A 40% excise tax on co-called Cadillac coverage under the Affordable Care Act will not be assessed until 2018, which gives employers time to tweak their plan design, but now there’s concern that platinum-level health insurance might disappear from public exchanges.

One unintended consequence of too many U.S. health care consumers buying down their HIX coverage could be that health insurers pull the plug on platinum-level options that simply aren’t selling. Another worry involves inappropriate benefit elections among sicker individuals who opt for high-deductible bronze and silver plans that trigger high out-of-pocket costs – even if trained “navigators” advise against such a move.

Gary Claxton, a vice president of the Kaiser Family Foundation, recently told Reuters that some health insurers are already eschewing platinum, quipping that there are now calls for a “lead” level that would drop down the 60% bronze coverage to just 50%.

Most insurers are heavily promoting mid-level silver plans, betting that the lion’s share of U.S. health care consumers will opt for that coverage. But many others are going for the cheapest option. For example, 42% of roughly 100,000 enrollees in the nation’s largest private HIX, Aon Hewitt’s private Corporate Health Exchange for large employers, purchased less coverage last year than they had previously owned. The number was much higher for enrollees in Liazon’s Bright Choices private exchange for more than 2,400 mostly small and midsize employers, 90% of whom have bought down during the past five years.

“It is hard to predict what plans employees will choose because it is such an individual decision and depends on a number of factors” including a significant change in one’s life or health status, explains Ken Sperling, national health exchange strategy leader for Aon Hewitt. He hastens to add that plan enrollees are free to modify their decisions annually.

Alan Cohen, Liazon’s co-founder and chief strategy officer, believes the consumer-empowerment trend in health care will continue beyond 2014. He expects more than 70% of employees who have access to his company’s private HIX will purchase less expensive coverage in the future.

“We are seeing cost-conscious consumers choosing to increase their cost-share in targeted areas, increasing their cost-share across the board in conjunction with a Health Savings Account, opting for a less expensive provider network option and electing to use a primary care physician-focused model,” he reports. 

The financial impact of inappropriate choices could be devastating. HIX enrollees stand to lose more than $611 a year if they do not select the most effective option for their needs, according to a recent Columbia Business School study, which also estimates a $9 billion cost to the federal government for subsidizing poor decisions. However, a Liazon analysis suggested that 75% of plan enrollees among one of its large clients made appropriate benefit selections.

Mindful of these trends, 44% of the nearly 800 large and midsize employers responding to Aon Hewitt’s 2013 Health Care Survey are considering adding in the next three to five years elective benefits that reduce short-term fears about not being able to afford treatment for a catastrophic illness among those with a high deductible. Currently, just 9% of those respondents say they offer elective benefits in conjunction with a consumer-driven health plan.

Bruce Shutan is a Los Angeles freelance writer.

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