Silver loading and confusion

Over the weekend, I wrote in the New York Times** why I think CSR funding may not come back:

Mr. Trump’s decision to end cost-sharing-reduction subsidies, known as C.S.R.s, and perhaps to derail a bipartisan bill by Senators Lamar Alexander, Republican of Tennessee, and Patty Murray, Democrat of Washington, that would restore C.S.R. funding through 2019 may actually lead to better coverage for more people paying lower monthly premiums.

That’s because insurers and state regulators prepared a workaround in anticipation of Mr. Trump’s move — and at least for 2018, most consumers could benefit from it.

This is the Silver Load and Gold Gap ideas that we’ve been talking about here at Balloon Juice for six months now. The basic thrust is that in normal situations, the price line runs Bronze-Silver-Gold-Platinum, but without CSR, the price line in most states will run Bronze-Gold-Silver-Platinum. And since premium tax credits are based on the relative price of Silver plans, this makes Gold and Bronze plans comparatively much cheaper in 2018 than they were in 2017 for subsidized buyers.

There is one major downside to this mechanical argument.

It is confusing and complex.

Over the past couple of weeks, I’ve been talking to reporters, Balloon Juice community members, and other interesting people via e-mail. The common response is always — “How does this affect me?”

This is hard to work through as our normal heuristics are being broken.

I think there are three sets of responses. First, if you buy individual insurance, actively shop on the Exchanges this year even if it is to confirm that you qualify for nothing. Weird things will happen, so see if the weirdness works in your favor.

Secondly, we have mechanical and decision support responses. We’ll review some of the ideas in this post.

Finally, tomorrow, I’ll start writing out cheat sheets depending on how your state decided to handle no CSR costs.

States need to be active in their outreach and they need to provide tools to help people figure out the weirdness.  Pennsylvania is partnering with

The Pennsylvania Insurance Department is partnering with Consumers’ Checkbook again this year to create a shopping tool that allows consumers to compare both on-exchange and off-exchange plans available in Pennsylvania. Consumers can enter their income to see what subsidies may be available to them and estimate the monthly premium and total annual cost of plans in their area. If consumers find a plan they would like to buy, the plan comparison tool will take them to either or the company’s website to make a purchase. Consumers can visit to use the plan comparison tool.

Open enrollment for 2018 health insurance runs from November 1 until December 15 – a change from previous years. Consumers must sign up by December 15 in order to have coverage effective January 1. The open enrollment period may be the only time consumers can enroll for 2018, and those who do not purchase a plan may be subject to a penalty as well as being uninsured for the year. On-exchange plans can be purchased at Consumers who need assistance enrolling may visit to find free resources in their area.

Andrew Sprung at Xpostfactoid is looking at

Metal level choices: Imperial 92222 (Region 13)

Monthly premiums for 40 year-old with $25,000 income (207% FPL)


Metal level



Cheapest bronze

$  1


Cheapest silver

$  1


Cheapest gold



States and potentially need plan tools to show how to avoid bad choices in this situation. If we are to assume that the insurer, plan type (HMO vs. PPO etc) and network are the same for a $1 premium plan, Bronze and Silver are dominated by Gold. Gold offers the same or better for the chooser attributes than Bronze and Silver. Dominated plan choices are bad. Decision support tools that either show only non-dominated plans or highlights the best choice by placing it at the top of the screen will help out.

Insurers need to be getting in front of the confusion as well. It is in their interest as placing people in zero or low dollar plans means that they won’t lose healthy members with few claims due to the non-payment of premiums. It improves their bottom line. This can mean paid advertising, it can mean funding navigator groups, it can mean social media campaigns and earned media campaigns. They need to get in front of this.

No matter what, this is going to be confusing, but there are steps that can, are and should be taken to reduce some of the confusion.


** My wife said I have one pretentious sentence and this was it.

23 replies
  1. 1
    rikyrah says:


    thanks for this.
    still confusing.

    PS-Please do a post about what the GOP’s ‘budget’ does to Medicare and Medicaid. THIS has gone under the radar, and we need to be calling.

  2. 2
    satby says:

    Mind bogglingly confusing. To the point where I wonder if it’s not part of a strategy to get people just to throw up their hands and opt out. Serfs who depend on employment health insurance will stay in those jobs despite lousy pay just to stay covered and out of the nightmare they’re making of the individual market.

  3. 3
    Spanky says:

    Good thing you added the “**”, Mr. Smarty Pants.

    I doubt there’s enough coffee in the world to allow me to understand everything you write, but, not for the first nor last time, let me thank you for writing this stuff up. Even if it does end up getting relegated to the FNYT. :^)

    And, not for the first time, let me say how happy I am that my employer provides my insurance (at least until retirement in <3 years). So I think this does NOT impact those of us under employers' plans. Or does the pricing bleed across into company plans?

  4. 4
    Jeanne says:

    As someone who is on ObamaCare, helps clients get on ObamaCare and is a professional mental health therapist who gets paid from insurance companies, I am exhausted! I read all your posts and they are very helpful for myself and my clients, but everyday I feel like I am starting from scratch. Thanks for all your help. I am in PA and will be using

  5. 5
    Alternative Fax, a hip hop artist from Idaho says:

    Okay, you wife may have a point there, but we are nevertheless grateful for your educational input here at this top 15,000 blog. Mrs. Mayhew forgot to correct your spelling of the homonym “affect,” which is among the most confusing. I’ll spare us all my long explanation, but you want it spelled with an a in the context here. Thanks so much for your writing on this topic.

