extra benefit. In 2018, insurers will price it in.

What excited folks like David Anderson, Charles Gaba and I* (though we're also appalled by the premium hikes for the unsubsidized) was the prospect that in many states and regions, gold plans would be cheaper than silver. That's because 38 states (according to Charles Gaba's tracking) instructed insurers to load the cost of CSR onto silver plans only, since CSR is only available in silver plans.

This has, um, panned out -- as we now know, since prices have been posted for almost all states. The cheapest gold plan is cheaper than the cheapest silver plan in Pennsylvania, Kansas, New Mexico, Wyoming, most of Texas and Wisconsin, much of Michigan and Florida (including Miami, which has the heaviest concentration of marketplace enrollees in the country), much of California, and parts of several other states. In other regions, the price of gold plans is closer to the price of silver plans than it used to be.

See plans and prices -- and get buttonholed for Cost Sharing Reduction -- on HealthCare.gov

Healthcare.gov has launched its "shop-around" feature for 2017 -- that is, the screen where you can enter a few basic facts about yourself and then preview plans and prices, with your subsidy built into the price estimate.

As in past years, the shoparound has been redesigned. The new design has plusses and minuses in my view. As always, my primary focus is on how well the app communicates about Cost Sharing Reduction (CSR) subsidies, which are available only with silver plans, and only to people with a household income up to 250% of the Federal Poverty Level (FPL).

CSR radically lowers deductibles and copays for buyers with incomes up to 200% FPL and offers a more marginal benefit to those in the 200-250% FPL range. Because the benefit comes only with silver plans, the silver level provides the best value in absolute terms to CSR eligibles.

Because it makes silver plans more valuable than gold plans for anyone with an income up to 200% FPL, CSR is inherently counterintuitive. And because silver plans cost more than bronze, they are easy to miss when plans are ranked by premium, lowest first.

Some state-run ACA marketplaces "default to silver" for CSR-eligible shoppers -- that is, they automatically show silver plans first in the display of available plans. HealthCare.gov appears to have thought long and hard about doing this. Current CEO Kevin Counihan ran Connecticut's ACA marketplace, which has "defaulted to silver" since its launch in 2014. Connecticut has had an unusually high CSR takeup rate.

What Hc.gov decided for 2017 was a kind of optional default to silver. If you're CSR-eligible, the screen below appears before you move on to view available plans (apologies for the cut off phrase at top: it should read "only if you pick a silver plan"):

Since this screen is meant to highlight the benefits of CSR, there's a disconnect in fronting the "estimated total yearly costs." That estimate derives from a prior screen, in which you forecast whether you'll need a low, medium or high level of medical care. The estimate above is for a "low" user.

There may be an appropriate place for that information, but this is not it. What's not highlighted is the radical difference in bronze vs. silver deductibles and copays -- a disproportionate difference, thanks to the CSR subsidy added to silver alone. The light-text explanation at bottom appears to fly in the face of the cost estimate -- which of course presumes that the buyer will be a light user as expected. Risk is left out of the equation implied by the bolded text, as is the extra value added by CSR.

A second flaw is in the contrast of the average premium at each metal level. That average can be skewed by some very expensive options. Most marketplace enrollees consider only the cheapest plans available at each metal level.  In this zip (07079) and income level $23k), the cheapest-plan contrast for a 40 year-old would be between a bronze plan at $69 per month with a $3,000 deductible and a silver plan at $104 with a $300 deductible. That would make a more compelling and coherent contrast:

The good news is, I got that comparison from the shop-around's excellent "compare plans" feature. But I had to first pick through the bronze selections to find the first silver (which, to make matters more confusing, was cheaper than several bronze plans in this zip code). The contrast of CSR-enhanced silver with bronze should be clearer in the intro screen.

A third flaw is that if you go back and edit your information, for example to change the income estimate, you don't get the CSR filter screen the second time around.  You just get plans ranked by premium, and the only alternative filter available at first blush is to rank them by deductible, which can yield off-putting results if there are gold plans at premiums that quintuple lower-cost bronze or silver.

There is in fact an additional "refine results" filter that enables screening for a host of options, but it's in a different color and took me several passes to notice it (I can be a very thick user, but I'm sure I'm not alone in that).

