Few individual health policies cover maternity

Anthem Blue Cross' Singer said that those states have much higher rates for individual insurance coverage than California. "The point of insurance is to insure against catastrophic care costs," he said. "Having a child is a matter of choice."

Victoria Colliver, Chronicle Staff Writer, Tuesday, March 24, 2009

The number of individual health insurance policies that do not include maternity coverage has risen dramatically in recent years, prompting concern among consumers and a legislative effort to require California insurers to include the benefit.

About 805,000 Californians have insurance policies that specifically exclude maternity coverage - a number that has more than quadrupled from 192,000 in 2004, according to the California Health Benefits Review Program, which provides independent analysis of proposed health insurance benefits mandates.

"You see this tremendous jump in just a few years. That's where we're going with this," said Assemblyman Hector De La Torre, D-South Gate (Los Angeles County), whose bill to require maternity coverage is headed to the Assembly Health Committee today. Insurance companies are "pushing these policies clearly onto people, and people are making their decisions based solely on dollars and cents."

As more people lose their jobs - and along with that, their health insurance benefits - an increasing number are expected to turn to the individual health insurance market for coverage, an option that is usually less expensive than paying to stay on their former employers' health plans.

De La Torre's bill, AB98, would require all health insurance products regulated by the state Department of Insurance to include maternity benefits. Gov. Arnold Schwarzenegger vetoed a similar bill authored by De La Torre last year as well as one introduced in 2004 by then-Sen. Jackie Speier, D-Hillsborough.

Health insurers and consumers who support the right to buy a policy that excludes maternity benefits say they shouldn't have to pay for a service they have no intention of using. They say requiring such coverage would increase premiums and force more people to go without insurance.

"Clearly there are a number of people out there who don't think they need or want a maternity benefit at this point in their lives and recognize there is a significant reduction in costs associated with this," said Ben Singer, spokesman for Anthem Blue Cross, which covers about half of the individual policyholders in the state who do not have maternity coverage. Singer said requiring the benefit could increase premiums by as much as 107 percent for some members.

Shared risk

Supporters of the mandate, however, argue that denying coverage is unfair to women and that, in exchange for an average $7.17, or 4.24 percent, increase in monthly premium price per individual policyholder, society would save money if fewer women were on government-supported programs.

De La Torre argued that excluding maternity flies in the face of the insurance philosophy of shared risk. "Why do women pay for prostate cancer? Why do men pay for breast cancer? Because that's the whole point of insurance," he said.

The controversy is limited to individual insurance coverage because group policies, those provided by an employer or group, include maternity benefits. Health maintenance organizations, or HMO plans, are required by the state to have maternity coverage, but preferred provider organization, or PPO, service plans are free to exclude the benefit.

People who buy individual plans typically do not have access to group coverage. They can be self-employed, work for an employer that does not provide health insurance or simply choose such policies as the most affordable options.

But with the growing popularity of such policies without maternity coverage - such as Anthem Blue Cross' low-cost Tonik plans, which are geared toward young adults - finding an affordable individual plan with the coverage can prove to be a daunting task.

No good options

When Wendy Root Askew of Monterey started looking for a doctor she hoped would be her gynecologist as well as deliver her future children, she was shocked to discover her health insurance policy didn't include a single OB/GYN in her county.

The 31-year-old considered changing health plans. But then she learned that while 85 percent of the plans available in Monterey County offered maternity coverage five years ago, just 15 percent offer it now.

She found only two individual policies that included maternity, but they were three to five times as much as the policy she already had and came with annual deductibles of up to $15,000.

"Who's going to be buying policy with a $10,000 or $15,000 deductible? Clearly only those women who are intending to use the service," said Askew, who went from running her own business to working for an employer that offers group health insurance. She said she made the decision in part because the job offered comprehensive health benefits.

Health insurers are not uniformly against mandating maternity benefits. Kaiser Permanente, which as an HMO is required to include maternity, has supported maternity mandates along with Blue Shield of California, which has come out in favor of De La Torre's bill. The California Association of Health Plans has not taken a position, while another insurance trade group, the Association of California Life & Health Insurance Companies, publicly opposes the bill.

