Health Reform … Round 2

Filed Under (Health Care) by Nolan Miller on May 18, 2010

The next round of the health reform debate is shaping up.  While the first battle was fought in Congress, the next will be fought in various federal agencies as regulators begin to flesh out the vague provisions of the gargantuan health reform bill.   I know, you’d think that a 300,000+ word bill would be pretty specific, but many of the details, from exactly how the insurance exchanges will work to exactly how provisions aimed at “curbing insurance company abuses” will be implemented, have yet to be described.

One such provision that has gained a lot of attention following Wellpoint’s well-publicized attempts to increase premiums for some of its California customers by up to around 39 percent is aimed at preventing “unreasonable premium increases.”  Of course, exactly what is “unreasonable” is not described in the bill, which has led state and federal regulators and insurance companies to return to the fight.

Of course, the model for all of this is Massachusetts, which enacted health care reform in 2006.  Using Massachusetts as a model for national reform is interesting for several reasons.  First, Massachusetts has the highest insurance premiums in the country.  Second, in designing Massachusetts’ universal coverage program, policymakers understood that they were first going to tackle the coverage aspect of the problem, expanding insurance to more people, and then take on the cost problem.  And, while we’ve seen the results of the coverage expansion, Massachusetts hasn’t yet done anything  significant to curb costs.  Those steps they have taken (described in the article above) have yet to show a real effect on cost.  It’s like we saw Massachusetts jump down the rabbit hole and jumped down after them, not knowing if they had any idea how to get us out.

Massachusetts’ approach to “unreasonable” premium increases was apparent last month.  Out of 274 applications by insurers to increase rates, Massachusetts denied 235 of them.  According to the regulator, Massachusetts “disapproved requests when companies significantly exceeded the region’s medical inflation rate of 5.1 percent, failed to justify why varying rates were paid to different hospitals, and did not forcefully negotiate prices with providers.”  This seems like an entirely plausible reason for denying an increase.  Who knows whether the regulators were right to do so or not.  I will end with a story about my own time in Massachusetts, though.  When we moved to Massachusetts in 1999, we were surprised to find that none of the large, national auto insurers offered coverage there.  When we asked around, it turned out that because of the state’s (technically “commonwealth,” la-di-dah) strict regulation of the auto insurance industry, many of the national players decided simply to bypass Massachusetts.  

Premium controls enacted at the national level may not drive insurers out of the market.  After all, it isn’t like they can just choose to operate in another country.  However, policymakers should anticipate that clamping down on premiums directly as a means of controlling costs may ultimately be counterproductive if it reduces competition.  The solution to the cost of health care is not going to come from top-down regulation of premiums and profits, but rather from reforming the system to one where we create health more efficiently, providing greater quality using fewer resources.  And, to the extent that healthcare providers are able to do this, they’ll deserve higher profits.

Adverse Selection — California Style

Filed Under (Health Care) by Nolan Miller on Feb 9, 2010

News from the West Coast today that Anthem Blue Cross, one of the largest private insurers in California, is raising the prices for the 800,000 or so people it sells individual health insurance policies by up to 39%.  The Obama administration is not happy, to say the least.  HHS Secretary Kathleen Sebelius fired off an angry letter to Anthem and its parent company, WellPoint, demanding an explanation.  Of course, this also comes at a time when the Obama administration is struggling to make the case that health insurance reform is urgently needed, so this also provides a perfect example for them.  The letter is kind of cool, since I have never seen an angry letter from a Cabinet Secretary before.  The text is here.

What I find more interesting as an economist, however, is WellPoint’s response.  They haven’t replied formally to the letter yet, but in a statement WellPoint’s spokesman said the following:

“As medical costs increase across our member population, premium increases to the entire membership pool result. Unfortunately, in the weak economy many people who do not have health conditions are foregoing buying insurance. This leaves fewer people, often with significantly greater medical needs, in the insured pool. We regret the impact this has on our members.”

So, where’s the economics lesson here?  In a competitive market, health insurance prices are driven by the cost of caring for the average person in the insurance pool.  That means that healthy people usually pay more than their actual cost of care and sick people pay less.  Although healthy people pay more than their average health expenditures in any year, they’re still willing to buy insurance because it provides them with, well, insurance.  In the event that they have a car accident or other unexpected, large expenditure on health care, they’re protected against the financial consequences.  This works fine as long as the premium (driven by the average cost of care) doesn’t get too high above what the healthy people are willing to pay for insurance against relatively rare events.

