Tag: Jonathan Halvorson

Improving the Affordable Care Act Markets (Part 2)


In a previous post, I described how some features of the Affordable Care Act, despite the best intentions, have made it harder or even impossible for many plans to compete against dominant players in the individual and small employer markets. This has undermined aspects of the ACA designed to improve competition, like the insurance exchanges, and exacerbated a long term trend toward consolidation and reduced choice, and there is evidence it is resulting in higher costs. I focused on the ACA’s risk adjustment program and its impact on the small group market where the damage has been greatest.

The goal of risk adjustment is commendable: to create stability and fairness by removing the ability of plans to profit by “cherry picking” healthier enrollees, so that plans instead compete on innovative services, disease management, administrative efficiency, and customer support. But in the attempt to find stability, the playing field was tilted in favor of plans with long-tenured enrollment and sophisticated operations to identify all scorable health risks. The next generation of risk adjustment should truly even out the playing field by retaining the current program’s elimination of an incentive to avoid the sick, while also eliminating its bias towards incumbency and other unintended effects.

One important distinction concerns when to use risk adjustment to balance out differences that arise from consumer preferences. For example, high deductible plans tend to attract healthier enrollees, and without risk adjustment these plans would become even cheaper than they already are, while more comprehensive plans that attract sicker members would get disproportionately more expensive, setting off a race to the bottom that pushes more and more people into the plans that have the least benefits, while the sickest stay behind in more generous plans whose premium cost spirals upward. Using risk adjustment to counteract this effect has been widely beneficial in the individual market, along with other features like community rating and guaranteed issue.

However, in other cases where risk levels between plans differ due to consumer preferences it may not be helpful. For example, it has been documented that older and sicker members have a greater aversion to change (changing plans to something less familiar) and to constraints intended to lower cost even if they do not undermine benefit levels or quality of care, like narrow networks. These aversions tend to make newer plans and small network plans score as healthier. Risk adjustment would then force those plans to pay a penalty that in turn forces enrollees in the plans to pay for the preferences of others.

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Improving the Affordable Care Act Markets (Part 1)


With each passing year, the Affordable Care Act becomes further entrenched in the American health care system. There are dreams on both the far left and far right to repeal and replace it with something they see as better, but the reality is that the ACA is a remarkable achievement which will likely outlast the political lifetimes of those opposing it. Future improvements are more likely to tweak the ACA than to start over from scratch.

A critical part of making the ACA work is for it to support healthy, competitive and fair health insurance markets, since it relies on them to provide health care benefits and improve access to care. This is particularly true for insurance purchased by individuals and small employers, where the ACA’s mandates on benefits, premiums and market structure have the most impact. One policy affecting this dynamic that deserves closer attention is risk adjustment, which made real improvements in the fairness of these markets, but has come in for accusations that it has undermined competition.

Risk adjustment in the ACA works by compensating plans with sicker than average members using payments from plans with healthier members. The goal is to remove an insurer’s ability to gain an unfair advantage by simply enrolling healthier people (who cost less). Risk adjustment leads insurers to focus on managing their members’ health and appropriate services, rather than on avoiding the unhealthy. The program has succeeded enormously in bringing insurers to embrace enrolling and retaining those with serious health conditions.

This is something to celebrate, and we should not go back to the old days in which individuals or small groups would be turned down for health insurance or charged much higher prices because they had a history of health issues. However, the program has also had an undesired effect in many states: it further tilted the playing field in favor of market dominant incumbents.

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Adjusting for Risk Adjustment

Risk adjustment in health insurance is at first glance, and second, among the driest and most arcane of subjects. And yet, like the fine print on a variable-rate mortgage, it can matter enormously. It may make the difference between a healthy market and a sick one.

The market for individual health insurance has had major challenges both before and after the Affordable Care Act’s (ACA’s) risk adjustment program came along. Given recent changes from Washington, like the removal of the individual mandate, the market now needs all the help it can get. Unfortunately, risk adjustment under the ACA has been an example of a well-meaning regulation that has had destructive impacts directly contrary to its intent. It has caused insurer collapses and market exits that reduced competition. It has also led to upstarts, small plans and unprofitable ones paying billions of dollars to larger, more established and profitable insurers.

Many of these transfers since the ACA rules took effect in 2014 have gone from locally-based non-profit health plans to multi-state for-profit organizations. The payments have hampered competition not just in the individual market, which has never worked very well in the U.S., but in the small group market, which arguably didn’t need “help” from risk adjustment in many states.

The sense of urgency to fix these problems may be dissipating now that the initial rush for market share under the ACA is over and plans have enough actuarial data to predict costs better. There has been an overall shift to profitability. But it would be a serious mistake to think that just because fewer plans are under water, the current approach to risk adjustment isn’t distorting markets and harming competition.

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It’s All Going According to Plan

Most people regard health care reform in America as thoroughly bungled. The proverbial train left the station weak and wheezing, was pushed off the rails by hooligans and is about to crumple in an inglorious heap in the ditch. Only about 20% say the reform hits the sweet spot, with the rest convinced it went too far or didn’t go far enough.

To review the most recent pilings-on: in a time of huge Federal deficits, we get depressing predictions that the PPACA will do little or nothing to slow the growth of health care costs. Only a year after passage of what was supposed to be comprehensive reform, Democrats acknowledge that Medicare and Medicaid spending remain out of control and propose new cuts in the hundreds of billions. In the span of four months, Republicans switched from posing as aggrieved defenders of Medicare spending, to proposing to slash it and leave seniors to absorb the spillover. Medicaid funding is probably even more precarious, since fewer Medicaid recipients vote.

To add injury to injury, the Supreme court may rule to invalidate the entire law, or perhaps just the mandate to purchase insurance, thereby removing the most hated part of the law, but eliminating the “universal” part of universal coverage and inviting an actuarial death spiral. Oh, and the few reforms that look like they might bring costs down, like the IPAB board in Medicare and the minimum medical expense ratio for insurers, are under threat of being watered down. A year after legislation has been passed that will transform nearly a fifth of the American economy, to the casual observer it looks like nothing much has happened and nothing in the future is secure, especially anything that the big industry players don’t like.

In light of this and more, pessimism is understandable, but what we are witnessing in these turns of events is not mere politically-driven chaos. There is good reason to think that events are unfolding more or less in line with a staged strategy for deep reform that emerged out of the experience in Massachusetts. The strategy is essentially this: enact universal coverage first to precipitate a sense of crisis. This will lead to deep reform on the problem that exacerbates all other problems: the cost of health care. Readers of this blog need little reminding that these costs are twice as high as in any other nation.Continue reading…


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