Fact-Checking the President
on Health Insurance
His tales of abuse don't stand scrutiny.
By SCOTT HARRINGTON
In his speech to Congress last week, President Barack
Obama attempted to sell a reform agenda by demonizing
the private health-insurance industry, which many people
love to hate. He opened the attack by asserting: "More
and more Americans pay their premiums, only to discover
that their insurance company has dropped their coverage
when they get sick, or won't pay the full cost of care.
It happens every day."
Clearly, this should never happen to anyone who is in
good standing with his insurance company and has abided
by the terms of the policy. But the president's examples
of people "dropped" by their insurance companies involve
the rescission of policies based on misrepresentation or
concealment of information in applications for coverage.
Private health insurance cannot function if people buy
insurance only after they become seriously ill, or if
they knowingly conceal health conditions that might
affect their policy.
Traditional practice, governed by decades of common law,
statute and regulation is for insurers to rely in
underwriting and pricing on the truthfulness of the
information provided by applicants about their health,
without conducting a costly investigation of each
applicant's health history. Instead, companies engage in
a certain degree of ex post auditing-conducting more
detailed and costly reviews of a subset of applications
following policy issue-including when expensive
treatment is sought soon after a policy is issued.
This practice offers substantial cost savings and lower
premiums compared to trying to verify every application
before issuing a policy, or simply paying all claims,
regardless of the accuracy and completeness of the
applicant's disclosure. Some states restrict insurer
rescission rights to instances where the misrepresented
or concealed information is directly related to the
illness that produced the claim. Most states do not.
To highlight abusive practices, Mr. Obama referred to an
Illinois man who "lost his coverage in the middle of
chemotherapy because his insurer found he hadn't
reported gallstones that he didn't even know about." The
president continued: "They delayed his treatment, and he
died because of it."
Although the president has used this example previously,
his conclusion is contradicted by the transcript of a
June 16 hearing on industry practices before the
Subcommittee of Oversight and Investigation of the House
Committee on Energy and Commerce. The deceased's sister
testified that the insurer reinstated her brother's
coverage following intervention by the Illinois Attorney
General's Office. She testified that her brother
received a prescribed stem-cell transplant within the
desired three- to four-week "window of opportunity" from
"one of the most renowned doctors in the whole world on
the specific routine," that the procedure "was extremely
successful," and that "it extended his life nearly three
and a half years."
The president's second example was a Texas woman "about
to get a double mastectomy when her insurance company
canceled her policy because she forgot to declare a case
of acne." He said that "By the time she had her
insurance reinstated, her breast cancer more than
doubled in size."
The woman's testimony at the June 16 hearing confirms
that her surgery was delayed several months. It also
suggests that the dermatologist's chart may have
described her skin condition as precancerous, that the
insurer also took issue with an apparent failure to
disclose an earlier problem with an irregular heartbeat,
and that she knowingly underreported her weight on the
application.
These two cases are presumably among the most egregious
identified by Congressional staffers' analysis of
116,000 pages of documents from three large health
insurers, which identified a total of about 20,000
rescissions from millions of policies issued by the
insurers over a five-year period. Company
representatives testified that less than one half of one
percent of policies were rescinded (less than 0.1% for
one of the companies).
If existing laws and litigation governing rescission are
inadequate, there clearly are a variety of ways that the
states or federal government could target abuses without
adopting the president's agenda for federal control of
health insurance, or the creation of a government health
insurer.
Later in his speech, the president used Alabama to
buttress his call for a government insurer to enhance
competition in health insurance. He asserted that 90% of
the Alabama health-insurance market is controlled by one
insurer, and that high market concentration "makes it
easier for insurance companies to treat their customers
badly-by cherry-picking the healthiest individuals and
trying to drop the sickest; by overcharging small
businesses who have no leverage; and by jacking up
rates."
In fact, the Birmingham News reported immediately
following the speech that the state's largest health
insurer, the nonprofit Blue Cross and Blue Shield of
Alabama, has about a 75% market share. A representative
of the company indicated that its "profit" averaged only
0.6% of premiums the past decade, and that its
administrative expense ratio is 7% of premiums, the
fourth lowest among 39 Blue Cross and Blue Shield plans
nationwide.
Similarly, a Dec. 31, 2007, report by the Alabama
Department of Insurance indicates that the insurer's
ratio of medical-claim costs to premiums for the year
was 92%, with an administrative expense ratio (including
claims settlement expenses) of 7.5%. Its net income,
including investment income, was equivalent to 2% of
premiums in that year.
In addition to these consumer friendly numbers, a survey
in Consumer Reports this month reported that Blue Cross
and Blue Shield of Alabama ranked second nationally in
customer satisfaction among 41 preferred provider
organization health plans. The insurer's apparent
efficiency may explain its dominance, as opposed to a
lack of competition-especially since there are no
obvious barriers to entry or expansion in Alabama faced
by large national health insurers such as United
Healthcare and Aetna.
Responsible reform requires careful analysis of the
underlying causes of problems in health insurance and
informed debate over the benefits and costs of targeted
remedies. The president's continued demonization of
private health insurance in pursuit of his broad agenda
of government expansion is inconsistent with that
objective.
Mr. Harrington is professor of health-care
management and insurance and risk management at the
University of Pennsylvania's Wharton School and an
adjunct scholar at the American Enterprise Institute.
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