How Badly Obamacare Beat Up On the Health Insurers, and What Does It Mean for the Individual Market

D.C. deals with health insurers

As Disease Management Care Blog readers are aware (for example, here and here), Obamacare forces health insurers to spend at least 80% (small group) to 85% (large group) of their premium income on health care, leaving only 15% for "other," including administrative overhead and profits. If that 80%-85% "medical loss ratio" (MLR) threshold is not met, insurers have to rebate the difference to their customers.

 While the White House has been happy to extoll the millions of dollars that were repaid to consumers (even though the individual checks were hardly eye-popping and then there is the risk that they're taxable), the DMCB is interested in what actually happened to the commercial insurers.  Did they game the system and garner even higher profits?  Or, have they gotten their comeuppance, are now losing money and have to pursue other lines of business, like covering zombie attacks?

This article in the latest Health Affairs looked at that impact of the law when it went into effect on January 1, 2011.  The authors used NAIC data to examine the impact on the individual (N=1,219), small group (N=804) and large group market (N=750) insurers.

Individual, small group and large group numbers are broken out below. If there is a *, the change is statistically significant.

In the individual market, from 2010 to 2011:

Median medical expenses, as a percent of premium, increased      by 5.5%*.
Administrative expenses, as a percent of premium, decreased            by 2.6%*.
Profit (otherwise known as "operating margin" or the bottom line) decreased by 1.3%*. "For profit" insurers fared even worse, with a decline in operating margin of 2.2%* vs. their nonprofit competition with a decline in 0.8%.

2011 operating margins were overall negative:

Individual overall -0.1%.
Nonprofits:  -3.5%.
For profits:  0.4%.

In the small group market:

Median medical expenses increased by 0.7%.
Median administrative expenses declined by 1%*.
The bottom line increased by .5%. Nonprofits saw an increase of 1.2%* vs. the for profits having a small decline of .3%.

2011 operating margins were positive, ranging from 2.8% to 3.8%  across the non and for profits, respectively.

In the large group market:
Median medical expenses declined by 0.7%.
Median administrative expenses declined by 0.9%%*.
Profit increased by .7%*. Nonprofits saw an increase of 0.1%* vs. the for profits having a increase of 1.2%.

2011 operating margins were positive, ranging from .7% to 2.6%  across the non and for profits, respectively.

The DMCB's take:

Obamacare had a single digit impact on health insurers.  More was spent on health care and less was spent on administrative costs.  While the shifts were relatively small, those changes represent swings of hundreds of millions of dollars to the bottom line in an already thin margin business. If the purpose of Affordable Care Act was to beat up on the health insurers, it was more of a push than a shove.

Small and large group profitability increased and operating margins were positive, while the individual market struggled. As readers may recall, the inability of individuals to obtain coverage at any price was a big factor in the eventual passage of the Affordable care Act. While the future individual market may eventually benefit from an influx of healthy young "invincibles" armed with an accompanying bolus of insurance subsidies, Obamacare ironically hurt the individual market in 2011. If health care utilization didn't go down in 2011 as a result of the economy, it could have been a lot worse.

That tells the DMCB that, contrary to the insurers' reports of doom and gloom, the 80%-85% MLR rule hasn't been a catastrophe.  On the other hand, it hasn't been good news for the individual market.  If the young invincibles don't 1) respond to the individual mandate, 2) use functioning insurance exchanges and 3) sign up, it could portend further stress on that sector of the health care economy.  No wonder the Obama Administration is pushing that so hard.

A February Edition of the Health Wonk Review: Insightful Nuggets From the Best Health Policy Blogs

A valuable nugget & more on the way

Welcome to the Disease Management Care Blog's hosting of the Feb. 28 Health Wonk Review.

This HWR is a summarized compendium of submitted posts by the smartest health policy bloggers in the known universe.  The DMCB assures you that you're in for a special treat because you'll find some insightful nuggets that generally go unseen in the mainstream media and academic literature.

When it's not mining the HWR for information, the DMCB combines acumen, skepticism, modesty, peer-reviewed science and occasional humor about health policy, care coordination, population health management as well as primary care, the medical home, health insurance and the electronic record.

It's so glad you stopped by.

The DMCB has organized the posts by topic: Obamacare's key reforms, various health economists' latest divinations on health care costs, hospitals, Medicaid, the internet, California, medical education and some British humor.  The quotes that head each section should give you a hint about what you're in for.

“This is a big f—-ing deal.” – Vice President Joe Biden

What's to Know About the Go-Go Growth of ACOs?