As in previous years, once you've input your basic information and before the screen discussed above appears there's an overview screen that also provides an explanation of CSR. But it's  in light type at the bottom of the page, very subordinate to the centerpiece focused on the tax credit:

The broader shoparound tradeoff is between keeping it short and simple, so that users get a quick view of what they're likely to pay, or slowing the process by adding more information, such as plans that cover the shopper's drugs and have her doctors and hospitals in-network.  This year's shoparound takes  a bit longer to get through  than last year's, which was slower than 2015's. Added this year is a filter to indicate whether one is eligible for subsidies at all, e.g., whether the user has an offer of affordable insurance from an employer, which renders him subsidy-ineligible.

In my view that is a worthy feature, as are the drug and doctor filters, and, if properly contextualized, the total cost estimator, which varies according to whether the user anticipates low, medium or high use of medical services. But I wonder whether a two-tier process mightn't be appropriate. In 2015, you could view plans and prices, with your subsidy priced in, within 30 seconds of visiting the home page.Perhaps the shoparound should start with the most basic info -- zip code, household members with their ages, and family income -- give the price quotes, and then prompt for the additional info in a second stage.  In particular, I'm wary of total cost estimators, which tend to push the cost of unexpected accident or illness out of view. I think the results should be carefully hedged, perhaps with views of what you'll pay under alternative scenarios.

Still, the current shoparound gets you results reasonably fast, and I can't say it ignores CSR, the workings of which are notoriously difficult to communicate. We'll see how it works out for users.

See also:
The ACA's uncertain shield against underinsurance: A CSR compendium

He who buys bronze absconds

In the spring of 2014 my son, knowing he'd enter a graduate program that September, switched his health insurance from COBRA to a bronze marketplace plan. Healthy, he gambled the premium difference between bronze and silver (or bronze and COBRA) against the deductible difference, essentially settling for catastrophic protection for a limited period.

Yesterday I noted that attrition in the ACA marketplace, which is sharpest in the months immediately following open enrollment since 10 percent or more of those who select plans never pay the first premium, is highest among those who enroll in bronze plans.   As of March 31 of this year, while bronze enrollment dropped 15.5%, from 2,873,422 to 2,427,337, silver dropped just 9.3%, from 8,520,787 to 7,721,983. A similar discrepancy was recorded in the spring of 2015.

It turns out that the same pattern held throughout the year in 2015. By December 31, total enrollment was down from 11,688,074 as of  Feb. 22, 2015 (not all of it "effectuated," or paid for in the first month) to 8,780,545, a 24.8% drop. Among bronze plan holders, the drop was 30.5%, versus 23.2% for silver, 18.8% for gold and 18.6% for platinum. Those with gold, hold -- relatively speaking.  And he who buys bronze... absconds.

As bronze plans typically carry deductibles over $6,000, many enrollees may decide that they're not worth the money. But I think it's also likely that those who know they have a short-term need for insurance, like my son, may lean toward bronze, basically holding their breath until employer insurance, or school-based insurance, or a spouse's insurance kicks in.

Proposed in Minnesota, an industrial-strength public option

Minnesota progressives and elected officials in the state's Democratic Farmer-Labor party (DFL) are yearning to get back to the future with MinnesotaCare, the state's excellent public insurance program for residents of low-to-moderate income who earn too much to qualify for Medicaid.

Prior to ACA implementation, MinnesotaCare was available to Minnesotans with incomes up to 275% of the Federal Poverty Level. In 2015, the plan was converted under the ACA into a Basic Health Plan, which qualified it for federal funding but cut off eligibility at 200% FPL. Former enrollees above that income level were sent to the ACA marketplace, where both premiums  and out-of-pocket costs are considerably higher.

A task force appointed by the governor recommended in mid-January that the state seek an ACA innovation waiver to restore MinnesotaCare eligibility to 275% FPL, with funding equivalent to the cost of federal marketplace subsidies for enrollees up to that income threshold. I wrote about that plan and its implications on healthinsurance.org in January. Its impact on the private plan marketplace and larger individual market would be fairly modest -- just 37,000 enrollees in the 200-275% FPL range are forecast -- but it would provide high actuarial value coverage to the majority of those who would otherwise be eligible for subsidies in the ACA marketplace if MinnesotaCare did not exist.

