Value-based insurance design (VBID) aligns patient cost sharing with the value of clinical services, so that patients pay less for high-value services and more for unnecessary, low-value services. While there has been increased interest in VBID, with CMS expanding the VBID demonstration in Medicare Advantage to all 50 states, the situation on the state exchanges is different: The plan has to be cost neutral, so in order to remove cost sharing for high-value services, cost sharing has to increase for other, low-value services.