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Vital Directions from the National Academy of Medicine
October 25, 2016

Improving Benefit Design to Promote Effective, Efficient, and Affordable Care

Author Affiliations
  • 1Harvard University, Boston, Massachusetts
  • 2University of Michigan, Ann Arbor
JAMA. 2016;316(16):1651-1652. doi:10.1001/jama.2016.13637

Increasing patient cost sharing is a common strategy implemented by private and public payers to alleviate the pressure on premiums, wages, and taxpayers due to escalating health care spending. The benchmark plan on the Affordable Care Act (ACA) exchanges has an actuarial value (the share of medical spending paid by the insurer) of only 70% compared with the typical employer-sponsored plan whose actuarial value is about 80%. Although ACA cost-sharing reductions can increase the generosity of coverage for beneficiaries with lower incomes (ie, reduce the cost paid by the patient), many enrollees in the exchanges may still have a significant out-of-pocket burden. Even with Medicare, the benefit package requires considerable cost sharing and does not cover some important services, such as hearing aids and routine dental care. Moreover, employer efforts to control retiree spending and policy changes, such as lower payments to Medicare Advantage plans, may lead to higher cost sharing for Medicare beneficiaries. The growth in cost sharing has led to concerns about an increase in underinsurance (when insured people must pay a large share of their income at the point of service to access care). In 2014, 23% of adults were underinsured compared with 13% in 2005.1

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