Another embarrassing gaffe has surfaced in this memo from the over-worked health staff at the CBO.  The problem is the parenthetical after the opening sentence:

(A medical loss ratio, or MLR, is the proportion of premium dollars that an insurer spends on health care; it is commonly calculated as the amount of claims incurred plus changes in reserves as a fraction of premiums earned.)

Ahem.  As any first-year actuarial student hopefully knows, the medical loss ratio is simply the amount of estimated claims incurred as a fraction of premiums earned.  They are getting way too clever by half.  What they suggest is a meaningless calculation.

One typical way you calculate incurred claims is to take paid claims and then add the change in reserves.  That would result in an estimate of claims incurred which could be used in the loss ratio calculation.  But if you already have claims incurred, there’s no point to adding the change in reserves.

Regardless, putting the CBO nonsense on an actuarial exam would warrant a failed paper and a well-deserved one year delay on the road to Fellowship.

My lesson is not that they are ignorant, but that they need more sleep.  After missing the CLASS Act premiums by 20-ish percent, and other recent problems, I think we have sufficient reason to be worried that they are being over-worked.

Just for fun predictions for the healthcare bill that Reid is set to unveil at 6:30 AM tomorrow.

* It will not have any substantive “public” option and will make some headway on the abortion issue;

* It will have significantly reduced individual mandates, but the CBO models will not have those result in significantly higher uninsurance rates;

* It will have woefully insufficient levels of subsidies for poor Americans, and will limit their growth in future years.  I define “woefully insufficient” as subsidy levels that will not reduce Exchange premiums for a family at 200% of poverty to lower levels than premiums available today in non-guaranteed issue states (like Arkansas).  As a rule of thumb, a 40-year old man can get an 80% actuarial value plan for under $100 per month today in Arkansas.

* It will not have the CLASS Act;

* There will be some sort of trigger that states can pass to “opt-in” to the Medicaid and other provisions of the bill;

* This bill will garner 60 votes for the 1 AM cloture vote on 12/21, and all subsequent cloture votes through the 12/24 vote.  This will be a straight party-line vote;

* This bill will be virtually impossible to reconcile with the House’s bill;

* The CBO will again fail to offer a final score, and will fail to offer any of the following:

* Estimated premium and uninsured impact by state, considering the rate regulations currently in place in each state;

* Estimated total subsidies by state;

* Estimated impact on national health spending;

* Exchange-only premiums, as opposed to average individual premiums which include grandfathered plans;

* Estimated impact on labor-force participation rates (and therefore Social Security) of the near-elderly;

* A result that has a reduction in grandfathered individual membership from 2014 through 2019;

* US Senators will be asked to cast deciding votes without knowing whether this bill will help their state, specifically, or by how much.  This damaging information will trickle out from 2010-2014, if this bill can be reconciled and signed by the President.

I hereby publicly challenge defenders of the CBO healthcare model to address the following:

a) Produce 2010 and 2016 state-specific non-group rates, before and after reform, so that an apples-to-apples comparison on premiums after reform can be demonstrated against premiums for sale in the marketplace today.

States like Arkansas today have rates 50% of the national averages being modeled by the CBO.  After reform, the regulatory changes will push all states closer to the subsequent national averages.  The maximum geographic variation in the CBO models appears to be 0.8 to 1.2, meaning that after reform, Arkansas will probably have rates equal to 80% of the national average.  That represents a 60% increase in premiums in the state of Arkansas.  This is BEFORE any effect modeled by the CBO with respect to reform’s impact on the national average itself.

b) Provide 2016 non-group premiums divided between the grandfathered and Exchange blocks.  Currently, the CBO is advertising that the national average COMBINATION of policies issued under current rating rules (grandfathering) and future rating rules (Exchange) will only increase by 10-13%.  Obviously, it is likely that the grandfathered plans will only see part of this increase (parts due to taxes and similar provisions), while the Exchange will be subject to higher rates and adverse selection.

c) Provide 2016 subsidies by state, by FPL category.  States like Arkansas, even after reform, may have premiums 33% lower than other states, simply because of cost of care differences.  That means that low-cost states like Arkansas will get fewer subsidy dollars per enrollee than states that have out-of-control costs.

d) Provide justification for the assumption that non-Exchange individual policies will remain steady or grow between 2014 and 2019 under reform.  It will be illegal to sell grandfathered policies.  Why are their models producing sales outside of the Exchange into 2019?  Most policies issued today terminate when you move across state lines; termination of grandfathered products will result from migration, if nothing else.  The concern here is that their Technical Documentation does not seem to allow for the actual features of individual products, namely their lifetime duration and exit provisions.  One concern is that their model may not be incorporating lapse rates within that block, meaning they are understating enrollment in the Exchange, thereby understating the cost of the bill.