Lots, thanks to this Health Affairs Blog post by Leavitt Partners' David Muhlestein. He counts 428 accountable care organizations (ACOs). While all eyes are on the Medicare versions, it turns out the private sector has been on a less visible parallel track with "full or partial capitation models, bundled payments, retainer agreements, in-kind services and subsidies provided by payers, and pay-for-performance incentives." Did you know that most ACOs are in the West Coast and Northeast, or that there's an even split between physician and hospital-led sponsors? Mr. Muhlestein also points out that 2013 will be the year that we'll get to see some early ACO data. David and the DMCB will be watching very carefully and, if we report Medicare's outcomes are less than expected, the DMCB is looking forward to getting a "you'll regret it" email from somewhere in the Administration.

What's to Love About the Individual Insurance Market?

Could be lots, says Nicole Fisher of Wright on Health. She wonders if there is a silver lining in the growing evidence that some employers will drop their sponsored health insurance benefit and force their workforce into the individual market. That may force the individual market to have better transparency, less discriminatory underwriting, more choice and increased competition. As result, costs could be lower than expected, consumers will better understand the true costs of health care and portability could paradoxically improve. If things go really well, we could see a self-reinforcing cycle of market demand. And, wonders the DMCB, long lines outside doctors' offices.

Maybe, But What's NOT to Love About the Individual Insurance Market?

Louise of the Colorado Health Insurance Insider blog worries that persons who aren't poor but who are also not wealthy are in for some bad news if they believe that the reformed individual market will translate into affordable health insurance.  Unlike today's market, individuals will be less able to trade lower premiums for HSAs, high deductibles and (for persons over 30 years of age) catastrophic coverage. While minimum coverage requirements are a good idea, Louise says they're also expensive. She suggests it would be good public policy to flexibly accommodate a demand for higher deductibles and lower premiums.

An economic forecaster is like a cross-eyed javelin thrower: they don't win many accuracy contests, but they keep the crowd's attention - Anonymous

Persistent Partisan Perfidy on the ACA's Costs

Maggie Mahar, over at healthinsurance.org, indicts the latest libel against Obamacare.  Her ire is directed at those repugnant conservative pundits who should have known better than to glom onto an ill-considered U.S. Internal Revenue Service document about 2016's health insurance costs. Beware, says Maggie, no one really knows what costs will be in 2016. The DMCB is shocked, shocked that economists' and actuaries' inaccurate predictions are being intentionally misinterpreted for political gain.

Numbers With A Lot of Zeros

Speaking of economists, The Hospitalist Leader has compiled a linked list of peer-reviewed references that estimates the health care costs for the big name medical conditions. He senses that there's something amiss, because adding them up is much like finding Italy's olive oil exports far exceeds that country's domestic production. He thinks science writers, patient advocates, policymakers and yes, us bloggers, should promote better numeracy and, for starters, contrast any absolute dollar figures with helpful comparisons. That's why the DMCB is pleased to post this short instructional video on some math basics courtesy of the health insurance professionals who staff the IRS:



100% Coverage of Screening Services Is Not Good Enough?

Guess what?  When health care consumers are thinking about the cost of undergoing screening for a disease, they're also thinking about the next steps if disease is found.  Quoting a study in the Journal of Health Economics, Jason Shafrin of Healthcare Economist points out that zero dollar coverage for services - while noble - will have less of an impact than anticipated unless it's linked to meaningful coverage of treatment of the underlying condition.  In other words, health screening subsidies are not enough to maximize consumer buy-in.  No wonder the DMCB spouse is unfooled by offers to screen some sales prices for a jumbotron-sized flat screen for the living room!

"Phlegm free zone" - Sign seen at a local hospital

The Riddle of Readmissions

In this posted podcast (here), David Williams asks the Robert Wood Johnson Foundation's Anne Weiss about the recent depressing report on hospital readmissions.  Based on 2010 Medicare numbers, it doesn't look like the national rate has gone down all that much and that the considerable variation between different areas of the country remains.  David and his guest also chat about some promising best practices that being used in some settings to reduce readmissions, what patients and their families can do about lowering the likelihood of a readmission and whether the practice style of hospitalists is part of the problem or a potential solution.  Despite evidence that population management can reduce readmissions, Ms. Weiss rejects for-profit vendor participation, believing that hospitals should be happy to hire more personnel in lieu of partnering.  Let the "build or buy" games continue, says the DMCB.

"Governor Brown's budget plan also counts on $488.4 million in savings from a 10% cut to Medi-Cal reimbursements. Medi-Cal is California's Medicaid program." 1/30/13 News Report.

Here's A Free Baby Elephant!

Joe Paduda can't blame many of the nation's governors for bowing to the common sense and fiscal reality of expanding Medicaid in their states, even though it can be viewed as distasteful.  The 100% federal financing is free money and their politically connected hospitals prefer Medicaid to uncompensated care.  Many states are likely to cut their Medicaid fee schedules, so providers have one more incentive to go along with testing new reimbursement strategies and delivery models.  All in all, he muses, "this is a very good thing."  Next step, muses the DMCB, is to convince the docs.

