CMS changes to marketplace plans may affect primary care

Healthcare costs are rising but wages are not. On the Affordable Care Act (ACA) marketplace, cost-sharing reduction payments are being eliminated. The Centers for Medicare & Medicaid Services (CMS) has announced changes in marketplace plans that affect the way patients choose to access their healthcare services. All of these add up to choices for patients that may impact their ability or desire to visit their primary care physician.

Financial considerations are significant in the choice of plans under the ACA for many patients. Low-income patients, in particular, must balance the monthly cost of their healthcare plan with their expected expenditures for preventive and catastrophic care. All patients must choose between the bronze, silver, and gold plans on the marketplace.

Although the bronze option is less expensive on a monthly basis, it does typically carry the highest deductible for the year. In fact, as explained in an article published by the Robert Wood Johnson Foundation (RWJF), “Marketplace plans as a rule have high deductibles; the medians for bronze, silver, and gold plans in 2018 are $6,400, $3,800, and $1,250, respectively.”

The RWJF article points out, though, that “Due to the quirks introduced by the elimination of cost-sharing reduction payments (CSRs), subsidy-eligible customers often found they could get better deals by choosing bronze or gold. The share of marketplace enrollees in bronze plans, in particular, increased from 23 percent to 29 percent. Among those new to the marketplace, the trend toward bronze was even greater—34 percent of new enrollees on healthcare.gov chose bronze plans.”

So while patients may choose the bronze option because it costs less each month to keep their healthcare coverage, they may be hesitant to visit their primary care physician because the visit itself will be costly for them as the plan does not offer primary care coverage. The RWJF article explains that, “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.” As patients look for ways to save on their healthcare expenses, these financial barriers may keep them from being able to access primary care services.