Now, enter the recession.  People are losing their jobs, wages for the employed are stagnating, and people are losing money on housing and financial investments.  In light of these challenges, some healthy people are looking at their health insurance premiums, their income, and the likely cost of going without insurance, and deciding not to buy health insurance.

This is a perfectly rational response to increasing premiums and decreasing incomes.  However, it results in the remaining people in the insurance people being, on average, sicker.  This means that the average cost of caring for the insurance pool will be higher, which will necessitate higher premiums.

Unfortunately (and interestingly if you study this stuff), this leads to the potential for what is known as an “adverse selection death spiral.”  The idea is that once premiums rise, the healthiest people who are still buying insurance may decide to drop out of the pool.  Since the remaining pool is even less healthy on average, premiums will once again need to rise to cover their higher medical needs.  And then the cycle starts over again.  In extreme cases, the premium just keeps going up until nobody is willing to buy insurance.

So, what next?  Well, the adverse selection story holds in competitive markets.  But, you can already see Secretary Sebelius telegraphing the administration’s punches.  They will argue that the price increases are not due to competitive pressure and an increasingly unhealthy insurance pool but rather a greedy, for-profit insurer trying to take advantage of people when they’re down.  For their part, WellPoint/Anthem will argue that this just shows why health reform is needed, but health reform of a fundamentally different sort than Obama has proposed.

My prediction is that we’re headed for a highly charged series of Congressional hearings that boil down to an attempt to drive home to voters that something needs to be done.  Really went out on a limb, there, didn’t I?

Tuesday was a good day for health insurance stocks.

Filed Under (Finance, Health Care) by Nolan Miller on Jan 20, 2010

Following up on a post from last month on the public option and health insurer stock prices, here’s a chart of the price of CIGNA, Aetna, WellPoint, Coventry Health, Humana and United Health (along with the DJIA and Nasdaq Composite Index) from Friday until now.   Due to the Martin Luther King Holiday there was no trading on Monday, which means that Tuesday morning was the market’s first chance to react to the series of reports over the weekend that Democrat Martha Coakley’s bid to take over Ted Kennedy’s seat in the Massachusetts special election on Tuesday appeared to be in trouble.  In fact, in the Tuesday special election Coakley was beaten by Republican Scott Brown who campaigned on a vow to oppose health care reform.  Due to the fact that Brown’s victory will result in only 59 Senators in the Democratic camp, preventing them from defeating Republican filibuster tactics, the media has speculated that Brown’s victory will spell the end of health reform.


(Source: Google Finance.  Click here to make your own graph.  The original idea came from the Huffington Post, here.)

The impact on stock prices is striking.  See the two flat curves hovering around zero?  They are the DJIA and Nasdaq Composite Index.  The other lines (the ones that jumped up Tuesday morning) are the major insurers CIGNA, Aetna, WellPoint, Coventry Health, Humana and United Health.  As to what this means for the prospects of health reform (and what health reform means for insurers), I think the graph speaks for itself.

By the way, Coakley, Brown and their families kept robo-calling me over the weekend despite the fact that I don’t live in Massachusetts anymore.  I hope they figure that out before this seat comes up again in 2012!

The Public Option and Stock Prices

Filed Under (Health Care) by Nolan Miller on Dec 24, 2009

I assume that everyone has better things to do than read this blog over the holidays.  But, cyber-space is forever, so I thought I’d post anyway.  Here’s an interesting piece from the Huffington Post (sent to me by Dan Karney — thanks, Dan!) that traces the stock prices of health insurers since Joe Lieberman laid siege to the Senate bill on October 27, threatening to support a filibuster unless the public option were removed.

As a health economist, I’m pretty unsure about what the public option will do.  But, the market seems pretty clear in its expectations.  Basically, the stock of major health insurers such as Coventry, CIGNA, Aetna, WellPoint, UnitedHealth and Humana went up anywhere from 13 to 31 percent between October 27 and December 18, relative to a 2.3 percent increase in the DJIA.  Now, this isn’t all due to the Lieberman threat and the possible removal of the public option.  Some of this may be due to increased skepticism about the likely passage of any bill at all or other changes in the legislation that were introduced during this time.  But, it certainly appears that developments over the last month and a half have been interpreted as good for insurance companies.

Here’s the link.

Happy holidays to all.