The Internet is the most important single development in the history of human communication since the invention of call waiting. - Dave Barry

Time To Take On Medical Tourism By Getting "Lean"

Jonena Relth of Healthcare Talent Transformation points out that the times they are a changin'. The steady increase in medical tourism is challenging the notion that U.S. domiciled health care is the best, especially when international health systems are adopting U.S. methods and employing U.S. trained physicians who are using state-of-the-art electronic health records that are modeled on U.S systems. The salvation, according to Ms. Relth, is the "Lean" approach that, according to a LinkedIn discussion group, helps providers 1) put patients first, 2) cut waste and 3) eliminate tasks that don't add value.  The DMCB's experience leads it to believe that many of its physician colleagues can accomplish much of that third goal by staying away from LinkedIn.  Maybe it's time to change its mind.

"There is science, logic, reason; there is thought verified by experience. And then there is California." - Edward Abbey

California's Health Insurance Exchange Chassis Unveiled. Next Up: The Hard Part

Health reform advocate Anthony Wright of California's Health Access Blog really extols the virtues of Covered California, the Golden State's health insurance exchange web site. Anthony can be forgiven for his use of terms like "conveniently," "breakthrough," "easier" and "bold" because the site's very existence is an important step forward in having a real functioning web presence where consumers can actually buy health insurance. Whether this leads to marketplace transparency, consumer ease-of-use and increased insurance coverage for Californians remains to be seen. The DMCB took the web site's calculator for a test drive and discovered it and the spouse's unsubsidized monthly premium would be $1723 per month, which is about $700 more than it currently pays in Pennsylvania. 'Nuff said.

A Ballooning Benefit Bonanza, Courtesy of Sacramento

Speaking of California, John Goodman of his eponymously named blog examines the state's tax policy, blaming it for a plethora of generous employee benefits. Since higher wages are taxable, loopy loopholes are prompting companies to compensate their employees with home cleaning, personal trainers and the daily delivery of fresh fish. Mr. Goodman faults the unraveling of the 1980's tax reform movement and suggests now is the time for a "progressive flat tax."  Now is also the time for the DMCB Inc. Board of Directors to consider installing a tax deductible gas-powered backyard fire-pit for its two employees. 

Income from Injuries

And Calfornia doesn't stop there. Jon Coopelman of the Workers Comp Insider Blog writes that professional athletes from across the U.S. have discovered that California's generous worker's comp law allows out-of-state players to file claims long after any in-state injury that could have contributed to a disability. Thanks to clever attorneys and vague inclusion criteria, its not hard for any ex-jock who played in the state to convince a California judge that a sports team should cover all future related medical expenses. Jon says its time for the California legislature to stop the abuse and for sports teams to address this in their labor contracts. Until then, the DMCB  invites readers to pay $6 to play to enter an upcoming wiffle ball tourney in Golden Gate Park; participants will receive $1 in California taxable income, $5 worth of beer and a certificate of a compensible injury. Date TBA.

How Much Is That Hospital CEO Worth?

Roy Poses of Health Care Renewal looks at examples of small town hospital CEOs being compensated with lavish pay. Dr. Poses is particularly exasperated because the hospitals are not only public, but they've had to make tough trade-offs between being profitable and having enough nurses and docs to care for their underserved populations. Roy has little difficulty finding numerous news reports - and most are from California -  that amply demonstrate that there is little correlation between hospital administrators' $800K salaries and their institutions' financial performance. Roy blasts the gimmicky talking points that have been used justify these outlandish compensation packages, the cluelessness of hospital boards and the public's need to wake up and smell this coffee. The DMCB looks forward to what Roy discovers in 2013 when he compares ACOs' financial success with their executives' compensation packages.

 "Beware of the young doctor and the old barber." - Benjamin Franklin

Strange Bedfellows

Did you know that 15 new allopathic and 10 osteopathic medical schools have opened since 2002 and that most operate campuses located in Republican Congressional districts?  Wing of Zock's James Lewis reviews the political implications of this, pointing out that these Republicans will gain a new appreciation for the value of our national health care infrastructure. What's more, they'll probably be reluctant to go along with their House colleagues' enthusiasm to reduce the U.S. budget with sacrifices in graduate medical education funding. What delicious irony!

"Bollocks!" An oft-heard exclamation "with a long and distingished history." - Wikipedia

Merry Old En-gland?

Ouch!  The InsureBlog's Mike Feehan looks at a London Daily Mail report on the lowball rate of £20,000 that is used by the Brits' National Health Service when it needs to compensate men for a nutty type of wrong side surgery.  The DMCB points out that one historical explanation for higher U.S. jury awards is the need to compensate for future medical services.  That's less necessary, thanks to the NHS' universal coverage.  The comments that follow testily debate whether the incidence of this complication is higher in the Sceptered Isles compared to the U.S.   The DMCB will never be able to think about NHS "budget cuts" in quite the same way.

That's it for this HWR.  Mark your calendar for the next iteration, due to appear on David Williams' smartly written Health Business Blog on March 13!