The Senate’s Better Care Reconciliation Act (BCRA) is a significant modification to the current Patient Protection and Affordable Care Act (PPACA) exchange structure in a variety of ways. One major change is the designation of the benchmark plan which determines the level of subsidy that the federal government provides to individual buyers on a health insurance marketplace. There are two elements of note. The first is that the benchmark plan is now a plan with a calculated actuarial value of 58%. This is a significant change from the current benchmark plan with a calculated actuarial value target of 70%. More importantly for this post is the benchmark plan in the BCRA is the median qualified plan.
Research has shown that consumers can be overwhelmed by too much choice. Dominated choices can and often will be selected. Buyers have frequently confused the value proposition of Gold and Bronze plans based on prioritizing either more out of pocket maximum protections or lower monthly premiums.  Buying and using insurance is a complex task with significant uncertainty and cognitive demands. The BCRA subsidy attachment system creates incentives for insurers to further increase complexity.
Within PPACA the incentive for insurers to clone plans with minimal meaningful differences between them only applies to the insurer which controls the least expensive Silver plan in a county. This single, low cost, insurer faces a decision as to whether or not to design a second plan with the same actuarial value in a slightly different cost sharing structure in order to guarantee that this single carrier controls both the least expensive and the benchmark Silver point. All other insurers plan offering decisions are made independent of subsidy attachment point manipulation purposes.
The BCRA creates a broader and more complex strategic design problem for carriers. Every entry in the benchmark category influences the benchmark price. Once an insurer has built a network and performed the basic actuarial calculations, modifying a basic plan design by altering co-insurance slightly or decreasing deductibles while increasing co-pays to achieve a constant actuarial value is a fairly low cost action. A high cost carrier can introduce an isomorphic plan design to increase the benchmark and asymmetrically decrease the relative post subsidy price of its preferred offerings. Low cost carriers have an incentive to offer one more plan to lower the benchmark and make its offerings more attractive compared to higher cost peers.
Counties with multiple insurers will face an unstable equilibrium. Every insurer will have an incentive to add a marginal, incremental plan to be offered on the BCRA exchanges in order to move the subsidy attachment point closer to their preferred position. Once this arms race begins, consumers will be asked to differentiate miniscule differences between dozens of plans offered by two or more insurers. Common heuristics such as evaluating a plan first on the inclusion of a specific doctor or hospital in network and then examining a subset of plans based on maximally acceptable premium with the final decision step based on minimizing deductible will be corrupted. Plans can be offered with low deductibles but higher maximum out of pocket exposure with a cost structure that significantly advantages or disadvantages certain types of consumers. Insurance buyers will face decision fatigue and be overwhelmed with almost meaningless choice.
There are two possible solutions. The first is for the Department of Health and Human Services to update stringent meaningful difference regulation. Current regulation allows carriers to offer multiple plans built on the same network ID and same plan type (HMO, POS, EPO, PPO) with fairly minor differences in cost sharing. Stronger meaningful difference regulation would restrict carriers to offer only a single cost sharing design per network ID and plan type dyad. The second is for the Senate to modify the benchmark. Every participating carrier would place their lowest cost plan in the benchmark set and the median plan from the benchmark set would be the benchmark plan for the county.
These design modifications lower consumer confusion and will minimize strategic manipulations of the subsidy formula which will lead to more effective and efficient markets.
 S. HR 1628, 115 Cong. (2017). Discussion Draft
 United States, Government Printing Office. (2010). Federal health care reform: Patient Protection and Affordable Care Act (PPACA ; Public Law 111-148). Richmond, VA, North Carolina: State Corporation Commission.
 Lowenstein, G., & Bhargava, S., (2017, June 09). The Simple Case Against Health Insurance Complexity. Retrieved June 26, 2017, from http://catalyst.nejm.org/simple-case-health-insurance-complexity/
 Bhargava, S., Loewenstein, G., & Sydnor, J. (2015). Do Individuals Make Sensible Health Insurance Decisions? Evidence from a Menu with Dominated Options. National Bureau of Economic Research. doi:10.3386/w21160
 Ubel, P. A., Comberford, D. A., & Johnson, E. (2015). Healthcare.gov 3.0 — Behavioral Economics and Insurance Exchanges. The New England Journal of Medicine, 695-698.
 2018 Letter to Issuers in the Federally-facilitated Marketplaces , § 45 CFR 156.298 (2017).