Last month, a more radical proposal was introduced in legislation in the Minnesota State Senate. I have a piece up about this proposal today on healthinsurance.org. It would offer MinnesotaCare at only modestly reduced actuarial value (if reduced at all) to anyone who wanted to buy in. While costs have not yet been closely calculated, the hope is that the premium would be in silver plan range:

A month of "yes buts"

For some reason, in the past month or so I've found myself pushing back against, or at least qualifying, assertions about the ACA by people with deep expertise in healthcare, or economics, or healthcare economics. They all know a good deal more than I do, but touched on areas that I've been preoccupied with.

These posts aim to put a corrective lens on...not myths, but partial truths that in some cases leave a misleading impression. Specifically:

It's fair, O Robert Pear, to spotlight high deductibles in ACA plans. But some context is missing.

An article by the New York Times' Robert Pear, spotlighting the plight of ACA marketplace customers who bought plans with sky-high deductibles, had my eyeballs shooting lasers in two directions.

On the one hand, kudos to Pear, not only for showing the absurdity of offering plans with deductibles north of $6,000 per person to people who are not affluent, but for spanking HHS for emphasizing low premiums uber alles:

Sylvia Mathews Burwell, the secretary of health and human services, issued a report analyzing premiums in the 38 states that use HealthCare.gov. “Eight out of 10 returning consumers will be able to buy a plan with premiums less than $100 a month after tax credits,” she said.

I have complained about that misdirection repeatedly, most recently noting that only about 5 in 10 will be able to buy a silver plan for under $100 and thus access the Cost Sharing Reduction (CSR) subsidies that are available only with silver. So Burwell is effectively hawking bronze plans to those who, as Pear illustrates, won't be able to use them.

On the other hand, Pear exaggerates the prevalence of super-high deductibles among marketplace enrollees. His acknowledgment of CSR is buried deep and lacks context:

Affordable underinsurance? That's where healthcare.gov's new total cost estimator may steer you

Buying health insurance is hard, experts tell us. Even highly educated customers have trouble weighing monthly premium vs. deductibles and copays - especially since many Americans don't know offhand what terms like "deductible" and "coinsurance" mean.  To help, many have called for a "total cost estimator" that will ask users about their current medical usage and then estimate what their total yearly costs are likely to be under each plan.

This year, healthcare.gov has delivered. The "Preview Plans and Prices" feature, which asks a handful of questions about age, income and household size before delivering price quotes, now includes a total yearly cost calculator. It's optional, easy to use, and only adds one question before showing plans and prices (two, if you count the question whether you want to use it).

I don't like it. At least, I don't like its prominent placement; I think it should be a Step 2 offering, after you see plans and prices. I fear it will make some people focus on the wrong number, and the wrong question.  It leaves out a core factor in the insurance equation: risk.

Take the case of a single 40 year-old man earning $17,000 a year in Las Vegas (gender and age affect the estimated medical cost calculus). Here's the cheapest bronze offering -- the first result the user (let's call him Vince) will see:

A quibble with Avalere over CSR takeup

9/3/15: See update at bottom for Avalere's response to questions posed here 

I may have to "never mind" this post if I'm missing something basic, but...it seems to me that Avalere Health lowballed Cost Sharing Reduction (CSR) takeup a little in an analysis released today.

Avalere's calculation is simple: 5.9 million buyers of private plans on ACA exchanges bought plans with Cost Sharing Reduction subsidies, available only to buyers with incomes under 250% of the Federal Poverty Level (FPL), and only if they selected silver plans.  8.1 million buyers were eligible for CSR, according to Avalere; hence about 2.2 million left the benefit on the table; most of them probably brought bronze plans with sky-high deductibles. The CSR takeup rate comes to just 72.8%,

Avalere says that it derived these numbers from HHS's March enrollment report,which broke out enrollees by income level in the 37 states using healthcare.gov, and a CMS update released in June, which adjusted for attrition (mostly no-pays) as of March 31.

We know where the 5.9 million figure for those who accessed CSR came from: the June update, which reported 5,850,936 enrollees with CSR. But what about the denominator, the 8.1 million? That's trickier. We know there were 10,187,197 enrollees as of March 31. But how many were CSR-eligible?

