Health insurers need to change their silver-tier health plans to use more modest and predictable cost-sharing, instead of four-figure deductibles, according to patient advocates.
About 25 percent of Americans with individual health plans opted not to receive a range of healthcare services because they thought they couldn't afford it, according to an analysis by Families U.S.A.
High deductibles of $1,500 or more "seem to be the leading cause for the missed care," the report found after studying data from the Urban Institute's quarterly survey of 7,500 adults ages 18 to 64.
More than 50 percent of non-group health plan members, both on and off-exchange, have deductibles of at least $1,500 per person, and 30 percent have a deductible of at least $3,000 per person, according to the Families U.S.A. report.
Among the estimated 11.7 million 2015 ACA exchange population, 43 percent of adults have deductibles of at least $1,500, and a quarter have deductibles of at least $3,000--about 15 percent to 20 percent less than in the non-exchange individual market.
These kinds of high deductibles, Families U.S.A. argues, "are especially harmful for middle-income adults because they do not qualify for cost-sharing subsidies through the ACA."
Cost-sharing reduction subsidies are available only in silver plans, and to those earning up to 250 percent of the federal poverty level, roughly $59,600 for a family of four and $29,000 for an individual. Those earning up to 150 percent FPL can get out-of-pocket costs capped at 6 percent of expenses; it's set at 13 percent for those at 200 FPL and 27 percent of those at 250 FPL.
"More than 14 million previously uninsured Americans gained health coverage in the past two years," said Ron Pollack, executive director of Families USA. "But gaining health coverage too often still leaves needed health care unaffordable due to high deductibles and other out-of-pocket costs. This needs to be fixed."
The group is calling on insurers and regulators to offer more silver plans with standardized "no-deductible" or low-deductible plan designs, which are already available in a number of states. The idea is is to avoid huge out-of-pocket costs that might discourage people from getting a test or treatment, while charging the likes of $20 or even $200 in co-pays depending on the service and reserving four-figure cost sharing for acute hospital care.
Seven states served by the federal marketplace, including Arizona, Pennsylvania and Texas, include no-deductible silver plans, with standardized in-network co-pays of no more than $50 for primary care visits, $100 for specialist visits and $30 for generic drugs.
California, Connecticut, Oregon and Vermont, also have standardized silver plans that have modest cost-sharing in lieu of deductibles, for primary care and specialist visits, urgent care, behavioral health and outpatient rehab. Primary care copays range from $20 in Vermont to $45 in California, urgent care copays from $60 in Vermont to $90 in California and Oregon.
California and Connecticut also have silver plans with standardized cost-sharing and no deductibles for diagnostics, laboratory tests and advanced imaging. CT and MRI scans in the California plans will run the silver plan members $250; members in Connecticut will pay $75 per service and up to $400 per year. Oregon's standardized, no-deductible silver plan has no deductible for prescription drugs, instead charging $15 copays for generics and $50 for preferred branded drugs.
Families U.S.A is also calling on state and federal regulators to track member experiences with cost-sharing to inform plan designs and coverage requirements in the years to come, through the new Qualified Health Plan Enrollee Satisfaction Survey and the Qualified Health Plan Quality Rating System.
States and the federal government "should start gathering data on how consumers are faring in different plan designs in order a) to monitor whether plans with higher deductibles are preventing some consumers from obtaining necessary care, and b) provide feedback to insurers on how they should structure plans to better meet consumer needs," Families U.S.A. argues.