None of these challenges should be interpreted as a professional statement that I am ceding that the CBO projections are otherwise reasonable.  Rather, I offer these challenges so that if they are ever taken up, all of us will either see the limitations of their work more clearly, or so that these fairly obvious concerns can be abated.  It is stunning to me that they did not provide greater specificity in response to Evan Bayh’s requests for greater information.

The CBO’s 11/30 premium analysis of the Reid healthcare bill estimates a 0% to 3% reduction in premiums per employee for large firms.  This has been interpreted as positively impacting large employers and their employees.  This interpretation is likely false.

A primary driver of this reduction in per-employee premiums is the addition of healthy employees and dependents driven to coverage because of the mandate.  This means that more employees and dependents will participate in the health plan.  Average costs may fall, but total costs will increase.  That will force employers to make budget decisions which, in turn, will likely increase the premium costs to individuals.

My discussion will focus on an illustrative example: a firm with 100 employees, 80 of who take up coverage.  The premium rates charged this groups are $200 per employee per month, and the employer pays 75% or $150.  The employer pays $12,000 per month ($150 * 80 employees).  Each employee pays the remaining $50.

Under reform, let’s assume that all 100 employees participate in the plan, driving the average cost downward by 2%, so the actuarially-fair rate is $196 per employee per month.  The employer continues to pay 75%, which is now $147.  The employer now pays $14,700, a 22.5% increase in their healthcare bill!

One response worth discussing would be if the firm keeps their $12,000 total contribution frozen.  This would translate into $120 per month off of each employee’s premiums.  This would result in the employee premiums increasing from $50 to $76, a whopping 52% increase.

Significant care must be taken to interpret the CBO numbers correctly.  Unfortunately, the CBO paper itself isn’t sufficiently detailed for us to discern the size of the impact I discussed above, nor how they model the employer contributions to health plans.

For the economics geeks out there, if you are still reading, you’ll recognize that the problem here is that the implicit wage reduction funding the healthplan is paid by all employees, yet the benefit is limited to a subset of people who sign up for the plan.  This results in cross-subsidization between workers.  The CBO is telling us that this cross-subsidization may fall after reform, with a resulting dynamic change in the implicit wage reduction.

(Note: they also tell us that the worst risk may bail on the employer healthplan, and go to the exchange.  This may happen for low-paid workers eligible for cost-sharing subsidies.  The fact that this may happen for some employers does not mitigate the fact that the effect I describe above will also happen for some employers.  They also tell us that large groups with better-than-average costs may be grandfathered, leaving the worse-than-average groups to participate in the Exchange-based pooling; somehow this does not impact large group premiums or cause an increase in the pooled rates insurance companies must charge).

What if the CBO was more than $90 billion off its cost estimate for HR3962 (blog entry here)?  I think it may be, and it is easy to explain why.

Yesterday, I pointed out that the projected non-group enrollments outside of the Exchange were highly implausible.  Specifically, since individual new-sales outside of the Exchange would be made illegal, it seems illogical to project a static or increasing population of individual policy holders outside of the Exchange.

In today’s marketplace, people tend to cycle through individual coverage; as many as 35%-40% of policies terminate before they reach their first anniversary.  We could take all of the CBO assumptions, but simply assume that only 25% of individual policies lapse annually.  The result would be more than $90b in additional costs between 2015-2019, as illustrated in the table below.

The first three lines in the following table are straight from the various CBO reports.  The fourth line simply assumes that 25% of the policies that existed in 2015 lapse in 2016, and so forth through 2019.  I then assumed that those who lapse join the exchange at an average cost equivalent to those already on the Exchange.  The result is a whopping $91 billion difference.