Some sidelights on Covered California's modest rate increases for 2016

Covered California, the state's ACA health insurance exchange, is boasting today with some justice that the state held 2016 rates down to an average weighted increase of 4%. Other talking points: the average (unweighted) increase of the cheapest silver plan in each region went up just 1.5%, and the average consumer can save 4.5% if she switches to the cheapest plan in the same metal tier.

That last point is somewhat...selective: the apples-to-apples question is what will happen to current holders of the cheapest plan in each metal tier if they switch to 2016's cheapest plan.  On the other hand...there are two other hands.

First, the talking point about switching to the cheapest plan in one's metal level has some extra validity in California, where benefits for all plans in each metal tier are standardized. In other words, the only substantial variable other than price is network quality. Hence, price shopping -- balancing premium versus benefits -- is likely to be less fraught and easier to get right in California than in most states.

Second, it's good news that the cheapest silver plan in each region went up an average of just 1.5%-- but the import of that factoid depends in part on a second data point. That would be the average increase for the second cheapest silver plan in each region, which is the benchmark according to which premium subsidies are set. That is, a buyer's premium is calculated to leave him paying a fixed percentage of his income for the second cheapest silver plan available to him. If the benchmark silver plan goes up more than the cheapest silver plan, that's good for the buyer: it increases the affordability of silver-level coverage.  Covered California's full rate report shows that the benchmark plans went up an average of 1.8%, very modestly (on average) increasing the spread and so the affordability of the cheapest silver plan. It also shows that the cheapest bronze plan went up an average of 3.3% -- making the cheapest silver relatively (albeit slightly) more attractive.

Alabama's Obamacare buyers ride a Silverado

Spotlight here is on Alabama in my continuing close look at how many low income ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies by buying silver plans. (Yesterday, HHS released detailed county-level data about buyers of private plans on healthcare.gov, the federal exchange, enabling a close look at state stats.)

CSR is available to buyers with household incomes below 251% of the Federal Poverty Level (FPL), and strongest for buyers under 201% FPL. It is available only with silver plans, the second-cheapest of four metal levels available on ACA exchanges -- a fact that's less than obvious to the average shopper, Buyers under 201% FPL are leaving a really strong benefit on the table if they don't buy silver plans (see the note at bottom for more detail). I consider the percentage of buyers under 201% FPL who select silver an important measure of how well the exchange is functioning in a given state. (Those in the 201-250% FPL range are likelier to have good cause to forego the relatively negligible CSR provided at that level.)

Connecticut continues to crush it on Cost Sharing Reduction

Connecticut's ACA exchange, Access Health Connecticut, has provided me with a breakout of private plan buyers' metal level selection sorted by income level. The data makes clear that Connecticut continues to lead the way among ACA exchanges in helping low income buyers make choices that will provide them with the strongest financial protection.

There's two things to keep in mind about metal level selection. The first is that bronze plans, the cheapest level with the lowest premiums, usually have deductibles in the $5,000-6,600 range for an individual.  The second is that the Cost Sharing Reduction (CSR) subsidies available to low income buyers are available only with silver plans. CSR reduces deductibles, co-pays and maximum out-of-pocket costs radically for buyers with family incomes below 200% of the Federal Poverty Level (FPL) and much more weakly for buyers in the 200-250% FPL range. Bronze plans are almost always a terrible choice for buyers under 200% FPL -- those buyers are leaving a large extra subsidy on the table and rendering most healthcare unaffordable for themselves.

ACA exchanges vary widely in how effectively they get that information across. The key measure is the percentage of buyers with incomes under 200% FPL who choose silver plans.

In Connecticut, 89% of 2015 private plan buyers with incomes under 200% FPL chose silver.  I had preliminary numbers indicating as much back in December, and the ratio held steady through the end of open season and to June 1. Slightly more than a third of all enrollees, 34,601, have incomes under 200% FPL, and 30,641 of them bought silver and accessed CSR.* Just 6% bought bronze plans. That is a real triumph. 4% bought gold.

New data on Cost Sharing Reduction in ACA marketplaces

The latest ACA enrollment snapshot from CMS shed some new light on the extent to which ACA private plan buyers accessed Cost Sharing Reduction (CSR) subsidies. CSR reduces deductibles, copayments and maximum out-of-pocket costs for plan buyers with incomes under 250% of the Federal Poverty Level (FPL) -- but only if they buy silver plans (and forego the often much cheaper bronze plans).