Higher individual rates

Several states, including Massachusetts, New Jersey and New York, already have laws in place requiring plans to pay for maternity services.

Anthem Blue Cross' Singer said that those states have much higher rates for individual insurance coverage than California.

"The point of insurance is to insure against catastrophic care costs. That's what you're trying to aggregate and pool for such things as heart attacks and cancer," he said. "Having a child is a matter of choice. Dealing with an adult onset illness, such as diabetes, heart disease breast or prostate cancer, is not a matter of choice."

Patricia Bellasalma, president of the California National Organization for Women, noted that not all pregnancies are planned. She said some insurance companies are discriminating against women.

"The philosophy of the insurance company on maternity coverage - the only pool of risk takers are women - is that all of the obligations to pay for child bearing is born solely on the woman and not on the man and not on society, which is just outrageous," she said.

Women in California pay an estimated 39 percent more than men for coverage in the individual market. San Francisco City Attorney Dennis Herrera filed a lawsuit against the state in January over the issue. Legislation also has been introduced by state Sen. Mark Leno, D-San Francisco, and Assemblyman Dave Jones, D-Sacramento, to forbid gender rating.

Wall Street Pursues Profit in Bundles of Life Insurance

Note from Greetings:

Many of these companies are also in the health insurance biz. I wonder just how hard they are going to work to keep their health insurance clients healthy? THEN you might see some of the "death panels" the anti-healthcare bill opponents are talking about... but from their backers!

By JENNY ANDERSON, NY Times, August 6, 2009

After the mortgage business imploded last year, Wall Street investment banks began searching for another big idea to make money. They think they may have found one.

The bankers plan to buy “life settlements,” life insurance policies that ill and elderly people sell for cash — $400,000 for a $1 million policy, say, depending on the life expectancy of the insured person. Then they plan to “securitize” these policies, in Wall Street jargon, by packaging hundreds or thousands together into bonds. They will then resell those bonds to investors, like big pension funds, who will receive the payouts when people with the insurance die.

The earlier the policyholder dies, the bigger the return — though if people live longer than expected, investors could get poor returns or even lose money.

Either way, Wall Street would profit by pocketing sizable fees for creating the bonds, reselling them and subsequently trading them. But some who have studied life settlements warn that insurers might have to raise premiums in the short term if they end up having to pay out more death claims than they had anticipated.

The idea is still in the planning stages. But already “our phones have been ringing off the hook with inquiries,” says Kathleen Tillwitz, a senior vice president at DBRS, which gives risk ratings to investments and is reviewing nine proposals for life-insurance securitizations from private investors and financial firms, including Credit Suisse.

“We’re hoping to get a herd stampeding after the first offering,” said one investment banker not authorized to speak to the news media.

In the aftermath of the financial meltdown, exotic investments dreamed up by Wall Street got much of the blame. It was not just subprime mortgage securities but an array of products — credit-default swaps, structured investment vehicles, collateralized debt obligations — that proved far riskier than anticipated.

The debacle gave financial wizardry a bad name generally, but not on Wall Street. Even as Washington debates increased financial regulation, bankers are scurrying to concoct new products.

In addition to securitizing life settlements, for example, some banks are repackaging their money-losing securities into higher-rated ones, called re-remics (re-securitization of real estate mortgage investment conduits). Morgan Stanley says at least $30 billion in residential re-remics have been done this year.

Financial innovation can be good, of course, by lowering the cost of borrowing for everyone, giving consumers more investment choices and, more broadly, by helping the economy to grow. And the proponents of securitizing life settlements say it would benefit people who want to cash out their policies while they are alive.

But some are dismayed by Wall Street’s quick return to its old ways, chasing profits with complicated new products.

“It’s bittersweet,” said James D. Cox, a professor of corporate and securities law at Duke University. “The sweet part is there are investors interested in exotic products created by underwriters who make large fees and rating agencies who then get paid to confer ratings. The bitter part is it’s a return to the good old days.”