This illustrates two things.  First, we have very little idea what is really going on inside the CBO models, and results this bizarre suggest that more peer review is warranted.  Second, even if the initial CBO model is perfectly fine, tiny tweaks in assumptions can result in massive swings in cost for this sort of program.  I would argue that this program design is inherently risky; the only way to keep the costs even remotely under control is to build a series of firewalls between employer-based coverage and individual coverage (less than 20% of people are even eligible for the Exchanges let alone the subsidies).  If any of these firewalls leak or if any of these assumptions are slightly wrong, we could be in serious fiscal difficulty.

Compare and contrast Table 2 from the CBO analysis of HR3962, the new House healthcare bill.  Specifically note that non-group /other net enrollment increases from 24 million to 30 million between 2015 and 2019.  Now compare this to the bill itself, Title II, Section 202, Page 94:

Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan.

How can enrollment go up if new enrollment is disallowed outside the Exchange?

The problem is further exacerbated when you realize the new dependents born after “Y1″ (A-1-B, page 91) are not allowed onto their parents’ plans and that individual business generally has a 30-40% lapse rate annually.  Granted, people may not be willing to part with the relatively cheaper grandfathered plans, so the lapse rate is likely to fall.  But it can’t go negative.

Perhaps the circle is squared by the ephemeral “other” category in the analysis.  But I doubt it.  Compare the HR3962 score with the Baucus bill score, which separated “other” from “non-group”.  In that score, those two categories moved in tandem under “current” law, and it seems reasonable to presume that the “other” category is mostly unaffected by reform (I presume it is Medicare disability, etc.).

There are many such examples like this, where you just want to shake the CBO and ask “What are you smoking?  And … Can I have some of that?”  I think I’ll need it.

Tom Maguire at “JustOneMinute” came up with that catchy phrase — Once Covered, Always Covered — to discuss the main component of my desired healthcare reform approach that I began to outline last year. With a catchy phrase in hand and with no hope of having any impact on the current healthcare deform bills being discussed today, here’s a talking-point listing of some of the components of my reform ideas.

PORTABILITY:

Portability of one’s insurance is the most easily addressed component of reform.  That’s where the Once Covered, Always Covered approach kicks in.  By law, everyone who is currently covered could switch coverage if they move, if they leave their job, or whatever.

All plans would be assigned an “actuarial value” and you could seamlessly turn in a group coverage plan for an individual-market plan as long as the newer plan was at the same actuarial value or lower.  Currently, the transition from group coverage to individual coverage is non-standard across states.  The transition to group coverage is covered by HIPAA, but has some holes.  Lastly, a Once Covered, Always Covered approach would eliminate administratively costly COBRA provisions.

All reform proposals carry with them tradeoffs; any pretention otherwise is dishonest.  The downside of this approach is higher “new business” individual rates.  State insurance departments would have to be vigilant to prevent carriers from capriciously entering a market, buying business, exiting the market, and then raising rates rapidly.  I have solutions in mind to minimize these problems, but they would get technical and wouldn’t entirely solve the problem.  But this is a tradeoff that I think many would willingly make.

UNINSURED:

If people are denied coverage today, they have guaranteed-access to state-run high risk pool insurance.  I would build on this in one of two ways.  First, we could federally subsidize the pools and streamline access.  Alternatively, we could work through the private insurance system entirely and have the federal government reinsure/subsidize high risk individuals.  Expected costs for initially sick individuals lower over time just as expected costs for initially healthy individuals rise over time.  I would taper the subsidies to mirror this reverse “underwriting curve”.  In either case, the federal subsidy should not fully pay for the increased cost of these individuals; there has to be some penalty for remaining outside the system until you become sick.  The penalty in today’s world is the administrative hassle to get into a high risk pool as well as the relatively high premiums in them.

