Thursday, August 20, 2009

Health Insurance Facts, Part 2: Why is Medical Insurance Different?

Link: Health Insurance Facts, Part 1

I have been brooding over the question of "Why Medical Insurance is Different" for many days now, trying to get succinct evidence to share. I have found it, and will present it shortly.

Medical insurance seems to have been first considered in 1694 [1], and first introduced into the United States in 1850 [2]. It was intended to cover injuries due to accidents, and seems to have been related to modern disability insurance. Sickness insurance followed in 1890, and employer-sponsored group disability insurance was first issued in 1911. [1]

Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II. [1]
The wage controls imposed during World War II are often cited as the leading cause of the importance of employer-sponsored medical insurance. With companies unable to offer greater wages to their workers by law, they turned to fattened benefits in order to compete for talented workers. Medical insurance policies covered more things as a result. This was fine for those individuals and families whose employers provided such benefits, but did no good for those employed elsewhere, such as by small businesses unable to afford such benefits, or unemployed (whether voluntarily or not).

Enter the states. Before I describe insurance mandates, let me take a moment to address the question of federal regulation of interstate commerce of health insurance.

The Health Care Choice Act, a bill introduced unsuccessfully into the House of Representatives in 2005 and 2007 has attempted to allow medical insurance to be sold across state lines, amending the Public Health Service Act (42 U.S.C. 300gg et seq.). I need more time to determine whether sections 300gg et seq. prevents interstate commerce with respect to medical insurance policies, but I think it is safe to say that if a bill in Congress is attempting to achieve the opposite, then it is safe to assume (for this article) that Congress has in fact prevented it.

Therefore, states have a monopoly on the chartering and regulation of medical insurance companies. Large insurers compete in states by creating (or acquiring) a subsidiary in the state in which they wish to do business, but all policies therein are unique to that state, even though the subsidiary is financially backed up by a multi-state parent insurance company. This type of organization raises the costs of entering the market in another state, and is therefore a barrier of entry to competition, and is one factor in the oft-cited fact that a few large insurers dominate the market in many states.

Add to this barrier of entry the manifold regulations by the states of what must be in policies. The Center for Affordable Health Insurance has catalogued 2,133 policy benefits mandated by the states in a 2009 report (pdf). (These 2133 mandates overlap considerably.) The report shows the mandates by state, and estimates the contribution of each mandate to the cost of the state's required policy. This means that medical insurance has evolved, under employers' hands and the state governments' hands, into something more comprehensive. What was once known simply as Accident Insurance, then (over time and as coverage increased) Hospital Insurance, Major Medical Insurance, and just plain Medical Insurance, now is known as Health Insurance, covering arcane things such as contraception and AIDS testing.

The method of payment for claims has also changed considerably over time. Insurance policies were once "indemnity" policies, meaning that we submitted our own claims and were reimbursed afterwards for whatever was covered. Later, insurance companies formed Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). In HMOs, the insurance companies own and operate the means of providing care, and employ the doctors and nurses. In PPOs, the insurance companies negotiate fees with the providers, and do not necessarily own the means of providing care. In HMOs, we pay whatever is not covered by our policy, and there is no extra paperwork between the provider and the insurer. In PPOs, the provider generally bills our insurer on our behalf, and collects the difference between what is covered and what is not directly from us. Preferred providers go a step further by waiving any part of their usual fee not allowed by the insurer (due to fee negotations). In short, we have become separated from the costs of care, because we no longer bear the full cost, no matter how temporarily, because the providers and insurers float the costs through their accounts payable/receivable. We once did the paperwork with the insurer for free; now we (or rather, our insurer) pay the provider to do it on our behalf.

I am forced to conclude that medical insurance is different from auto insurance and home insurance because we the people, ostensibly through our employers and elected representatives, have chosen it to be this way, for better or worse.

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