Saturday, August 29, 2009


One of the effects of the exaggerations, misinterpretations, distortions, and downright lies about Congressional health care reform proposals—mostly from far-right politicians and their hangers-on—has been to deter more objective analysis.

In fact, two key features of the current Senate and House bills—the insurance exchange structure, and the controversial public plan option—need much closer examination, and possibly considerable revision.

FIRST, the insurance exchange structure. It’s a reasonable concept: if insurers were to compete via an exchange for individual and small group business, they would offer highly competitive rates to attract as much business as possible.

Unfortunately, as a Health Affairs blog piece by the former managers of the PacAdvantage exchange makes clear, it isn’t as simple as that. PacAdvantage, which served some 150,000 California small business employees, ultimately collapsed and closed its doors in 2006, a victim of adverse selection. As the PacAdvantage managers explain, having insurers also marketing directly to small groups allowed them to cherry pick the best risks, leaving the less-good risks in the exchange. As adverse selection continued its work, the exchange went into a death spiral with worsening exchange risk leading to higher rates, leading to the least-bad risks leaving the exchange, leading to even higher exchange rates, and so on.

The obvious way to avoid this problem in national reform is to require that ALL individuals and ALL small group employees be included in each regional exchange. Unfortunately, health reforming politicians have adopted “you’ll be able to retain your existing coverage” as part of their reform pitch. It’s understandable, since forcing groups to switch to an exchange is not going to help the prospects of legislation that’s already in trouble, but it instantly opens the door to cherry-picking by insurers, with the prospect of failure of every exchange.

Is there a solution? Rather than imposing an additional mandate on businesses, current bills could be modified to require that all insurers participate in the exchange, and that their exchange rates be no higher than those offered directly to any insured group, thereby forcing insurers to treat exchange and non-exchange insureds as part of the same pool and avoiding the adverse selection effect.

SECOND, the public plan option. So far, the political controversy has focused on the obvious arguments for and against the public plan: it would force insurers to offer better rates, but it could push millions of Americans out of private coverage into a government program.

A close look at data from Medicare Advantage, in which private plans compete with the traditional government option, indicates that both arguments are questionable.

MA’s private coverage alternative is indeed more costly than traditional Medicare, by some 13 percent—more than $11 billion in 2009. However, most of the difference is due to the additional benefits offered. The private plans’ 2009 base bids to CMS—excluding the cost of additional benefits—averaged 102 percent of FFS rates, with HMO and PPO bids averaging just 99 percent of FFS.

These base bid rates include profit and administrative costs, in contrast to the FFS rates which exclude both administration and financing costs. Even the most conservative estimate of these additional costs would put fully-loaded FFS rates above those of the average private plan.

The comparison of Medicare FFS and MA plans is further skewed by the MA bid process. Not only do the ridiculously high “county benchmarks” used in payment setting favor high bids, but the payment formula (which discounts the difference between the base bid and the benchmark, but not the base bid itself) encourages excessive loading of profit and administration into the base bid. In other words, in a more rationally designed competitive environment, average private plan costs should be significantly below those of traditional Medicare.

In terms of the current Senate Health and House bills, with proposed payment rates higher than Medicare, the public plan looks even less competitive. While there would undoubtedly be some who would opt for a government program over a private plan, the vast majority are likely to choose the lower cost option, with the public plan more likely to increase health care costs than decrease them.

Are there compromises that might satisfy liberal politicians’ desires for a public plan? One possibility is to build a “trigger” into the bills that would allow creation of public plans only where private plans fail to meet cost control benchmarks.

Another possibility is to build on the existing public plan for the non-elderly: Medicaid. Congressional committees are already proposing Medicaid expansions, while simultaneously proposing subsidies to make exchange participation more affordable for non-Medicaid eligibles, leading to an anomalous situation in which one family may receive free Medicaid coverage, while a second family whose income is only a few dollars greater is forced to pay a significant part of the exchange premium in order to comply with an individual coverage mandate.

A less costly and unfair approach might be to allow individuals to buy-in to Medicaid. Since average per capita Medicaid costs are approximately $2000, compared with estimated subsidy costs of close to $4000 (based on CBO estimates, in 2009 dollars), this would eliminate both the anomaly and the need for subsidies, with a potential dramatic reduction in the ten-year cost of reform of some $770 billion.

1 comment:

  1. Great analysis and sound ideas. What's sad and somewhat ironic is that mixing Medicare and/or Medicaid any further into the debate at this point will only provide more fuel for opponents to throw on the fires of misinformation and distortions that are consuming most of our hopes for meaningful healthcare reform.

    Like you, I see some real opportunities for extending existing solutions to the problems at hand. But, by now, the American public has become too confused by the complexity of the issues surrounding healthcare reform and far too misguided by the right-wing and special interest opposition to reform. It's been hard enough to get meaningful reform for Medicare and Medicaid in the past several decades when no one's interests were seemingly at stake (save the elderly and poor). Throwing these programs into the mix now is simply too much for the American public to handle. What's the current phrase? TMI? Too much information?

    The point is that all of the information (and disinformation) overload is playing right into the hands of those who would kill meaningful healthcare reform. Or at least, water-it-down to a largely meaningless bill that'll do nothing to reign in escalating medical costs nor the growing monopolistic power of Big Insurance. In the end, the American public may be forced to throw in the towel, which means the status quo will win and little will change.

    From your perspective, why haven't major U.S. employers more vocally weighed in on this issue? They're the ones paying the lions' share of the escalating costs and suffering with the declining service from their managed care companies and dissatisfaction from employees.

    My perspective is that they've been held hostage for so long by their managed care companies that they've lost the capacity to object to or even question the ways in which the insurance industry operates. Unfortunately, doctors, too, have been held hostage in HMO and PPO networks to the extent that few have been willing to bite the hand that feeds them by cancelling network agreements that are bad for them.

    Our backgrounds have a number of similarities, Roger, and I invite you to visit my blog, ajlesterblog.blogspot. com or website, ajlester. com. I'd be pleased to hear your feedback in a post or personal phone/email exchage to my firm's approach that cuts out the managed care middleman and allows employers to contract directly with providers.