COST:

No one has a good idea how to rein in cost in the current system.  Therefore, the only way we can be certain to lower costs is to reduce what is covered.  I would divide claims into four categories.  1) Claims that would be continued to be paid under private insurance, 2) claims that are not socializable and therefore will not be allowed to be paid under private insurance, 3) claims that fulfill a well-defined public objective, 4) non-essential medical services.  Examples of the latter two cases are as follows.  Examples of “non-socializable” claims are those that aren’t clinically more effective than cheaper and available alternatives, drugs advertised direct to consumer, claims that carry a disproportionate personal benefit and therefore don’t need to be socialized, like Chantix for smokers (Chantix is cheaper than cigarettes).  Examples of claims that fulfill a public objective include vaccinations, preventive health measures, etc.  I would also argue that maternity claims (which aren’t “insurable”) should fit into the category, including the extremely high cost and ethically electric issues of premature baby costs.  Tax revenue would have to raised to pay for this last category of benefits.  Non-essential medical services would include chiropractic services, mental health benefits, etc.  These services could be included in healthcare plans, but plans without these services must be sold to make sure coverage for essential services is affordable.

By focusing private insurance on just those sorts of claims that are medically necessary and that can be insured and socialized across individuals, we can significantly reduce the cost of coverage.  We need to begin a wave of “reverse insurance mandates” because we need to make truly necessary care affordable.  And if you want to tack federal subsidies onto these leaner.

I could go on, but what are the odds that anyone is actually reading this, let alone someone who could make this healthcare deform movement make some sense?

I hate to say it, but I think the excellent bloggers/economists Andrew Samwick and Donald Marron are entirely wrong when they say that “The problems of adverse selection and moral hazard in insurance markets are well known — they are what stands in the way of extending the benefits of competition to health care.  Addressing them should be the central features of the reform, with a risk-adjustment mechanism to address the former and high-deductible plans to address the latter.”

Adverse selection does not exist when the insurance company knows more about your expected costs than you do.  Here’s a quick question to illustrate:

You’ve had a simple fracture in the past three years.  What is your additional expected healthcare cost next year?  Do you know?  I do.  Change the question to a “wait-and-see” diagnosis for a pre-cancerous lesion and I’d still say I know more about that expected cost than you do.  We’ll rate for that expected cost, load for profit, and sign the contract.  Cool?

Insurance companies can issue surcharges for significant extra risk.  Profits don’t come from only insuring the healthy.  Insurance companies actually earn more profit insuring the <i>identifiably</i> sick <i>who also choose to be covered</i>.  Those contracts have more risk and more associated profit, almost always (if nothing else, profits are generally priced as a percent of premium, and the sick will be charged more premium because insurance companies are able to identify them with reasonable accuracy).

The problem is that there comes a cost level where the expected cost plus needed risk charges will exceed the person’s willingness / ability to pay.  And/or the needed price will be so high that it will make a demure health insurance company blush, making them worry about PR.  And rates are also frequently capped by regulatory limits on surcharges (I’m not arguing against those regs, I am simply pointing out that their existence leads people to be denied coverage).

This leads naturally into a second error I believe that Andrew and Donald are making when they trumpet potentially imperfect and administratively costly risk-adjustment mechanisms (actuaries are a top 3 profession and someone has to pay us for something).  Risk adjusters aren’t really a solution for adverse selection; risk-adjusters are really a way to transfer resources between individuals.  Again, an illustration:

A 20 year old male with a risk-score of 0.5 walks into a bar that sells insurance (yeah, yeah).  The bartender says “what’ll you have?”  The male says a $1,000 deductible plan.  The bartender says that he used to be able to sell that for $100 … but now he has to compensate for the 20-year old’s low risk score, so that he has to charge $300.

A 55 year old woman walks into that same bar.  She has a risk score of 1.5 because she had a zit on her nose when she was a teenager.  Yadda, yadda, yadda, and instead of being charged $600, the bartender can sell a policy to her for $400.  The bartender can (has to) do that because he has $200 shifted from the 20-year old.

Has any adverse selection problem been solved here?  Nope.  Either could have gotten the service for the initial price (and notice that the initial prices are independent of the quantity of competitors since they are simply a function of their true cost, which insurance companies can guess at better than you).  The difference is that after risk-adjustment, the healthier pay more and the sick pay less.

In fact, risk-adjustment may <i>cause</i> adverse selection, because, suddenly, the bartender can’t charge the 20-year old the low rate his health deserves.  The 20-year may just tell him to kiss off.  In which case everyone except the actuary will lose since you’ll have to pay the actuarial salaries to offer the exact same contract to the 55 year old that you would have without risk-adjustment.  Because even risk-adjusted markets can cause adverse selection, actuaries are (misguidedly) demanding that an insurance coverage mandate accompany this push to deform healthcare.

