Here are my longer comments on the RAND study about Consumer making in the individual insurance market published on the web last week by Health Affairs. Somewhat ironically I was interviewed and fairly extensively quoted in this Olga Pierce UPI story (yup, the Moonies got to me!) before I’d read the whole study, so I was mostly venting my prejudices about the individual insurance market as a whole in my comments there. This is a little long, so I’ve put it below the jump — but I think it’s very important.
Reaction to the study has largely focused on the unsurprising finding
that paying subsidies to poorer people to buy into the individual
market wouldn’t do much to lower overall uninsurance. There was also
some comment about the problems with information availability for
people purchasing insurance. I’ll have some more to say about the
information piece later, but first we need to look at the core results.
Before I do that, I must congratulate the authors for their work and
Jill Yegian and her crew at CHCF for funding research into the
individual insurance market. No one has really touched this stuff other
than Mark Pauly, and long-term THCB readers won’t need me to remind
them what I think of his analysis. (BTW I think that the authors of
this study accept some of his results a little too easily).
So what do they say? Their main conclusion is this:
A 20 percent subsidy to the price of individual insurance would
reduce the number of uninsured people by at most 12 percent, or about
5.5 million people. On the other hand, we also find that tax subsidies
in the individual market would not lead to an unraveling of the group
market as some fear; a 20 percent subsidy in the individual market
would reduce the number of workers participating in their own plan by
less than 0.05 percent. At the same time, subsidy approaches will also
help achieve other policy objectives—namely, promoting whole-family
coverage and continuity of coverage. They are likely to be an
inefficient way to achieve any of these objectives, however, because it
is difficult to target subsidies only to those who would not otherwise
purchase insurance for some or all family members and to those who need
longer-term coverage but would leave the market because of high prices.
I think that’s code for saying that the individual market is
un-reformable, outside of the complete re-tooling of the health care
insurance system or giving everyone 100% subsidy to buy in. That gets
no argument from me. And don’t forget that a very small percentage of
Americans get their insurance from the individual market—even if that
number happens to include many self-insured health care consultants—but
the current erosion of employer coverage means that that number will be
growing, and it’s the great white hope of the wing-nuts in charge of
what passes for policy in the White House these days.
But there’s plenty more that’s actually more interesting in the study.
Our analysis confirms earlier studies’ findings that there is
considerable risk pooling in the individual market and that high risks
are not charged premiums that fully reflect their higher risk
My first real problem is that the earlier studies who’s findings
they are confirming were done by Mark Pauly — but I should be a big
boy and get over that. But here’s where they start talking about risk
pooling, and the impact of underwriting.
Among new enrollees, families that include an adult with a
chronic medical problem pay an actuarially adjusted premium that is
about 10 percent higher than the premium for new enrollees with no
chronic conditions. Among longer-term enrollees, families that include
an adult who contracts a chronic medical condition after enrolling in
the individual market pay more than longer-term enrollees with no
health problems (7 percent) but less than families with a chronically
ill adult at enrollment (who pay 12 percent more than the healthy
families). This is consistent with the hypothesis that pooling
increases over time.
Thus, there may be less separation of risks among longer-term
enrollees than among new enrollees. The evidence on this is somewhat
mixed (Exhibit 2). The less generous PPOs include fewer longer-term
subscribers with newly acquired chronic conditions than we would expect
at random. Thus, there continues to be a separation of risks in the
less generous PPOs, even among those who acquired chronic conditions
subsequent to enrollment. On the other hand, the share of longer-term
enrollees who become sick who are in higher pricing tiers is about the
same as their share in the population, which is consistent with a
decrease in separation of risks over time as a result of health status
So they’re saying that the less generous PPOs (i.e. the HDHPs) find
a way to weed out the chronically ill (more on that later) but that the
more expensive plans don’t over time. This may be true but there are
several things that do not seem to be considered in their analysis (or
at least didn’t make into the final report).
First, the impact of insurance avaibility (or unavailability) on
defraying health care costs is not evenly spread on the average—it’s on
the margins and on the margins the unlucky are getting screwed—or
worse, having their insurance cancelled. (That news broke after this study was concluded but before it was published).
Now the study’s data shows that people 60% of people turn over within the individual market every 3 years.
About 60 percent of new coverage episodes continue more than one
year, and more than 30 percent continue for more than three years
In fact it’s only around 50% of even the near-elderly who last more
than 3 years in an individual plan—and that’s the group that’s least
likely to find other options and therefore has the greatest incentive
to sit tight in an individual plan. So the individual market is highly,
highly unstable. What’s happening is that people go from individual
plans into group plans when they change jobs. People change jobs
frequently, (they have their plans changed on them by employers
too) and in that process, as anyone who’s looked for a job knows, they
have frequent periods of needing insurance. Often they have relatively
long periods of uninsurance. Commonwealth estimated that 80m Americans had at least a 4 month period of uninsurance over a 2 year period—as
there are about 20m long term uninsured, that means 60 million odd are
being ground through the group to individual to uninsured mill, with
plenty more going from group to individual and back.
Then when people come back into the individual market, they have to
be re-underwritten. It’s an arduous process, and as I just wrote about
at Spot-on it produces wildly varying results in premiums offered for the same individual. And when they get re-underwritten, life is not so much fun.
Underwriting might prevent some high-risk market candidates from
obtaining insurance because insurers are free to deny coverage. Those
who obtain health insurance are in better health than those who remain
uninsured. About 32 percent of those who recently purchased individual
health insurance reported that an adult family member included on the
policy has a chronic medical condition, and 4 percent reported that an
adult family member was in fair or poor health.
So the real story should be the focus on what happens to those who
turnover, not the 30% stuck in the individual market longer term.
Unfortunately, as far as I can tell, the only way that you can do this
study properly is to longitudinally follow a group of people into and
out of the individual insurance market over time, and then discover
what happened to those who developed chronic conditions. Were they
charged much higher premiums? Did they become uninsured? What coverage
were they offered? What happened to their premiums, max out of pocket
costs, benefits while they were insured, etc, etc. All the anecdotal
evidence (and THCB readers know how I berate various Canada-bashers for
only using anecdotal evidence) points to many problems that this study
didn’t uncover. It looks to me like the researchers at RAND might
have got at some of this data for some people by linking
the individuals’ experience between the three insurers from whom they
got data (although from some of my other data work I know there’s lots
of complexities in doing that linking, and the data set wouldn’t
capture those who found another plan or no plan at all). But as far as
I can tell they didn’t do that, so the information they captured on the
experience of individuals over time was incomplete.
Unfortunately, other research indicates that underwriting is much
more prevalent and aggressive than the RAND team suggest, even though
their data (Exhibit 2) suggests that in the HDHP (or what they call the
“less generous PPO”) sector the insurers are getting pretty damn good
at weeding out new entrants with chronic conditions. Click on the chart
for details, but the important part is that 92% of people joining those
plans are healthy compared to 79% joining individual plans overall (and
this “overall” number is within an already underwritten individual market!).
In a study researchers at Georgetown University found that even an
applicant with just hay-fever only received a “clean” acceptance for
insurance only three out of sixty times.
The rest of the time they were asked for higher premiums, or their
illness wasn’t covered at all. (California doesn’t allow those
exclusionary riders—so they’d just be denied coverage here).
What counts as a chronic disease? In the study it tells us in
Footnote 17–The chronic conditions included in the measure are
arthritis, cancer, diabetes, hypertension, heart disease, lung disease,
back pain, and ulcers. For example, I just got totally rejected
from health insurance from one of the carriers the researchers examined
for a) prior surgery, b) groin strain, c) elevated cholesterol and d)
gout—even though most of these diagnoses were over four years old and I
have had no health expenses other than $40 a year for medication for
the gout in the past 18 months.You could argue that the elevated
cholesterol is heart disease and that gout is arthritis and thus are
within the categories of chronic condition, but that’s really pushing
it. And don’t forget that a virtually identical plan from a competitor
let me in at the most heavily underwritten rate although I’m obviously
an identical risk!
But they come up with a statement that I just don’t believe
Among new enrollees, families that include an adult with a
chronic medical problem pay an actuarially adjusted premium that is
about 10 percent higher than the premium for new enrollees with no
Some of this may be because the study focused on families rather
than individuals, so there’s a little pooling going on there already.
But as I say, this really matters on the margins not the average.
Here’s the actual math from my “marginal” case for basically identical
benefit policies in California ($2,500 deductible). Remember that my
“group” was kicked out of the PacAdvantage buying group, making me
eligible for HIPAA guaranteed issue. What happened was that my $220
monthly premium for the group policy via PacAdvantage became a $110
premium for a healthy individual. The alternative if I’d failed
underwriting (and I did with one of my applications) was a $400 premium
with a higher deductible for the HIPAA guaranteed-issue
In previous years the gap between the "healthy" price and actual
underwritten price I was offered care for—when they found my history of
knee surgery—was even greater ($60 vs $420 if memory serves me right).
This of course ignores the reality of groups kicking out individuals
into the individual market all the time, no matter what their health
status may be. My association was kicked out of a state-sanctioned
buying group, but plenty of people lose their jobs and find that the
group doesn’t exist as their employer has gone bankrupt (something that
happened to me in 2002) and hence has no COBRA plan to buy into. For
that matter, given the cost of insurance via COBRA and the fact that
most people trying to buy into it are now unemployed, that’s equally
likely to cause more uninsurance or at the least to try to buy into a
cheap underwritten plan. And of course, although it’s theoretically
illegal, a small employer that gets rid of an employee with a chronic
illness will see a marked improvement in its premium the next year.
Don’t think that they don’t know that in an “employment at will” state.
So even though they’re talking about the whole individual market for
families and I am focusing on the “less generous PPOs” for
individuals, I’m having real trouble accepting the overall conclusions
on the price differential between healthy and chronically-ill groups.
A price 10% difference would be a dream for most individuals with
chronic illness trying to buy into individual insurance, given that the
mandated rate for the HIPAA plan is 300% higher than the advertised underwritten rate.
Here’s the real unstated conclusion. Creating an unmanaged risk pool
and calling it the “individual insurance market”, is a complete
disaster. By definition healthy people will logically pick the cheapest
option—whatever Grace Marie Turner thinks will happen.
That will mean worse choices for those who have some type of chronic
illness, who are after all the ones who need the damn insurance in the
Now a few words on the information side of the equation.
My own experience with eHealthinsurance.com
suggests that there is plenty of information available for people
trying to buy individual insurance, but it’s at best incomplete and
unhelpful, or even worse deliberately misleading. The current state of
the individual market means that because of the variation in:
a) premium price b) co-paysc) co-insurance d) benefits e) coverage of those benefits f) Rx formulary g) deductibles, and most importantly h) maximum out of pockets,
it’s well beyond the average consumer’s ability to figure out what
they are paying for what. Unless of course they can do multi-factorial
equations in their head and know how sick they’re going to be
in the coming year. And then, the premium price you are given is
subject to underwriting, so you have no idea what the actual price is
until you’ve been through the hellish underwriting process.
There needs to be at least a mandated apples to apples comparison.
For example, eHealthinsurance doesn’t even put the max out of pocket
cost –which is the most important number of all as is well explained in this LA Times column from a cancer patient–on
their main results page. What would be much better is mandated national
identical benefits (including Rx formularies) so that consumers can
make a real apples-to-apples comparison. Of course the current so
called "free-market" advocates want to allow all kinds of shenanigans
in the insurance market which will take us even further away from that
ideal–even though such comparisons are the centerpiece of any rational consumer choice plan.
This is one area where I’m totally in favor of transparency, and the
current market incentives for insurers are totally in favor of
opaqueness. But, and here I disagree with the emphasis placed on
information by the RAND folks, even if you showed a transparent view
into the workings of the current individual market, it wouldn’t help
those who actually need it and can’t get into it at a decent price.
They’d just be able to see up front that they the system was conspiring
That’s why we need one national health insurance pool.
“but it is hard to imagine that individual mandates, mandatory enrollments, and a public option would make us worse off.”
No No and Yes. No one thought Medicare and Social Security would be the disaster they are headed to be. The problem is mandatory enrollments and individual mandates should have been passed at the same time COBRA and HIPAA passed and created the problem. A system that allows true underwriting of the risk can sustain. A system that requires Universal participation can sustain. A system where the politicians pass only the mandates that fit into 30 second sound bites likely to increase their chance of getting reelected will fail every time.
Medicare, Medicaid, Indian Health are all public options, our government has never proven capable of running a sustainable insurance program. Politics and one sided greed will destroy them every time.
“For insured patients, there is little incentive to constrain demand.”
This ignores the millions of people who live successfully now without insurance and lived without it for hundreds of year prior to Medicare. The general public is quit capable of living within their means if they are required to live within their means. Its when politicians set up a table of free handouts that things get skewed.
“Meanwhile, the most likely solutions to the arms race–collusion (e.g. allocating markets) or monopolization (through consolidation) –replace one set of inefficiences for others.”
Why ignore the obvious and turn a blind eye to history? Independent hospitals competing against each other worked for decades until Washington allowed to much consolidation in the insurer market. Technology today allows for efficient operation of 10,000 insurers as much as 1,000. Cap market share for both insurers and break up the health organizations. It will leave some issues with rural care but competition would solve the urban cost crisis.
“procedure-based payments to physicians encourage unnecessary procedures”
This is only a problem when the person receiving the care isn’t paying the bill. Cars, housing, electronics, and almost everything else in our life is priced this way. While there will always be a sucker the majority of Americans deal just fine.
“What I said was that underwriting meant that the same policy varied in price by a factor of up to 7 to 1”
Actually Matt you said 8 to 1 and even at 7 to 1 you’re still wrong. CA law does not allow you to charge one person $700 and another $100 if they are the same age, sex, and zip code.
How do you jump from an argument about individual underwriting then as an argument use small group underwriting? Your talking two completely different sets of laws and rates then bash me for the clarity of my argument?
Your exact words;
“I can assure you from personal experience that variations in rates charged in the indiv insurance market in California for exactly the same coverage based on health status vary by more than 3 to 1–more like 8 to 1.”
You know what you say before stays above your new comments right?
CA law does not allow a carrier to sell one person a policy at $60 and the same person with conditions $420. It doesn’t happen. Rom your writing I can’t even tell what your trying to say. What are basically identical benefit policies? That throws up a major red flag when someone is trying to make your argument and starts with “they are basically the same”. Either it is the same policy or it isn’t. Do you consider a policy with $100,000 lifetime max basically the same as one with unlimited if all the co-pays, deductibles, and co-insurance are the same? Are you even talking about two policies from the same carrier? One PPO and the other POS?
It sounds like in your zeal to propagandize you compared the cost of your small group reform group policy to both the cost of the lowest priced carriers individual plan with no underwriting load and then finally to the price of the highest cost carrier’s fully loaded individual plan. And to all shock and amazement they came out with a 7 to 1 spread, a completely meaningless analysis but makes your political point.
If you want to argue then do it right, what does the same carrier charge for the same policy to a healthy person and the maximum loaded person and finally the state HIPAA plan? It is not 8 to 1, or 7 to 1 or would you like to claim 6 to 1 now?
Matt S., As you have figured out I’m for a single pay same good quality care for all plan. I do think we need to decide what’s necessary to be covered and whats extra, Lasix or Viagra, etc. But when I see providers being allowed to cherry pick richer payers I see a two or three tier system where the “unwashed masses” won’t get good quality care at reasonable time expectations because all the I wanna get rich docs are serving the high payers and the better plans. I have stated that there really needs to be an ethics discussion on what the principles should be in setting up any plan. Canada has been fighting this for many years. Most people there prefer a one tier system for all because they know that limited resources will get more limited in any other model. Did I misunderstand Matt’s comment?
Question: What data would have to be added and analytics performed to make the eHealthinsurance.com information truly useful to a consumer trying to select the best suited policy?
I understand the one pool concept, though I still think varied deductibles could work if the higher deductible polices were priced to be actuarially neutral (loss of premium revenue equals the value of paid claims that are shifted from the insurer to the consumer).
I don’t understand the one basic policy with people paying out of pocket for anything not covered by it. It seems to me that the good / better / best approach outlined by the Century Foundation with the value of the premium support voucher being sufficient to buy the “good” plan would be a better fit with our national culture. People who want a better or more comprehensive plan at a higher cost and are prepared to pay the difference with their own resources should be able to do so. Why is that a problem?
I don’t understand your response to Mr. Holt’s statement. What exactly is wrong with paying for perks, and letting the provider market respond to those perks? Isn’t this simply letting people’s preferences (making trade-offs based on what they value) express themselves financially? While the provider market would indeed respond, I don’t quite get the logical leap to the original pool being doomed. Please explain.
“Then if you want extras (nicer chairs in the waiting room, Lasix, other stuff not in the nationally mandated plan) you pay up.”
Would you allow those that don’t want the nicer chairs, or to pay for them, to sit in them waiting for the same service from the same doc? If this is your intent then you are dooming a national all in one pool plan. As providers will offer some perks to attract better paying unsured.
Okay. I get that.
Would you, by extension, also end Medicare and Medicaid? And what about using untaxed dollars? Would you remove the hidden subsidy created by this as well?
Who would administer this plan? The government or private insurers that attempt to competitively negotiate lower rates for only that extra stuff?
Matt. Not quite. I want everyone in one pool. And then everyone to buy a plan (or be given one) that has the same benefits. Then if you want extras (nicer chairs in the waiting room, Lasix, other stuff not in the nationally mandated plan) you pay up.
The reason for not allowing different dedutible level plans is that the healthy would go into one and the sick into the other, and the pool would die. See this article as to why
Interesting (if dated) study:
Just to see if I’m getting this:
Let’s say we put everyone in one pool with a standard-based premium and a high deductible plan, and make it a requirement to have such a plan. At this point, we then let people purchase additional supplementary insurance based on need (willingness to pay). As such, everyone contributes to overhead, but only those who need more coverage pay for it.
Is this a rough start of a plan you would be for?
[LEVEL3] Understanding The Individual Market
Matthew muses on a new RAND study of consumer decision making and the individual insurance market.