John C. Goodman

As noted in a previous post, most insurers believe that the young and the healthy tend to buy on price, while older and sicker prospects tend to look more closely at which doctors and hospitals are included in the health plan's network. Accordingly, competitors in the newly created health insurance exchanges are choosing to keep their premiums down by offering very narrow networks. The result is a race to the bottom. The price of a lower premium is less access to care.

After enrollment, these perverse incentives do not go away. The health plans have an incentive to overprovide to the healthy (to keep the ones they have and attract more of them) and underprovide to the sick (to encourage the exodus of the ones they have and discouraged the enrollment of any more of them).

I don't know why this isn't obvious to other health economists. Nothing involved here is more complicated than Economics 101. Here is a very clear presentation.

In competitive markets competition tends to cause the price to change until it equals average cost. Thus, to the extent that price is a measure of the value consumers place on a good or service, the marginal benefit people receive tends to equal the cost of producing that benefit.

The same tendencies exist under managed competition. Because of community rating, premiums are not allowed to adjust to reflect each enrollee's expected health care costs, the way they would in a normal insurance market. As a result, community rating is similar to a price control. At the community rated premium, some enrollees will be overcharged and some will be undercharged. And since price cannot vary to match expected costs, competition will cause costs to change until they tend to equal the premium.

Take those patients who have above-average health care costs and who are therefore "unprofitable." If premiums are free to rise for those people, insurers will compete them up to the level of the cost of their care. But if the premiums are artificially constrained at a lower level, insurers will tend to compete the cost of their care down to the level of the artificial premium. The reverse pressures exist for those people who have below-average health care costs and who are therefore "profitable." If the artificial premiums cannot be competed down to the level of average cost, the tendency will be to compete cost up to the level of the artificial premium.

Bottom line: if you give producers in a market perverse incentives, you will get perverse outcomes.

Unfortunately no one told Edie Sunby about it. Or anyone else, for that matter.

John C. Goodman

John C. Goodman is President of the Goodman Institute and Senior Fellow at The Independent Institute. His books include the widely acclaimed A Better Choice: Healthcare Solutions for America and the award-winning Priceless: Curing the Healthcare Crisis. The Wall Street Journal and National Journal, among other media, have called him the "Father of Health Savings Accounts.”