One of the fundamental questions of healthcare reform is “Who has the right to benefit from or pay for your health?”  If you answer that you do, then you don’t support risk-adjusters.  That has very little, if anything, to do with adverse selection.  Conversely, if you answer that no single person should benefit from or pay for their health, then by all means, risk-adjust away. They are great make-work for actuaries with tons of cool intellectual problems I’d like to try to be clever and solve.  And if that isn’t enough of a reason to support them, they can also be very successful at redistributing the financial gains and losses that would otherwise be caused by your health.

Just don’t pretend that you did it to solve a perceived adverse selection problem.  You did it to solve a perceived maldistribution of resources.

Part II: The Math of Individual Coverage

The benefit plan defined in the House healthcare reform bill is designed to limit a family of four’s annual healthcare expenditures to under $20,000 in 2013, assuming they are at 400% of Federal Povery Level (FPL) or lower.  Here’s how they do it.

First, the direct premium subsidies in the bill will limit the premium paid by a family of four to just over $800 per month, or $9,680 per year (see Section 243; assuming 400% of FPL and no increase in salaries between today and 2013).

The plan that can be purchased for that price, or lower, is the “basic plan” that will be designed to cover 70% of your allowable medical costs.  For a typical plan that might have $10,000 in expected allowed costs, this means that the family of four will expect to have $3,000 in additional copayments and coinsurance amounts.  The total expected outlay would therefore be less than $12,680 in after-tax dollars.  Impressed yet?  If not, there’s more.

This plan separately caps the household’s potential out of pocket cost.  For that same family in 2013, the House bill promises that you will not owe more than $10,000 per year.  The total annual out of pocket outlay would therefore be capped at $19,680 for that family.  This out of pocket maximum is much higher than the expected outlay in 2013.  In later years, the expected outlay will increase faster than the out of pocket maximum, pushing those values closer together.  I’m not sure why they chose to do that.

This maximum $19,680 will have to come from after-tax income.  Most families at 400% of FPL are in a 15% tax bracket and perhaps a 5% state bracket.  That means that $24,825 in pre-tax earnings will cover the maximum outlay designed by the basic plan in the House.

For the same family of four earning 200% of poverty, things look much better.  Their maximum premium is $2,200, with (potentially) the same out of pocket maximum.  Their total maximum out of pocket cost would then be $12,200.  On average, they would expect to pay “only” $3,700 in cost in after-tax dollars, however, because they will enjoy another feature of the bill: lower copayments for poorer families.  This after-tax difference of about $9,000 represents a sizeable implicit penalty that this plan will levy against those who get wage increases, take on second jobs, etc.  When making forecasts, the CBO assumes that this implicit penalty does not signficantly affect the labor market.

For those earning more than 400% of FPL, there is no cap on premiums, but the $10,000 cap on out of pocket medical expenses remains in the base plan.

Expect the Senate Finance Committee to be much stingier with subsidies, thereby raising these annual cost levels.  Also expect the Blue Dogs to fight to reduce these subsidies, also increasing these annual costs.  Lastly, this bill is planned to increase the size of all deficits in 2013 and beyond.  This increased budget pressure in the second half of this decade will force budget cuts, also decreasing these subsidies.

Therefore, I suspect that the $20,000 annual cap on costs is a best-case scenario.  We do need healthcare reform.  I’m concerned that the focus on federal deficits and budgets has obscured the fact that this bill does little to solve the average family’s problems.  If anything, it could make it worse.  Sad.

The first part of this series was posted here.

