Using primary care as an example, we can see there are big differences by metal, particularly between bronze and silver. For example, 62 percent of bronze plans require that the deductible be met before any cost-sharing for primary care, while this is the case for less than 25 percent of silver and about 18 percent of gold plans. One clear takeaway is that the gap between bronze and silver is wide, and the choice of bronze can have big affordability implications for low-income consumers, since the average office-based primary care visit costs more than $100.
There is also spatial variation in cost-sharing characteristics, reflecting insurer differences and the geography of market participation. Due to both supply and demand factors, the impact of this shift to bronze is likely to vary by market. Consequences for individuals and providers could include underutilization of care or an increase in bad debt. Another outcome could be higher use of retail clinics, where visit prices are lower, or greater use of cheaper cash market options, if the prospect of meeting the deductible seems unrealistic. Consumer dissatisfaction and lapsed enrollment is another possibility if plan characteristics are not well understood, although the very low premiums should be helpful in that regard.
Barring any surprise announcements from CMS, silver loading is likely to continue next year and will probably expand to more states. While silver loading has increased affordability for many subsidized consumers, and the low bronze premiums are attractive, the benefit design may prove challenging. Consumers, providers, plans, and regulators will be assessing their respective experiences, with the potential for further adjustments in plan design and/or metal choice going forward.