It is not very difficult to understand health insurance and how it works if you have ever been to Las Vegas. Think of health insurers like the big casinos. They are like the “house” and you are like an individual “bet”. The house is betting that you are not going to “win”, at least not “win” repeatedly. In fact, most people know that when they go to Vegas the odds are stacked against them. The house has calculated the odds and knows precisely what they can expect to win based on a predetermined volume of activity. They may lose occasionally or even have a short losing streak to a lucky winner but the long-term odds are in favor of the house.
In fact, most of us know that in the long term the house CANNOT lose. The long-term odds are enormously stacked in their favor. That’s why Casino’s can afford to hand out free drinks and why they own all the big tall shiny buildings.
What most people don’t realize is that in some ways Health Insurance operates in the same way. Many people think that it is some kind of a pay as you go system. They pay in all their life and at some point in the future if and when they need it, it will be there for them, but it does not work that way at all. When you can pay to the insurance companies all your life, and once you stop paying, you’re out. In fact, there are a lot of situations that can happen that can put you “out” of the insurance game.
Health Insurance companies, like the big casinos, have the long-term advantage. The odds are stacked in their favor and they do a lot to make sure it stays that way. Insurers calculate the statistical probabilities of paying out claims. In fact, insurance companies have large staffs of actuaries and underwriters. The underwriters assess the risk of each insurance policy written and the actuaries are continually recalculating future payment trends and payouts. They do everything in their power to keep the healthy people and shift those that are the sickest to someone else.
What some people don’t understand is that in the case of health insurance companies, their largest expenses are the “cost of care”. It means that to the extent a Health Insurance company can pick healthier people and select lower risk insurance groups and minimize the payouts by shift the sickest to someone else, they can make more money. All of these cost-shifting maneuvers increase the profitability of the health insurance companies. In our casino comparison, it would be like the house stacking the odds in their favor. It would be like having the casino prescreen you in order to play. They would look at your winning history, the amount of money you play and the odds of you losing before letting you in the game. If you happened to be a consistently lucky winner they wouldn’t let you play.
Insurance companies reduce their risk of paying out high health care claim dollars by “cherry picking”, “cream skimming” and “cost shifting” to US taxpayers. By picking the best hands and by shifting the sickest populations, health insurance companies decreases the likelihood that they will pay out more than they took in on the premiums paid. They are stacking the odds in their favor and by doing this. They are maximizing their profits by eliminating the sickest of the population. It’s a great way to make a lot of money but a horrible system for a nation that wants to protect everyone and provide for their population when they become ill.
“We the people” the ultimate stakeholders in our national health care policy, need to understand how Health Insurance companies are doing this so we can stop paying, paying and paying again for health care. Health Insurance companies “cherry pick”, “skim the cream” and “shift the sickest” in order to maximize their profits. Make no mistake, the profits insurance companies make on the backs of anyone that has every paid a premium dollar are theirs not yours. Actually, they are the shareholders that own these mega corporations and those shareholders are singularly focused on profit and shareholder value. It’s a horrible way to run a health care system for a nation, especially a democracy of the people.
Cherry picking is when a health insurance company picks out the most profitable customers leaving the more expensive customers for someone else. Health Insurance companies blatantly participate in cherry picking by insuring healthy people and refusing to insure those that are less healthy. They use a number of different tactics to pick through the population of people seeking insurance and weed out the people with a higher risk of potential claims. The most common practice is through disqualifying people that have any kind of a pre-existing health condition. Insurance companies also use lengthy questionnaires that applicants are required to fill out and disclose not only health issues they have been treated for but also any personal habits they have that may be unhealthy. Cherry picking is designed to make insurance companies more profitable by insuring the healthy and denying the sick. Nothing precludes an insurance company from eliminating the sick from their insurance pools, in fact it is encouraged, all insurance companies participate in the practice and shift the sickest to the public (taxpayers). That’s right, taxpayers already pay for the sickest populations in our society, no insurance company will touch them.
Cream skimming occurs when an insurer knows more about a customer’s potential costs than the consumer themselves know. The insurance company uses marketing or plan design to enroll attract and enroll a healthier than usual population. One example would be if a plan offered excellent obstetric care but offered poor oncology care. They would probably attract a healthier population than if the opposite were true. Lower cost health plans often keep their costs low by enrolling healthier people (or encouraging unhealthy people to leave the plan) rather than by providing better care to their enrollees.
Shifting the Sick
(Note: You can view every article as one long page if you sign up as an Advocate Member, or higher).