Monday, October 5, 2015
October 2, 2015
Big shortfall in Obamacare risk program could hurt insurers
By Tami Luhby
A key federal program designed to cushion health insurers' risks in the
Obamacare exchanges has a massive shortfall, which could throw some
insurers into financial turmoil.
Insurers requested $2.87 billion in so-called "risk corridors" payments
for 2014, but will only receive $362 million, or 12.6%, said the Centers
for Medicare & Medicaid Services, which oversees Obamacare.
The risk corridors program's goal is to help insurers transition into
the individual exchanges, which opened in 2014. Insurers had a tough
time setting premiums since they didn't know how sick their new
customers would be.
Under the three-year program, insurers whose premiums exceeded claims
pay into the fund, while their peers who didn't charge enough premiums
to cover claims could draw from it.
But too many insurers miscalculated when they set their rates for 2014.
"Insurers underestimated the riskiness of their customer base and set
their premiums too low," said Tim Jost, a health law professor at
Washington and Lee University School of Law.
The shortfall could put a financial strain on some insurers, especially
some smaller ones who were counting on the funds. Some firms have
reported losses in their Obamacare line of business, while four health
insurance cooperatives are shutting down because of financial pressures.
Obamacare insurers have already set their premiums for 2016 and can't
adjust them now. The shortfall in risk corridor payments could prompt
insurers to raise premiums in future years or exit the program.
The administration said the remaining 2014 risk corridor claims will be
paid out of the 2015 and, if needed, the 2016 collections.
Insurers are still getting billions from two other Obamacare risk
programs. They will receive $7.9 billion from the reinsurance program,
designed to spread the cost of very large insurance claims across all
insurers. And they will receive $4.6 billion from the risk adjustment
program, which requires insurance companies with healthier consumers in
a state to help offset some of the costs of those insurance companies
with sicker customers in that state.
Health Policy Briefs
February 19, 2015
With the new restrictions on premium setting and the unpredictability of
medical expenses from the newly insured, insurers faced a high level of
uncertainty when setting their premiums. To buffer insurers from high
losses in the initial years, keep premiums affordable, encourage
insurers to participate in the Marketplaces, and minimize year-to-year
premium fluctuations, the ACA authorized three premium stabilization
programs: risk adjustment, reinsurance, and risk corridors.
The risk corridor program has proven to be one of the more controversial
aspects of the ACA with critics, including a number of Republicans in
Congress, characterizing the program as an insurer bailout. They argue
that as a result of HHS and state officials putting pressure on insurers
to keep premiums low in the Marketplaces, the federal government will
end up picking up the tab to bail out insurers if they underpriced.
Critics also claim that the program encourages insurers to underprice
their plans in order to gain market share, knowing the government will
offset their losses.
While the Consolidated and Further Continuing Appropriations Act of
2015, which funded the government for the 2015 fiscal year, did give HHS
the authority to collect user fees, an amendment was included that
specifically prohibited HHS from transferring money from either trust
fund. The amendment did not eliminate the risk corridor program, nor did
it prevent HHS from using payments received from insurers to pay out
claims under the program (that is, user fees), but it effectively made
the risk corridor program budget neutral unless HHS can find another
source of funding.
If risk corridor claims exceed receivables and HHS does not find an
alternative source of funding, it seems likely it will revert to its
earlier proposal to prioritize paying off shortfalls from previous years
before making new payments. If the shortfalls were great enough, this
could effectively eliminate payments to insurers for the final two years
of the program.
Comment by Don McCanne
Although the media are covering this story as a shortfall in the risk
corridor stabilization funds, the real story here is about the behavior
of private insurers competing in the insurance exchanges established
under the Affordable Care Act (ACA). An explanation is in order.
So what are the risk corridors and why do they exist? It was understood
that insurers could be exposed to significant losses if they attracted
more than an expected number of enrollees who had greater health care
costs. So for the first three years, a portion of losses above a certain
threshold (the upper margin of the corridor) would be covered by a
stabilization fund. Likewise, if the insurers were successful in
enrolling more individuals with very low health care costs (below the
lower margin of the corridor), those insurers would be required to pay a
portion of their net gain into the stabilization fund ("user fees").
So how would private insurers respond? For the first year of marketing
plans on the exchanges, they would want to have lower, competitive
premiums in order to corner market share. Their losses for high cost
enrollees would be largely covered (up to 80%) so they could accept some
losses for those with average health care needs, knowing that they could
later adjust fees modestly upwards after having gained market dominance
(a version of the insurance underwriting cycle). As would be expected of
the private insurers who are masters at gamesmanship, they were able to
show that not many of their enrollees fell under the lower margin of the
corridor, thus their payments to the stabilization fund (user fees) were
kept to a minimum.
As a result, the stabilization fund is able to cover only about 13% of
of the losses above the upper margin of the corridor. Although HHS says
that they would find the funds, Congress has created barriers to using
funds other than the user fees authorized by the risk corridor
stabilization program. Since they are budgeting 2015 and 2016 user fees
to pay for 2014 losses, obviously the funds will be rapidly depleted,
with little or none available for the second and third years of the program.
Risk corridors, risk adjustment, and reinsurance are not for the benefit
of patients, rather they are to protect the insurers. Not only do they
add to our profound administrative waste, they also open up
opportunities for insurers to profit even more through chicanery and
We could completely do away with this and all of the other insurer
excesses by simply enacting a single payer national health program. Why
not now? Are not the voters in charge?
at 5:09 PM