Hugely Important Clause in Obama’s Healthcare Reform
As reported by Forbes, there is a provision of the healthcare reform law called the medical loss ratio, that requires health insurance companies to spend 80% of the consumers’ premium dollars they collect — 85% for large group insurers — on actual medical care rather than overhead, marketing expenses and profit. Failure on the part of insurers to meet this requirement will result in the insurers having to send their customers a rebate check representing the amount in which they underspend on actual medical care.
I had thought that this was just a general rule of “we cap your profits at 15-20% overall.” However, if I am understanding some paperwork my company recently got from BCBS, it seems that this is on a per customer basis.
Let that settle in for a bit, because it’s huge.
So let’s say that I’m on my company plan, and I don’t use my insurance for much of anything. Regardless of what the other people in my company on that plan do, I personally get a rebate check back. The insurance company sends it to my employer, who is then legally required to send it on to me. On first look it’s pretty awesome, but I think there are some side effects to this.
Possible Positive Side Effect
It encourages people to be healthy. If you’re healthy and don’t need anything other than routine check-ups, you could get a sizable rebate back.
Possible Negative Side Effect
This actually discourages people from getting regular check-ups, and even discourages them from being treated when they are sick — especially people in lower income brackets who stand to gain more proportionally from these rebates.
Debatable Side Effect
A bigger side effect, however, is that I’m pretty sure this will eventually mean the end of private insurance companies, or at the very least it will mean some serious changes to them. Whether this is a good or bad thing is debatable, but let me explain why it is likely.
Insurance companies are only allowed to make 20% profit max off of any one individual, yet the losses they can suffer from someone who costs them money are not currently capped. So one person who needs regular arthritis medication, or a heart surgery, or cancer treatment, will be worth many healthy people. And with the health situation of this country only getting worse, I can’t imagine that insurance companies will be able to stay afloat if this medical loss ratio is on a per-person basis.
Insurance companies can only work around this in two ways, that I see. First, they could severely lower lifetime max benefits — so maybe most plans would only pay out a maximum of $100,000 over your entire life. Second, and more likely, they could jack rates up so high that the 15-20% that they’re getting from healthy people still pays for the less-healthy people.
Example: Let’s say that there are 4 “healthy” (never need anything but routine check-ups) people for every 1 unhealthy person, and that on average the unhealthy person costs the insurance company an average of $600 per month — that’s off the top of my head, but I think that including surgeries, medications, specialist visits, etc. that number isn’t too far off. To just break even they would have to charge $600/mo for each person on the plan. And even that would actually cause the insurance company to go under because they couldn’t pay for workers or buildings. So let’s also assume that the insurance company has about a 15% overhead (which I believe is insanely low as far as insurance companies go). That means $690/mo per person on the plan, and that’s assuming it’s not a large group plan. If it is, that number jumps to $920/mo per person.
If insurance companies take that “jacking the prices up” route, and there is a government option for healthcare, I think that employers and individuals are all going to opt for the government option. Hence, the eventual end of private insurance.
If we were a healthier country, or had lower medical costs (a huge portion of medical costs go toward medical insurance because of our messed up legal system), those numbers would be much lower. For example, if we have one unhealthy person for every 9 healthy people, it cuts those premiums in half. But this speaks to a different point that I will likely make in another post.