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Monday, July 27, 2009

At last someone mentions the real problem with the for-profit health insurance model
Posted by Jill | 5:08 AM
Lost in all the talk of mandated insurance and coerage of pre-existing conditions is the fact that you can pay into the system for decades, and when you get sick your insurance company can drop you like a hot potato.

Last month, former CIGNA executive Wendell Potter testified before Congress, blowing the cover off the idea that insurance is there for you when you get sick:
To win the favor of powerful analysts, for-profit insurers must prove that they made more money during the previous quarter than a year earlier and that the portion of the premium going to medical costs is falling. Even very profitable companies can see sharp declines in stock prices moments after admitting they've failed to trim medical costs. I have seen an insurer's stock price fall 20 percent or more in a single day after executives disclosed that the company had to spend a slightly higher percentage of premiums on medical claims during the quarter than it did during a previous period. The smoking gun was the company's first-quarter medical loss ratio, which had increased from 77.9% to 79.4% a year later.

To help meet Wall Street's relentless profit expectations, insurers routinely dump policyholders who are less profitable or who get sick. Insurers have several ways to cull the sick from their rolls. One is policy rescission. They look carefully to see if a sick policyholder may have omitted a minor illness, a pre-existing condition, when applying for coverage, and then they use that as justification to cancel the policy, even if the enrollee has never missed a premium payment. Asked directly about this practice just last week in the House Energy and Commerce Committee, executives of three of the nation's largest health insurers refused to end the practice of cancelling policies for sick enrollees. Why? Because dumping a small number of enrollees can have a big effect on the bottom line. Ten percent of the population accounts for two-thirds of all health care spending. The Energy and Commerce Committee's investigation into three insurers found that they canceled the coverage of roughly 20,000 people in a five-year period, allowing the companies to avoid paying $300 million in claims.

They also dump small businesses whose employees' medical claims exceed what insurance underwriters expected. All it takes is one illness or accident among employees at a small business to prompt an insurance company to hike the next year's premiums so high that the employer has to cut benefits, shop for another carrier, or stop offering coverage altogether — leaving workers uninsured. The practice is known in the industry as "purging." The purging of less profitable accounts through intentionally unrealistic rate increases helps explain why the number of small businesses offering coverage to their employees has fallen from 61 percent to 38 percent since 1993, according to the National Small Business Association. Once an insurer purges a business, there are often no other viable choices in the health insurance market because of rampant industry consolidation.

An account purge so eye-popping that it caught the attention of reporters occurred in October 2006 when CIGNA notified the Entertainment Industry Group Insurance Trust that many of the Trust's members in California and New Jersey would have to pay more than some of them earned in a year if they wanted to continue their coverage. The rate increase CIGNA planned to implement, according to USA Today, would have meant that some family-plan premiums would exceed $44,000 a year. CIGNA gave the enrollees less than three months to pay the new premiums or go elsewhere.

Purging through pricing games is not limited to letting go of an isolated number of unprofitable accounts. It is endemic in the industry. For instance, between 1996 and 1999, Aetna initiated a series of company acquisitions and became the nation's largest health insurer with 21 million members. The company spent more than $20 million that it received in fees and premiums from customers to revamp its computer systems, enabling the company to "identify and dump unprofitable corporate accounts," as The Wall Street Journal reported in 2004. Armed with a stockpile of new information on policyholders, new management and a shift in strategy, in 2000, Aetna sharply raised premiums on less profitable accounts. Within a few years, Aetna lost 8 million covered lives due to strategic and other factors.

We're hearing a lot about mandating "coverage" for pre-existing condition, but we're not hearing a damn thing about being able to KEEP that "coverage" if there are actually bills associated with that condition.

Today Paul Krugman actually mentions this, even if only in passing:
Reform, if it happens, will rest on four main pillars: regulation, mandates, subsidies and competition.

By regulation I mean the nationwide imposition of rules that would prevent insurance companies from denying coverage based on your medical history, or dropping your coverage when you get sick. This would stop insurers from gaming the system by covering only healthy people.

On the other side, individuals would also be prevented from gaming the system: Americans would be required to buy insurance even if they’re currently healthy, rather than signing up only when they need care. And all but the smallest businesses would be required either to provide their employees with insurance, or to pay fees that help cover the cost of subsidies — subsidies that would make insurance affordable for lower-income American families.

I recognize that when you have a real unemployment rate in the double-digits, you can't have an entire industry fold up shop and go home. But if we are going to continue with the insurance model, coverage is going to have to actually mean something. To mandate that people buy insurance without doing something about the practice of dumping is worse than doing nothing at all.

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2 Comments:
Amen and preach it, sister!

The illusion of a Real Plan is what I fear we're going to get.

Fortunately, I'm secure as anyone can be these days with a state job and excellent BC/BS. Considering changing jobs in my case would require serious scrutiny of the health insurance: Jackson's probably used up most all of his lifetime $ limit, and what's his future outlook on pre-existing this or that, being an extreme preemie...?

It's the ultimate good-health incentive: I have to take care of me, I'll need to work till I'm 100!
7/27/09, 8:33 AM  
Blogger Interrobang said...
This is yet another reason to find Obama's administration's pushback against its own antitrust regulators to be so depressing. "Industry consolidation" is a giant antitrust red flag.

The significance of which is that not only are you stuck with a for-profit system, you're stuck with a for-profit system governed by a cartel. Does anyone think that insurance industry executives would be so quick to admit to shady practices and then refuse to stop if enforcement had any actual teeth?
7/27/09, 9:39 AM  
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