  6. 6
    Spanky says:


    Mind bogglingly confusing. To the point where I wonder if it’s not part of a strategy to get people just to throw up their hands and opt out.

    That’s a well-used trick, in insurance and everywhere else that fine print is mass-produced.

  7. 7

    @Spanky: Correct, if you get insurance through work, no worries.

  8. 8
    Brachiator says:

    So let me see if I’ve got this straight. Trump tried to kill Obamacare, declared it dead and gone, but may actually make it better for some people..

    I love it.

    More seriously, I wonder whether the shorter enrollment period, lack of advertising and deliberate sowing of confusion will make it harder for people to make the best decision.

    Also, thanks to David Anderson for the ongoing excellent analysis.

  9. 9
    Ohio Mom says:

    I made my calls to my Congresscritters already. Their staffs have gotten a lot better at deflecting whatever point I’m making. Their lack of humanity is scary.

    I’m another one who doesn’t always follow everything you write, David, but I remain very grateful for all your efforts. And I am reassured to have it confirmed that it *is* getting more confusing, it isn’t just my brain wearing out on its own.

  10. 10
    JPL says:

    Since the republican budget calls for 1 1/2 trillion dollar cut from medicaid and medicare, I expect your future posts will be interesting.

  11. 11
    Spanky says:

    @Ohio Mom:

    I made my calls to my Congresscritters already. Their staffs have gotten a lot better at deflecting whatever point I’m making. Their lack of humanity is scary.

    If I had to field phone calls from constituents about having their safety nets pulled out from under them – for ten straight months – because of whatever shit my boss and his leadership were plotting ….
    Well, I’d be a hollowed out hulk too. Probably going to impact their jobs and/or hireability for the rest of their lives.

  12. 12
    Han says:

    What might help, and I think I finally got it from your NYT article, is what the flow of money is. Up to this point, all I heard was that with CSRs going away, the Gold plans would be cheaper and people would have better insurance. But someone’s paying for that Gold plan, and that’s where the confusion was for me. So Silver plans had CSRs to keep the consumer price low, but the Gold plans got tax credits based on the cost of the Silver plans. With the rise of the cost of silver plans, the Gold tax credits got bigger, correct? Will the insurance companies wait for you to get your tax credit though, or does it go directly to the insurer, or how does that work?

  13. 13
    Ohio Mom says:

    @Spanky: I believe in being explicit. I end the call by telling them, “I know you are a young person who took this job to learn. Well, keep your mind open and try to learn from each call! I’m old but you are going to be living a long life in the world that is being created right now.”

    Doubt it does much good but it makes me feel better. A little.

  14. 14
    ken says:

    My rough and ready estimate is that my post-APTC premium will fall 60% from 2017 to 2018 for Bronze in NM. Would’ve been better but NM didn’t force all insurers to Silver load so the premiums on the benchmark Silver are not as high as they would have been.

  15. 15

    @Han: YES!!!!

    The insurance company gets the tax credit every month (usually around the 20th)

  16. 16

    @ken: Look at Molina Gold plans as I think Molina Gold will be priced a lot like everyone else’s Bronze plans in New Mexico

  17. 17
    JGabriel says:

    @Alternative Fax, a hip hop artist from Idaho:

    Mrs. Mayhew forgot to correct your spelling of the homonym “affect,” which is among the most confusing. I’ll spare us all my long explanation, but you want it spelled with an a in the context here.

    Oh, c’mon, everyone knows affact is not a word. You’re just playing mind games.


  18. 18
    Betsy says:

    David, you are the greatest! Thanks for your hard work and consistent delivery on these issues.

  19. 19
    Eric NNY says:

    Good stuff

  20. 20
    Humdog says:

    @David Anderson: My husband’s boss has been threatening to stop covering spouses for the past few years. It seems to me that small group coverage could spike in expense and that would end my coverage and put me on unsubsidized individual market with numerous preexisting conditions.
    I feel the NYT wants to showcase “liberal” wonks saying this is all no big deal. Your couple of small points where you think it might not be bad for some people may be being construed as no big deal on all of it. Please watch to see if you are being used just like Fox News uses its token “liberals”.

  21. 21

    “…if you buy individual insurance, actively shop on the Exchanges…”

    …and off-Exchange, as you have said before. Depending upon local circumstances in your state, you may need to be very pertinacious even to identify off-Exchange options. Ask your life- or car- or homeowners’-insurance agent to put you in touch with a broker who handles health insurance. There may be (among other “weirdnesses”) off-Exchange plans that are “offered” only because of a regulatory requirement, but that the carrier does not actually want to sell.

  22. 22

    You: “…States need to be active in their outreach and they need to provide tools to help people figure out the weirdness….”

  23. 23
    Bill Arnold says:

    That NYTimes article took a while to get to the wonk-snark punchline, nicely done, also interesting.

    Question/thought experiment for anyone: if e.g. somebody on Fox News explained the transmutes-silver-to-gold effect to POTUS Trump clearly and simply in a sentence or two, any guesses on how POTUS(i)DJT [1] would respond, if at all? He does like gold, a lot.
    [1] pun, just noticed, needs work. (Am slow.)

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