Several people here have mentioned that they are reading The New Health Insurance Solution by Paul Pilzer, with his book and website coming up in several discussions on this forum. Yesterday I borrowed his book from the library and did a quick read. His general proposition is that the market place will take care of the health insurance issues in this country if we just let the free market operate. He maintains that individual health insurance is widely available at reasonable cost and people, including employers and employees, should take advantage of the individual market for health insurance. I believe he tends to force the facts to fit this basic proposition.
He is easy to read with a breezy style. The book has pretty good explanations of HIPAA and COBRA and a number of good tips. However, health insurance in the United States is complicated. The price he pays for simplicity is accuracy and thoroughness. It is a pretty good book if you are 35, perfectly healthy, and thinking about buying insurance. But what is good for when you are 35 is not necessarily good 5, 10 or 20 years later. (Should I pay for drug coverage?. . . pregnancy coverage?) I would never rely on this book for making policy decisions or for forming opinions on healthcare in the United States. I strongly disagree with many of his policy recommendations.
Some problematic propositions from the book:
1. Several places in the book he claims that insurance companies in the individual market only turn down or place exclusions on 20% of applicants and 80% are accepted as healthy. He uses this statistic to support his idea that most people can get coverage in the individual market. I don’t know about the accuracy of this statistic, but one problem is that people who are uninsurable often do not apply for insurance on the open market. They stay on their employer plan. They go into a risk pool. They buy a conversion plan. Etc. Even Pilzer advises against applying for insurance if you think you might get turned down. So the healthy gravitate to these plans and the unhealthy do not.
Pilzer doesn’t discuss what “healthy” might mean and his discussion of the underwriting process doesn’t describe what are the typical issues that exclude people from coverage. He does not address the possibly of the healthy fleeing to cheap plans while the unhealthy are trapped in what they already have, causing greater cost disparity.
2. For those who say they can’t afford health insurance Pilzer claims that “If your annual income is below the federal poverty line, about $20,000 for a family and $10,000 for a single individual—you probably qualify for Medicaid.”
This simply is not true, unless you have children at home, are disabled, or meet some other special category. Low income alone does not qualify a person for Medicaid.
In this same vein, he claims that of the 45 million uninsured, 16 million earn more than $40,000 for a family of four ($20,000 for a single) and 29 million earn less. He assumes that the 29 million earn at least $20,000 if a family and $10,000 if single. Otherwise he claims they would be on Medicaid. He maintains that these low income families could easily buy a low cost HSA plan. But how are they going to pay those big deductibles? Also, his cost data is for people age 35 and their families. In most states, the older you are the more expensive insurance gets. In this discussion, he ignores the issue of underwriting and possible exclusions for preexisting conditions and ignores the fact that in most states, this population could not afford the risk pool which runs on the average, 200% the cost of the same plan for a healthy individual.
3. “Despite what you read in the newspapers, there are health insurance options
available for every American, although it may take you some time, effort and expense to get them.” This is one of his soundbite quotes he uses in advertising materials for his book. This is misleading. Insurance on the individual market is not available for many people. The risk market policy will have preexisting condition exclusions and may have coverage riders unless you are coming off of a group plan and have HIPAA rights. The risk market may be unaffordable. If you don’t have HIPAA rights, there may be no option for you at all in some states.
4. He states that “the premium you pay for an individual or family policy cannot be raised each year, nor can the policy be canceled based on your health or your prior year healthcare costs.” He mentions this several times in the book. At best this is a case of overgeneralization, at worst it is a misleading statement to support his thesis that individual health insurance is the solution to our insurance woes.
I have read a lot about health insurance. Federal law requires guaranteed renewal of individual health insurance plans. Does this mean that rates cannot change based on your health status? Many state’s insurance regulators think so. But that does not make it law. Most states allow rates to increase based on age. Some states’ laws do provide that your rates can’t go up based on your personal health situation. But other states have no laws that apply and in general, the individual market is not highly regulated. From what I have read, experts are not in agreement as to the extent re-underwriting occurs on renewal and insurance companies are not very forthcoming with information about why a particular person’s rate increases. Some experts believe that re-underwriting is occurring more and more by a number of insurance companies. Also, some insurers have durational rate settings. This means that your insurance costs can go up considerably after a few years. At that time, you can reapply for a lower cost policy, but can be denied if you are not in good health.
4. Pilzer repeatedly claims that individual health insurance is cheaper than employer provided insurance. It probably is cheaper if you are 35 and healthy. Probably not if you are 60. This is because employers charge the same rate to everyone, whether you are 20 or 60. Also, only 4% of people in the US have insurance on the individual market. So it is a small part of the overall market. Pilzer doesn’t break down what that market looks like as to age and health of its participants.
5. Pilzer’s discussion of the uninsurable and state subsidized programs like riskpools leaves much to be desired. Mostly because there is so much state variability. This is another circumstance where I really disliked that he used figures applicable to a 35 year old male. The costs are considerably higher for those 50 and over. He fails to mention that some risk pools have low lifetime limits and other restrictions.
