Maria Polyakova (
Lynn Mei Hua is a research associate in the Department of Health Research and Policy at the Stanford University School of Medicine.
Health Aff (Millwood). 2017 Dec;36(12):2078-2084. doi: 10.1377/hlthaff.2017.0660.
The Affordable Care Act (ACA) has increased the number of Americans with health insurance. Yet many policy makers and consumers have questioned the value of Marketplace plan coverage because of the generally high levels of cost sharing. We simulated out-of-pocket spending for bronze, silver, or gold Marketplace plans (those having actuarial values of 60 percent, 70 percent, and 80 percent, respectively). We found that for the vast majority of consumers, the proportion of covered spending paid by the plans is likely to be far less than their actuarial values, the metric commonly used to convey plan generosity. Indeed, only when annual health care spending exceeds $16,500 for bronze plans, $19,500 for silver plans, and $21,500 for gold plans do plans in these metal tiers cover the proportion of costs matching their actuarial values. While Marketplace plans substantially reduce consumers' exposure to financial risk relative to being uninsured, the use of actuarial values to communicate plan generosity is likely to be misleading to consumers.
平价医疗法案（ACA）增加了拥有医疗保险的美国人的数量。然而，由于成本分担普遍较高，许多政策制定者和消费者对市场计划覆盖范围的价值提出了质疑。我们模拟了青铜、银或金市场计划（分别具有 60%、70%和 80%的精算值）的自付支出。我们发现，对于绝大多数消费者来说，计划支付的覆盖支出比例可能远低于他们的精算值，这是通常用来表示计划慷慨程度的指标。事实上，只有在青铜计划的年度医疗保健支出超过 16500 美元、银计划的年度医疗保健支出超过 19500 美元、金计划的年度医疗保健支出超过 21500 美元时，这些金属层级的计划才会覆盖与其精算值相匹配的成本比例。虽然市场计划大大降低了消费者相对于无保险状态下的财务风险敞口，但使用精算值来传达计划的慷慨程度可能会对消费者产生误导。
