Hypothetical Mean

Commentary from an Actuarial and Economic Perspective

Once Covered, Always Covered

leave a comment »

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 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.


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.


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?


Written by Victor

October 26, 2009 at 11:45 pm

Leave a Reply

Please log in using one of these methods to post your comment:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: