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Defining health benefits

I don't want to spend a lot of time talking about actuarial values and you don't want to spend a lot of time talking about actuarial values, but they're pretty much at the center of the Senate health-care reform bill, so we both better get used to it.

The minimum benefit package (the "bronze plan") in the Senate proposal has an actuarial value of 60 percent. That means that it expects to cover 60 percent of a population's expected health-care costs. Silver is 70 percent, gold 80 percent, and I won't insult your intelligence by listing the value of a platinum plan, but suffice to say it follows the trend.

The fact that these plans have similar values, however, doesn't mean they work the same way. Consider this example from the excellent Congressional Research Service report (pdf) on valuing benefits:

Consider two actuarially equivalent plans. Plan A has a $400 deductible, after which 20% coinsurance is charged, with an out-of-pocket maximum of $5,000. Plan B has a deductible of $2,500, after which the plan pays 100% (out-of-pocket maximum of $2,500). Both have an actuarial value of 80%; that is, if a standardized population of adults enrolled in job-based coverage had this benefit package, both plans would be expected to pay 80% of the medical expenses incurred for that population.

Now consider the experience of two individuals -- one who has total medical expenses of $2,500 for a broken leg, compared to one who has $25,000 for outpatient cancer treatments. For the person with the broken leg, Plan A would pay a higher percentage than Plan B -- 67% rather than 0%. For the cancer patient, however, Plan A would pay a lower percentage than Plan B -- 80% rather than 90%.

Want a bit more confusion? People tend to prefer PPOs to HMOs. PPOs tend to be more expensive than HMOs. But HMOs tend to have a higher actuarial value. The average PPO is in the low 80s, while the average HMO is 93 percent.

The reason is that PPOs make up for their easy access to specialists by building in more copayments and cost-sharing. HMOs offer more first-dollar coverage, and though specialists are more irksome to access, there's less cost-sharing. But people prefer ease of access to coverage, so the HMO's actuarial advantage doesn't translate into a market preference. In other words, actuarial value isn't everything.

But it is a lot of things, particularly for poorer folks who can't afford much cost-sharing. In the Senate plan, the subsidies are tied to the silver plans, with the poorest folks paying about two percent of their income and people between 300 and 400 percent paying 9.8 percent of their income. There are also cost-sharing protections that kick in to ensure that people between 100 percent and 150 percent of the poverty line get 90 percent of costs covered, and people between 150 percent and 200 percent 80 percent of costs covered. People between 200 and 400 percent of poverty are also protected on the cost sharing front, but their formula is tied to HSAs, and it gets a bit more complicated.

By Ezra Klein  |  November 19, 2009; 11:15 AM ET
Categories:  Health Reform  
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Hey Ezra,

I'm an actuary, and I do want to talk about actuarial value. 60 percent is a god-awful number. Just look at Kenneth Sperling's testimony to the House Way & Means Committee on how awful this figure is ( In both the HELP and Finance Committees, Mike Enzi offered an amendment to set the minimum actuarial value at 60 percent, and both times Democrats beat back his amendment. So I am baffled as to why Harry Reid set the minimum actuarial value at 60 percent.

The other issue I see is whether the 3:1 community rating will make health insurance affordable enough for older adults.

And the smoker rating, which isn't allowed in the House bill or here in Massachusetts, will mean blood tests for every American -- including their children -- every single year. As if that's not going to spark a political backlash.

Posted by: BradGabel2002 | November 19, 2009 12:16 PM | Report abuse


i agree about the blood tests. once people get wind of that there will be hell to pay. And I don't see a substantial differential in cost (although you're the acutary not me) to warrant not only the intrusion of the test but also the added expense. If it was 2 to 1, 3 to 1 maybe but that's not the answer either.

PPO's vs HMO's deal with the idea of freedom of choice vs cost control. It gets back to Director Elmendorf's point that American's want the best healthcare in the world but don't want to pay for it. THey want a PPO style of choice but an HMO style of price. Sorry, it doesn't work that way. If you want to be able to afford it you're going to need cost control.

And again i LOVE the talk of out of pocket caps. You can't have out of pocket caps on PPO plans. Not unless you force providers to accept whatever an insurer pays on an out of network basis. Now, you can have IN NETWORK caps because of contracts but they don't explain it that way do they?

Posted by: visionbrkr | November 19, 2009 12:27 PM | Report abuse

These Congresscritters and wonks (and Ezra) don't get it. Pseudo-insurance that pays 60 percent (if you have a week or so to spend documenting and fighting bureaucrats for it) is insurance normal people can't use.

At that level, the individual mandate simply makes this "insurance" a tax.

Posted by: janinsanfran | November 19, 2009 3:45 PM | Report abuse

It's my understanding that the cost sharing cap applies to everybody, not just those less than 400%FPL. It's tied to the HSA amount for higher income people.

The emphasis on low AV plans troubles me a lot. Those on Medicaid, CHIP, and the Basic Health Plan are going to get much better quality care than most middle class people on the exchange.

Hopefully this will be an eye-opener to people that leads to a better system in the next iteration of reform.

Posted by: bmull | November 19, 2009 9:33 PM | Report abuse

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