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Aren’t insurance markets more efficient than the government?

Markets efficiently distribute many goods and services, but health insurance is not one of them. More than any major industry, health insurance is best left to the public sector. There are two main reasons.

First of all, in order to have a functioning market, both parties involved in a transaction have to have adequate information to make a rational decision. That simply is not the case with health insurance. Insurance policies are long and complicated. The insurance companies wrote them, but few policies holders are capable of reading them, let alone understanding them well enough to make comparisons while shopping. It is true that other major purchases — automobiles for instance — involve highly complicated products. However, people experience the various aspects of automobiles in their daily lives. When somebody is shopping for a car, they know from their own experience whether they are likely to need seven seats or two, how often they need to accelerate rapidly to merge onto a highway, and how gas mileage will impact their wallets.

This is simply not the case with health insurance. So many of the terms of an insurance policy tend to be very intangible, and buyers rarely understand the content of their policies. In order to understand the relationship between premiums, deductibles, coinsurance rates, and out-of-pocket maximums, a proficiency in probability and statistics, which very few people have, is required.

Obamacare made great efforts to “level the playing field” by establishing on-line markets that would disclose more information in an easier to digest fashion. Still, even with its best efforts to make policies comparable using metallic levels based on the percentage of medical bills that the consumers will likely pay, consumers will purchase policies without any knowledge of the pricing arrangements between the insurers and providers like doctors and hospitals. Providers accept very different prices from different insurers. It’s like when one furniture store advertises a sofa at 30% off and another store claims 50% off, but off of what? Unless you know the base price, you don’t know which store’s discount actually results in a lower price. Likewise, unless we know the network discounts insurance plans negotiated with providers, you don’t know which policy will allow you to pay smaller bills.

Insurance is by its very nature focused on unlikely events. Someone who breaks a wrist, for example, is not likely to have any idea about what expenses they are likely to incur, and they are not going to know even what procedures to expect without a diagnosis. They are not going to be able to call the emergency rooms at various hospitals and get pricing information in order to comparison shop. Even when they show up at the emergency room, the doctors and staff are not going to know the details of the person’s insurance policy, and even if the patient or staff calls the insurance company from the hospital, the best they can hope for is a vague statement that the treatment is covered by the policy, but that payment is not guaranteed. The treatment may be subject to a pre-existing condition exclusion, for instance. (Grandfathered individual plans under the ACA are allowed to continue these exclusions.) So when people actually use the insurance for services, they have no idea of the price that they are going to be asked to pay until weeks later. Could you imagine buying a car without any idea of the price until weeks later? So a functioning market for insurance is out of the question.

The other reason that government does a better job at health insurance than the market is that competition in health insurance does not lead to greater efficiency the way we would expect it to in many other industries. Consider a situation in which there were two companies, both offering a single plan with the same terms and same premiums to everyone. If insurance company A offered a single policy to the entire population at a single premium, it would minimize per capita administrative costs and could, on average, provide the population with the lowest possible premiums due to efficiencies of scale. However, insurance company B, knowing that older people tend to use more medical services than younger people, could offer a single nation-wide policy with graduated premiums that are less expensive for younger people and more expensive for older people. There would be some additional administrative costs in setting the premium scales and verifying peoples’ ages, but company B would be able to pull away Company A’s younger customers with more attractive rates. Company A would have to raise premiums on its remaining, mainly older customers in order to maintain profit margins. Company C could come along and add regional health care costs to the age-based model that Company B developed. Although assessing regional costs would add administrative overhead to Company C, people in regions where health care is less expensive would flock to the lower premiums offered by Company C, and Companies A and B would have to raise rates on their remaining customers to offset the loss of customers from the more profitable regions. Another company could come along and add a dimension known as relative risk of industry, charging employers in relatively safe and healthy industries lower group rates. Again, there would be more per capita administrative costs, but a relatively profitable risk pool would be gained. Another company could add a layer of personal health history or family background. And so on. Each time the population is sliced and diced in order to obtain a profitable pool, overall administrative costs are increased and these are passed on to the consumer. Moreover, the consumers in the pools left behind are faced with rate hikes in order to make up for the loss of the more profitable pools. For the company slicing off a profitable risk pool, it makes perfect sense. For the population as a whole, it is inefficient.

Insurance companies are go-betweens for consumers, and they should act as agents for consumers vis-a-vis providers, pharmaceutical companies, and even (if indirectly) medical equipment manufacturers. They need to use their purchasing power on their behalf seeing as individual consumers do not have the information at the point of transaction to make rational decisions in the way posited by mainstream economic theory.

However, there are other obstacles to a properly functioning market for healthcare. As mentioned before, consumers have no information on in-network discounts and arrangements, so would have no way of judging between insurers even if insurance companies acted as honest agents for consumers.

What is even more problematic is the trend towards vertical integration of insurer and provider, especially in western Pennsylvania. How can UPMC Healthplans act as the consumer’s agent if it is owned by the provider UPMC. Likewise, if Highmark owns a financially struggling West Penn Allegheny hospital system, how aggressively can it be expected to represent the policy holder’s interest?

The improved ability of people to shop meaningfully for policies may prove to be one of the bigger benefits. Competition and consumer choice are nothing more than buzzwords if consumers lack the knowledge and information to make rational decisions. While some complain that there is not enough choice in some parts of Pennsylvania, an uninformed consumer can be worse off when faced with too many choices. Many people nowadays are finding that they are spending more on health insurance than on any other part of their budget, including food, transportation, or even housing. With so much at stake, consumers need to be able to make informed decisions, but insurance policies can differ in so many aspects such as deductibles, co-insurance, co-pays, out-of-pocket maximums, covered services, provider networks, and in-network discounts that apples to apples comparisons are extremely difficult.