I’m one of the very few health policy wonks you know (maybe the only one) who believes everyone should have access to health insurance the same way they currently have access to life, disability and homeowner’s insurance. In fact, I often refer to my blog as about the only health policy blog on the Internet that believes real health insurance is a legitimate business.
Wait a minute, Goodman. How can you say that? What about the Commonwealth Fund and Families USA? Don’t they believe everyone should have health insurance? What about everyone in Congress who supported ObamaCare? What about the president himself? Aren’t they all promoting the business of health insurance?
The short answer to all those questions is “no.” Real insurance involves a pooling of risks. The insurer must make sure each new entrant to the pool pays a premium that reflects the expected costs that entrant brings to the pool. Otherwise, the insurer won’t be able to pay claims. The business of insurance is the business of pricing and managing risk.
The organizations and people noted above don’t believe that “pricing and managing risk” is a legitimate activity. In fact, they went a long way toward completely outlawing the practice in the health reform bill. The only legitimate purpose of insurance, in their view, is to collect money and pay bills. For public insurance, this means collecting taxes and paying expenses. Their view of acceptable private insurance is to copy government insurance — a sort of private sector socialism.
Okay, Goodman, let’s accept that distinction for the moment. Doesn’t pricing risk mean charging me a premium that reflects my health status? The less healthy I am, the more I have to pay. Why should I want to buy insurance from a company that does that?
Because if your insurer doesn’t do that, a lot of bad things will happen.
Against the wind
Remember the phrase, “You’re in good hands with Allstate”? It was the voiceover at the scene of an auto accident where there has been catastrophic damage. The ad speaks volumes about what happens in real insurance markets. Basically, insurance is unimportant to you until things go very wrong. It’s at that point that you want good service.
Contrast Allstate’s ad with the kind of ads federal employees are subjected to during the fall open season for choosing a health insurance plan. What you never see in Washington are ads saying, “You are in good hands with [Aetna, Cigna, UnitedHealth, etc.] if you get [AIDS, cancer, heart disease, etc.].” Instead, the typical open season ad pictures young families with healthy children and no apparent health problems. The not-so-subtle message is: “You’ll be in good hands with us if you look like the people in these photos.”
Why is the health insurance market so different from auto insurance? Answer: health insurers are not allowed to charge federal employees premiums that reflect their health status.
Since the health overhaul legislation plans to make the federal employee health benefit system the model for health insurance exchanges nationwide, it’s instructive to stop and consider the incentives the health plans in these systems have. As explained in a previous analysis, if insurers have to take all applicants for the same premium, they will obviously try to attract the healthy (on whom they will make profits) and avoid the sick (on whom they will incur losses). After enrollment, their incentive is to overprovide to the healthy (to keep the ones they have and attract more of them) and to underprovide to the sick (to encourage them to leave and discourage enrollment by others just like them). If a TV ad could summarize how this health insurance market works, it would say, “You’re in good hands with us, unless you really need us — then we hope you will go somewhere else.”
And the reason this works is because people really can go somewhere else if they get sick — paying no extra premium.
So the incentives of the healthy employees are: Find plans that have lots of services for healthy people — knowing that if they get sick, they can always enroll in some other plan. The incentives for employees with a serious health problem (or more likely, a family member with a health problem) are to seek out plans that are the best at treating costly illness. But, as in a game of musical chairs, no insurer wants to be chosen.
In such a world, comparative effectiveness research, FDA rulings on drugs, end-of-life counseling and so many other controversial issues of late become very relevant. Insurance companies can’t just dump their sickest patients out on the street. They need cover. They need reasons not to pay for the latest cancer drug or the latest expensive test. Given the slightest encouragement, denial is in their self-interest.
Okay, Goodman. This is all very persuasive. But if my premium reflects my health status, what happens to people who are too poor or too sick to be able to afford those premiums? And what happens if a healthy person gets really sick (high medical costs) and wants to switch insurers?
These are good questions. I will answer them in a future Health Alert
John C. Goodman is president and CEO of the National Center for Policy Analysis. The Wall Street Journal and the National Journal, among other publications, have called him the "Father of Health Savings Accounts," and the Media Research Center credits him, along with former Sen. Phil Gramm and columnist Bill Kristol with playing the pivotal role in the defeat of the Clinton Administration's plan to overhaul the U.S. health care system. He is also the Kellye Wright Fellow in health care. The mission of the Wright Fellowship is to promote a more patient-centered, consumer-driven health care system.
Dr. Goodman's health policy blog is the only right-of-center health care blog on the Internet. It is the only place where pro-free enterprise, private sector solutions to health care problems are routinely examined and debated by top health policy experts throughout the country-conservative, moderate and liberal.
