Monday, June 29, 2009

Will Eliminating Medical Underwriting and Merging the Small Group and Individual Market Into a New Insurance Exchange Work? Lessons From Massachusetts

Creating a universal system of health insurance is everyone’s objective. But even if we pass an expensive health care bill in 2009 we won’t achieve it. We just don’t have enough money to cover everyone. Maybe, in the most expensive proposals, we would make it possible for 90% to be covered. In others, far less.

The problem is that without an absolutely seamless system there will still be people outside the system and able to game it.

So, how do you balance the goal of giving everyone access to the health insurance system without letting others game it?

Massachusetts has merged the small group and individual health insurance markets and eliminated medical underwriting—people can buy insurance when they want to even though a good number, albeit far fewer than before, of the state’s citizens continue to be uninsured.

So what can we learn from their experience—particularly because most insurance exchange proposals here in Washington, DC look a lot like the Mass health care law?

Harvard Pilgrim’s CEO Charlie Baker has a very important post on his blog. When you read it, remember that Harvard Pilgrim, based in Massachusetts, is undoubtedly one of the really good guys in the American health care system. Their plans continue to score at the very top in service and quality among all the leading surveys and they are one of those community-based health plans that make less than 1% profit.

Here is a portion of his post:
Now here’s the costly wrinkle. When the merger occurred, the state told the health plans in Massachusetts that we could no longer apply a pre-ex exclusion or waiting period to individual purchasers unless we applied it to all purchasers in the merged market (including all small businesses). No one was willing to impose such a condition across the entire merged market - primarily because it would be unfair to small businesses to impose such a requirement. In the end, we all hoped that the new state requirement on individuals to have health insurance - or pay a tax penalty - would encourage healthy individuals to purchase insurance every year, and offset this now wide open front door for individual coverage.

Long story short, I don’t think it’s working. A few months ago, brokers started posting comments on this blog site that implied that people - and some brokers and employers - were gaming that wide open front door - purchasing health insurance for a few months at a time, using a lot of services, and then dropping their coverage. The penalty for not having coverage isn’t all that steep - about $900 - and while a few months of coverage might cost $2-3,000 in premiums - that’s peanuts compared to the cost of many medical services, which can run into thousands of dollars in a matter of days.

After about the fifth broker comment, I asked our finance people to check and see if individuals purchasing insurance from us either directly or through the state’s Connector web site were buying for a few months at a time, and using a lot of services. The results were astonishing. Between April of 2008 and March of 2009, about 40% of the people who purchased individual insurance from Harvard Pilgrim stayed covered by us for less than 5 months. Even more amazing, they incurred, on average, about $2,400 per person in monthly medical expenses - roughly 600% higher than what we would have expected. It wouldn’t surprise me if other health plans have the same problem.

This is a problem. It is raising the prices paid by individuals and small businesses who are doing the right thing by purchasing twelve months of health insurance, and it’s turning the whole notion of shared responsibility on its ear. It’s also created a new way for people who don’t want to play by the rules to avoid them. The state needs to reconsider its policy to eliminate waiting periods and/or pre-ex exemptions for individuals purchasing health insurance in the merged market. That would be the simplest and easiest way to protect individuals and small businesses who are playing by the rules - and limit the very costly impact of this wrinkle in health care reform.

You can read the entire post here.


Avoid having to check back. Subscribe to Health Care Policy and Marketplace Review and receive an email each time we post.

Blog Archive