Part I: Individual Coverage Purchased after 2013

The House healthcare reform bill will significantly change the way you buy individual coverage.  Here’s a summary of the more striking provisions, and possible ramifications:

• Beginning in 2013, all individual insurance must be purchased through the government’s Exchange.  No more ehealthinsurance.com, although I wouldn’t be surprised if they aren’t a bidder for the government contracts to build the Exchange.
• Premiums on young men must be at least 50% of the premiums charged men age 64; the impact of this will differ around the country.  In states like New York where full community rating is already in place, this may lower premiums for young men; in most of the country, this will significantly increase premiums for young men.
• Premiums cannot reflect the cost differences between men and women; since women utilize care more intensely than men, at least through most of the age spectrum, this means that women will enjoy better value from plans offered after 2013.
• You will have up to 4 possible plans to choose from, three of which will basically be the same but with slimmer copays, with the fourth potentially adding dental and vision benefits.  These plans will focus on the use of copayments, avoiding coinsurance whenever possible.  Plan design will be governed at the national level through the Benefits Advisory Committee.
• Member copayments will increase faster than medical cost inflation which in turn will almost certainly continue to increase faster than the Consumer Price Index; the reason for the rapid rise in copayments is technical, and I’ll reserve for another post.  This is also little different than what is going on in the market today; the important distinction is that the Exchange plans will be tightly constrained by this law in how they deal with this mathematical problem whereas in today’s market, consumers decide how they want to spread this cost around.
• Over time, the basic plan will converge into something that will look like a $5000 deductible, 100% coinsurance major medical plan; the other plans will likely follow suit unless Congress intervenes.
• For members with incomes less than 400% of the Federal Poverty Limit, payments will be made by the Commissioner to the offering healthplans to help offset lowered copayments.  Healthplans, in turn, are to require lowered copayments, consistent with subsidized actuarial values.  How this consistency is determined is quite complex theoretically, and the proposed law is silent on measurement and enforcement, other than that the Commissioner’s actuarial models are to be used to establish the size of the payments from the Commissioner to the healthplans.
• For healthy members, the basic plan will almost certainly be the best value.
• For poor members, the basic plan will almost certainly be the best value, since the plan will be enhanced, for free, through government subsidies.
• You will need to annually file evidence of coverage.  Healthplans will send you information on what months you had qualifying coverage.  You will owe 2.5% of gross income in taxes if you did not have qualifying coverage for yourself or your dependents.  This is prorated if you let coverage lapse for any portion of the year.
• You will need to notify the commissioner when your income or family status changes.  This way your subsidies and plan design can be reconfigured by the Benefits Advisory Committee.  Failure to do so may result in penalties, especially if your benefits or subsidies should have been reduced because of an increase in income.
• If you don’t like the commissioner’s reconfiguration (i.e., change in copayments), you will be allowed to change plans during your annual election period.

Some other items (either more obvious or related to features that exist today):

• Individual plans purchased on the market today are “guaranteed renewable”, meaning that the healthplan cannot drop your insurance if you get sick.  Other laws prevent them from raising your premiums because of your health status, after you have insurance.  Plans under the Exchange will most likely NOT be guaranteed renewable; this isn’t a problem, for the most part, since you will have guaranteed issue rights to a new policy from the same or different carrier.  Your premiums still won’t increase because of your health status; in addition, they won’t be able to increase your initial premiums based upon your health status.
• The policies won’t have pre-ex periods or exclusion riders.
• The first few years are likely to see volatile premiums; after that, however, rate increases should be more stable than what you see in the individual market today.  That’s because rate increases due to aging will be limited (you will pay a much, much higher premium when young, but the flip side of that is that your premiums won’t increase as much as you age), rate increases due to “duration wear-off” won’t exist because initial underwriting won’t exist; and you will be part of a larger risk pool.
• The larger risk pool likely means you will be included in a higher average cost risk pool, but administrative expenses may be somewhat lower because of reduced underwriting costs.  This improvement in administration costs may be offset by behind-the-scenes reporting requirements for risk-adjusters, monthly copayment recalculations, plan coordination, and increased bureaucratic oversight.  The CBO has net yet modeled these administrative costs.

For CNN’s perspective on what healthcare reform means to you, see this piece by Sahadi.  Obviously, I think CNN’s discussion focuses more on the talking points than the likely result of the specifics of the legislation.  Lastly, these plans are in flux and so any of the aforementioned opinions or predictions may be obsolete at the time of this writing.  I also wrote these while reading the legalese of the House bill while playing with my oldest son.  Caveat emptor.  But I feel confident that these predictions are reasonable enough that they should be contravened carefully before being dismissed.  The devil is truly in the details.

Part II of this series details the House’s $20,000 annual household cap on medical costs.