CSR takeup is especially important for buyers under 200% FPL, because below that income level it raises the actuarial value of a silver plan from 70% to 94% (for buyers under 150% FPL) or 87% (for buyers in the 150-200% FPL range). At 200-250% FPL, CSR weakens, raising the AV just 3 points to 73%. Silver plan selection accordingly drops suddenly at 201% FPL.

The new report doesn't deliver any great surprises on the CSR front, but it does for the first time provide overall CSR numbers for the 13 states plus D.C. that run their own exchanges. The percentages of buyers accessing CSR in state-based marketplaces (SBMs) have always been lower than in the states using healthcare.gov, for several reasons

1. All the SBMs except Idaho have expanded Medicaid, which means that subsidized private plan eligibility begins at 138% FPL rather than 100% FPL.  The lower the income, the higher the CSR takeup rate - especially below 138% FPL, where the benchmark silver plan premium can't exceed 2% of income.
2. States with SBMs are generally wealthier, so a lower overall percentage of private plan enrollees are eligible for CSR.
3. Several SBMs do a much poorer job than healthcare.gov of highlighting CSR for those eligible -- though conversely, several SBMs do a better job than hc.gov on this front.

All that said, here are some new facts, along with some extrapolation from info that was in HHS's March report but not updated in this one.

1) In states using healthcare.gov (federal facilitated marketplaces, or FFMs) 60% of enrollees accessed  CSR -- 4,550,205* out of a total enrollment of  7,524,234.  In the SBMs, 49% accessed CSR -- 1,300,731 out of 2,662,964.

Affordable health insurance vs. affordable health care

One of the flaws of the Affordable Care Act is that it partially (not entirely!) confuses affordable insurance with affordable health care.

On the plus side, for insurance purchase purposes, the ACA benchmarks affordability to silver-level plans and calibrates the out-of-pocket costs these plans impose on buyers to income, via Cost Sharing Reduction (CSR) subsidies, which raise the plans' actuarial value to 94% for buyers with incomes under 150% of the Federal Poverty Level and to 87% for buyers under 200% FPL.

On the minus side, CSR fades to near-insignificance at 201% FPL; silver plan premiums slope toward unaffordability for a lot of buyers somewhere over 150% FPL; and the ACA dangles cheaper bronze plans with deductibles north of $5,000 in front of low-income buyers, for many of whom many of those plans will do very little good.

Also on the downside, for the purposes of determining whether a person or family has access to "affordable" insurance (and so whether they are subject to the mandate to purchase it), the ACA benchmarks affordability to the cheapest available bronze plan -- which, again, is likely to have a per-person deductible and out-of-pocket maximum in the $5000-6,600 range. Some bronze plans offer some services, such as low-copay doctor visits or generic drugs, before the deductible is reached, but many (my spot-checks make me suspect most) do not. They do offer mandated free preventive services, but those are a patchwork.

Hey, HHS, you're boasting about the wrong metric

If you read the inimitable Elisabeth Rosenthal's account of unhappy ACA plan holders this weekend, you know that high deductibles and out-of-pocket costs are one serious weakness of the coverage offered to many buyers on ACA exchanges.*

One mitigating factor is that most buyers with incomes under 200% of the Federal Poverty Level get Cost Sharing Reduction (CSR) subsidies that strongly reduce deductibles and maximum out-of-pocket costs, to levels superior to those offered by most employer-sponsored plans.  CSR is only available with silver plans, but as I've labored to deduce, best evidence suggests that over 80%** of buyers with incomes under 200% FPL do buy silver, resisting the temptation of lower-premium bronze plans that would leave them on the hook for huge out-of-pocket (OOP) costs.

Given this partial success, I find it baffling that all of HHS' reports of enrollment data are written as if nothing matters but premium -- the lower the better. The report released today boasts:

Maryland's low income ACA customers benefit from Connecticut's site design

Maryland's ACA exchange was a disaster last year, so the state started over, creating a freely offered clone of the highly successful Connecticut exchange. That's worked out very well.

