Public officials and health care experts have recently suggested a number of reforms to reduce the cost of individual health insurance. Most of the proposals fail to address the contribution of mandated benefits to the high cost of insurance in many states.
Mandates Increase Costs
Differing regulations and mandates among the states cause wide variations in individual health insurance rates. The federal McCarran-Ferguson Act, which permitted states to set their own requirements for coverage, has protected state markets from competition and led to an assortment of mandates—many of which the insured do not want or need. For example:
* About one-fourth of states require health insurance to cover acupuncture and marriage counseling.
* More than half of states require coverage for social workers, and 60 percent mandate coverage for contraceptives.
* Seven states require coverage for hairpieces, and nine for hearing aids.
In all, there are more than 1,900 state mandates across the United States. Some legislators contribute to this excess by giving in to special interests’ demands that insurers cover their specific services and providers. The result is higher premiums for consumers—pricing an estimated one-fourth of the uninsured out of the market by this means alone.
Competition Stymied
Although most insurers operate in multiple states, their plans must be tailored to each state’s specific requirements.
As a result, there is no competitive national market for individual health insurance. Instead, there are fragmented markets and large price differences. (See Figure 1.)
* A family purchasing a health insurance policy in Wisconsin would pay about $3,087, but that policy would cost $10,398 in New Jersey.
* A similar policy in Utah would cost $3,259, but $12,254 in New York.
* A family policy in Michigan would cost $4,118, but an astronomical $16,897 in Massachusetts.
The difference in premiums is largely the result not of regional variations in health care costs, but of state mandates.
Raise Prices, Uninsurance
Recent proposals advocating universal state-run or -mandated care—including those of Democratic presidential candidate Barack Obama and legislators in California, Illinois, and Pennsylvania—all include two regulations consistently shown to raise health care costs: guaranteed issue and community rating.
Guaranteed issue means insurance companies offering policies must sell coverage to all who apply, regardless of medical condition.
While this sounds like it protects consumers, it actually harms them. For example, it has driven up premiums in Massachusetts and New Jersey.
When insurance companies are forced to accept all applicants, they raise premiums to guard against losses. As a result, health insurance becomes a poor value for everyone except those with serious health conditions. Business dwindles as demand decreases, insurers leave the market, and rates increase even more from a lack of competition. This pattern has occurred in every state that requires guaranteed issue.
Community rating means insurers cannot adjust premiums to reflect the individual health risks of consumers. When everyone pays similar premiums, healthy people are charged more than they otherwise would be, and sick people are charged less. Therefore, premiums rise for the majority who are healthy.
Because of the higher cost, younger (or lower-income) individuals with few health problems tend to drop insurance, leaving an increasingly unhealthy risk pool. This drives premiums even higher—and fewer and fewer people can afford coverage.
Interstate Competition Cuts Prices
To remedy this situation, Rep. John Shadegg (R-AZ) has proposed interstate competition at the federal level with the Health Care Choice Act (HR 4460).
The bill would allow consumers to shop for individual insurance on the Internet, over the telephone, or through a local agent. Insurers would still be subject to the regulations of their home state, but residents of any state would be free to choose among policies from insurers in any state.
Consumers who do not want expensive health plans that pay for benefits they do not need—such as acupuncture, fertility treatments, or hairpieces—could buy from insurers in states that do not mandate such benefits.
With interstate competition, consumers would be more likely to find a policy that fits their budget, which would give more people access to affordable insurance. A recent University of Minnesota study found approximately 12 million additional people would be covered if health coverage could be purchased in a competitive national marketplace. Consumers in currently highly regulated states would benefit most.
Other Reforms Needed
In addition to interstate competition, insurers should be allowed to experiment with innovative products such as limited benefit plans, often known as “mini med” plans, which generally provide coverage for a limited number of physician visits each year, a limited amount of inpatient care, and sometimes coverage for prescription drugs.
Other reforms, such as mandate-free policies that take advantage of cross-border providers, would also provide consumers with a greater range of options and affordability.
Protection from interstate competition allows special-interest lobbyists to impose expensive mandates. Allowing people to purchase coverage across state lines would create more competitive insurance markets, and letting insurers experiment with different designs to create innovative and cost-effective health plans also would help decrease the number of people who cannot afford care.
Devon Herrick ([email protected]) is a senior fellow and Ariel House ([email protected]) is a junior fellow with the National Center for Policy Analysis. First published on September 9, 2008 as NCPA Brief Analysis No. 630; reprinted with permission.
