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.
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…