Charles Gaba reports that Maryland is one of 18 states that have exceeded HHS's goal for private plan enrollments in 2015.  As of January 11, Maryland has enrolled 91,137 residents in private plans, versus 67,757 in the first open season that ended last April.

Equally importantly. the Maryland exchange has strongly boosted the percentage of plan buyers who selected silver-level plans and reduced the percentage that bought bronze -- the lowest level, with deductibles averaging over $5,000 for a single enrollee. In 2014, just 49% of Maryland private plan customers bought  silver, and 31% bought bronze. That's in contrast to 65% silver/20% bronze breakdown in the nation as a whole,and 69%/17% in the 36 states using healthcare.gov.  This year so far, Maryland's silver plan takeup has risen to 61%, while bronze takeup has dropped to 23%.* 

In Rhode Island, low-income ACA buyers chose silver

From Rhode Island comes fresh evidence that a very high percentage of lower-income private plan buyers nationwide who bought silver plans, and thus accessed the Cost Sharing Reduction (CSR) subsidies that reduce deductibles and out-of-pocket expenses (CSR is available only with silver plans).

I have been tracking, in states that publish or provide me with the info, the percentage of buyers with household incomes under 200% FPL who bought silver plans, because at under 200% FPL, CSR is really strong. Without CSR, a silver plan is mandated to cover 70% of the average plan holder's yearly medical expenses - that is, its actuarial value is 70%. For buyers with incomes under 150% of the Federal Poverty Level (FPL), CSR raises the AV to 94%. For those with incomes between 150-200% FPL, the AV goes to 87%. For those between 200-250% FPL, it's 73%.

The ACA's invisible deductible discounts

The healthcare Twittersphere was riveted yesterday by Robert Pear's spotlight on Harvard professors up in arms about comparatively modest deductibles and copays added to their excellent health plan.

The main underlying story, as Adrianna McIntyre pointed out, is that cost-shifting to employees is accelerating in employer-sponsored insurance, driven in part by the ACA's Cadillac tax on the most generous plans.

There's a second story, however, in Pear's use of the ACA exchanges as a foil to highlight Harvard employees' relative privilege. Pear contrasted the Harvard plan's 91% actuarial value with that of a silver ACA plan, which he said "typically" covers just 70% of the average user's medical costs. As I pointed out yesterday, only about 20% of silver plan buyers get plans with an AV of 70%. For the rest, income-based Cost Sharing Reduction (CSR) raises the AV -- to 94%, 87% or 73%, depending on the buyer's household income. Available stats indicate that over 60% of silver plan buyers are at the AV 87% or 94% levels.

The broader point here is that the apparent prevalence of high deductibles on the ACA exchanges is somewhat misleading. As has been widely reported, bronze plans single-person deductibles average over $5,000, and silver plans (unenhanced by CSR) close to $3,000. Moreover,if you take a spin on the shop-arounds offered by Healthcare.gov and most state exchanges, the first price quotes you'll see are for bronze plans with deductibles in the $5,000-6,600 range, since available plans are most often displayed sorted by premium, lowest first.

Not quite the Harvard plan, but....

The NYT's Robert Pear reports that Harvard profs are up in arms because a small deductible and copays have been added to the university health plan, taking the actuarial value all the way down to... 91%.

Pear contrasts this to the 70% AV mandated for silver ACA plans, the "most popular" metal level. Which is fine, except...more than half of silver plan buyers qualify for Cost Sharing Reduction (CSR) at a level strong enough to take the AV up to 87% or 94%, depending on income level.

I have a post coming up on healthinsurance.org that teases out of enrollment stats published by New York State and HHS the likely percentages of ACA private plan buyers who access the higher levels of CSR, and the overall percentages of direct ACA beneficiaries who have obtained high-AV insurance.

The broader point: clunky or overly complex as the ACA's subsidy and means-tested benefit formulas may seem, they do work broadly to keep out-of-pocket costs relatively low for low-income beneficiaries.

Hope you'll tune in to the healthinsurance.org piece.

Update: The New York enrollment numbers also show that only 18% of silver plan buyers in the state had no CSR at all. I tend to discount the value of CSR to buyers with income between 200-250% FPL, for whom CSR boosts the silver plan AV to just 73%.  But it's really inaccurate to say that silver plans "typically" cover 70% of costs. That's probably true for less than a quarter of silver plan buyers.