Health care lessons from Texas: How ACA insurance affects physicians and patients

Physician groups were involved in shaping Texas health insurance policies, with ongoing engagement during legislative sessions, including a bipartisan 2021 bill that more strictly enforced the ACA’s single risk pool requirement and increased subsidies for bronze and gold plans. While concerns initially existed that ACA plans might be less attractive to physicians due to higher deductibles and copays, plan generosity varies widely — particularly for lower-income patients with silver plans that include cost-sharing reductions — making it difficult for physicians to generalize financial impact based on plan type alone. Charles Miller, JD, director of health and economic mobility policy for Texas 2036, explains more.

Medical Economics: When you talked earlier about the notion of the uninsured level in Texas, and then actually Texas 2036 really getting into the diving into the data, into patients, were doctors involved in any of the creation of these policies? And maybe what has the response been?

Charles Miller, JD: We have a very active medical lobby here in Texas, and so when we're looking at state level policies, there are all sorts of physician groups that are involved in the crafting of those policies. During any given legislative session, I work and interact regularly with those individuals. One of the policies that has actually had a unique impact in Texas and has made some of those bronze and gold plans more affordable. Was a bill that was passed back in 2021 and this was a bipartisan bill that actually enforced the ACA’s single risk pool requirement more stringently than a lot of other states did. And that might sound odd or interesting that Texas would have such a strong interest in enforcing the ACA requirements, but the reason we did is that it had this really beneficial impact in that it increased the amount of tax credits or subsidies that were available for folks who were purchasing those bronze or gold plans.

So to bring it back to your audience, in terms of their interest, the way that the plans operate, just as a general matter, is, they're rated by these medal levels, right? So there's bronze, silver and gold, and the different plan medal levels are supposed to correspond roughly to plan generosity. So bronze plan is the least generous plan, it'll have the highest deductibles, the highest copays and so forth. The silver plan is kind of this mid-range level, and then the gold plan is the most generous, except that there's also this other weird factor, that if you earn less than 250% of the federal poverty level, silver plans and silver plans only have what they call these extra cost-sharing reductions, and that brings down the deductibles and copays to a very, very low amount. So when the Affordable Care Act was first coming out, a lot of the discussion among provider groups was that these plans were going to be less appealing for doctors because they had higher deductibles and higher copays than maybe a more traditional employer-sponsored insurance plan. There's a wide variation among these plans. And if we are talking about a relatively low-income enrollee who has a silver plan, they actually have a very, very generous plan level. And the expected out-of-pocket cost contribution from those patients is going to be very low. So there's less perhaps having to keep track of that patient cost-share amount from a financial perspective for your folks. But there are wide variations. Again, a bronze plan could have deductibles that are exceeding $10,000 in some cases. And gold plans tend to be more generous, but there's wide variation within the plans. And so there is no one single answer from a physician standpoint of looking at the patient and oh, well, you've got a gold plan, that means that your cost share is going to be lowest. It's a little bit more complicated than that, unfortunately. So there is no one single filter to look at for which one is going to be the most business-friendly plan for me.