6. Pilzer pushes the idea that small employers should go to a reimbursement model, leaving their employees to buy health insurance on the individual market. Employers with older/sicker employees are in fact facing higher costs. However, their employees are going to have problems getting insurance on the open market and may end up with only very high cost options. The employer that has a young and healthy workforce already has lower costs.
I think you get the idea.
He is easy to read with a breezy style. The book has pretty good explanations of HIPAA and COBRA and a number of good tips. However, health insurance in the United States is complicated. The price he pays for simplicity is accuracy and thoroughness. It is a pretty good book if you are 35, perfectly healthy, and thinking about buying insurance. But what is good for when you are 35 is not necessarily good 5, 10 or 20 years later. (Should I pay for drug coverage?. . . pregnancy coverage?) I would never rely on this book for making policy decisions or for forming opinions on healthcare in the United States. I strongly disagree with many of his policy recommendations.
Some problematic propositions from the book:
1. Several places in the book he claims that insurance companies in the individual market only turn down or place exclusions on 20% of applicants and 80% are accepted as healthy. He uses this statistic to support his idea that most people can get coverage in the individual market. I don’t know about the accuracy of this statistic, but one problem is that people who are uninsurable often do not apply for insurance on the open market. They stay on their employer plan. They go into a risk pool. They buy a conversion plan. Etc. Even Pilzer advises against applying for insurance if you think you might get turned down. So the healthy gravitate to these plans and the unhealthy do not.
Pilzer doesn’t discuss what “healthy” might mean and his discussion of the underwriting process doesn’t describe what are the typical issues that exclude people from coverage. He does not address the possibly of the healthy fleeing to cheap plans while the unhealthy are trapped in what they already have, causing greater cost disparity.
2. For those who say they can’t afford health insurance Pilzer claims that “If your annual income is below the federal poverty line, about $20,000 for a family and $10,000 for a single individual—you probably qualify for Medicaid.”
This simply is not true, unless you have children at home, are disabled, or meet some other special category. Low income alone does not qualify a person for Medicaid.
In this same vein, he claims that of the 45 million uninsured, 16 million earn more than $40,000 for a family of four ($20,000 for a single) and 29 million earn less. He assumes that the 29 million earn at least $20,000 if a family and $10,000 if single. Otherwise he claims they would be on Medicaid. He maintains that these low income families could easily buy a low cost HSA plan. But how are they going to pay those big deductibles? Also, his cost data is for people age 35 and their families. In most states, the older you are the more expensive insurance gets. In this discussion, he ignores the issue of underwriting and possible exclusions for preexisting conditions and ignores the fact that in most states, this population could not afford the risk pool which runs on the average, 200% the cost of the same plan for a healthy individual.
3. “Despite what you read in the newspapers, there are health insurance options
available for every American, although it may take you some time, effort and expense to get them.” This is one of his soundbite quotes he uses in advertising materials for his book. This is misleading. Insurance on the individual market is not available for many people. The risk market policy will have preexisting condition exclusions and may have coverage riders unless you are coming off of a group plan and have HIPAA rights. The risk market may be unaffordable. If you don’t have HIPAA rights, there may be no option for you at all in some states.
4. He states that “the premium you pay for an individual or family policy cannot be raised each year, nor can the policy be canceled based on your health or your prior year healthcare costs.” He mentions this several times in the book. At best this is a case of overgeneralization, at worst it is a misleading statement to support his thesis that individual health insurance is the solution to our insurance woes.
I have read a lot about health insurance. Federal law requires guaranteed renewal of individual health insurance plans. Does this mean that rates cannot change based on your health status? Many state’s insurance regulators think so. But that does not make it law. Most states allow rates to increase based on age. Some states’ laws do provide that your rates can’t go up based on your personal health situation. But other states have no laws that apply and in general, the individual market is not highly regulated. From what I have read, experts are not in agreement as to the extent re-underwriting occurs on renewal and insurance companies are not very forthcoming with information about why a particular person’s rate increases. Some experts believe that re-underwriting is occurring more and more by a number of insurance companies. Also, some insurers have durational rate settings. This means that your insurance costs can go up considerably after a few years. At that time, you can reapply for a lower cost policy, but can be denied if you are not in good health.
4. Pilzer repeatedly claims that individual health insurance is cheaper than employer provided insurance. It probably is cheaper if you are 35 and healthy. Probably not if you are 60. This is because employers charge the same rate to everyone, whether you are 20 or 60. Also, only 4% of people in the US have insurance on the individual market. So it is a small part of the overall market. Pilzer doesn’t break down what that market looks like as to age and health of its participants.
5. Pilzer’s discussion of the uninsurable and state subsidized programs like riskpools leaves much to be desired. Mostly because there is so much state variability. This is another circumstance where I really disliked that he used figures applicable to a 35 year old male. The costs are considerably higher for those 50 and over. He fails to mention that some risk pools have low lifetime limits and other restrictions.
6. Pilzer pushes the idea that small employers should go to a reimbursement model, leaving their employees to buy health insurance on the individual market. Employers with older/sicker employees are in fact facing higher costs. However, their employees are going to have problems getting insurance on the open market and may end up with only very high cost options. The employer that has a young and healthy workforce already has lower costs.
I think you get the idea.