Indeed, what is good for Wall Street could be bad for the insurance industry, and perhaps for customers, too. That is because policyholders often let their life insurance lapse before they die, for a variety of reasons — their children grow up and no longer need the financial protection, or the premiums become too expensive. When that happens, the insurer does not have to make a payout.

But if a policy is purchased and packaged into a security, investors will keep paying the premiums that might have been abandoned; as a result, more policies will stay in force, ensuring more payouts over time and less money for the insurance companies.

“When they set their premiums they were basing them on assumptions that were wrong,” said Neil A. Doherty, a professor at Wharton who has studied life settlements.

Indeed, Mr. Doherty says that in reaction to widespread securitization, insurers most likely would have to raise the premiums on new life policies.

Critics of life settlements believe “this defeats the idea of what life insurance is supposed to be,” said Steven Weisbart, senior vice president and chief economist for the Insurance Information Institute, a trade group. “It’s not an investment product, a gambling product.”

After Mortgages

Undeterred, Wall Street is racing ahead for a simple reason: With $26 trillion of life insurance policies in force in the United States, the market could be huge.

Not all policyholders would be interested in selling their policies, of course. And investors are not interested in healthy people’s policies because they would have to pay those premiums for too long, reducing profits on the investment.

But even if a small fraction of policy holders do sell them, some in the industry predict the market could reach $500 billion. That would help Wall Street offset the loss of revenue from the collapse of the United States residential mortgage securities market, to $169 billion so far this year from a peak of $941 billion in 2005, according to Dealogic, a firm that tracks financial data.

Some financial firms are moving to outpace their rivals. Credit Suisse, for example, is in effect building a financial assembly line to buy large numbers of life insurance policies, package and resell them — just as Wall Street firms did with subprime securities.

The bank bought a company that originates life settlements, and it has set up a group dedicated to structuring deals and one to sell the products.

Goldman Sachs has developed a tradable index of life settlements, enabling investors to bet on whether people will live longer than expected or die sooner than planned. The index is similar to tradable stock market indices that allow investors to bet on the overall direction of the market without buying stocks.

Spokesmen for Credit Suisse and Goldman Sachs declined to comment.

If Wall Street succeeds in securitizing life insurance policies, it would take a controversial business — the buying and selling of policies — that has been around on a smaller scale for a couple of decades and potentially increase it drastically.

Defenders of life settlements argue that creating a market to allow the ill or elderly to sell their policies for cash is a public service. Insurance companies, they note, offer only a “cash surrender value,” typically at a small fraction of the death benefit, when a policyholder wants to cash out, even after paying large premiums for many years.

Enter life settlement companies. Depending on various factors, they will pay 20 to 200 percent more than the surrender value an insurer would pay.

But the industry has been plagued by fraud complaints. State insurance regulators, hamstrung by a patchwork of laws and regulations, have criticized life settlement brokers for coercing the ill and elderly to take out policies with the sole purpose of selling them back to the brokers, called “stranger-owned life insurance.”

In 2006, while he was New York attorney general, Eliot Spitzer sued Coventry, one of the largest life settlement companies, accusing it of engaging in bid-rigging with rivals to keep down prices offered to people who wanted to sell their policies. The case is continuing.

“Predators in the life settlement market have the motive, means and, if left unchecked by legislators and regulators and by their own community, the opportunity to take advantage of seniors,” Stephan Leimberg, co-author of a book on life settlements, testified at a Senate Special Committee on Aging last April.

Tricky Predictions

In addition to fraud, there is another potential risk for investors: that some people could live far longer than expected.

It is not just a hypothetical risk. That is what happened in the 1980s, when new treatments prolonged the life of AIDS patients. Investors who bought their policies on the expectation that the most victims would die within two years ended up losing money.

It happened again last fall when companies that calculate life expectancy determined that people were living longer.

The challenge for Wall Street is to make securitized life insurance policies more predictable — and, ideally, safer — investments. And for any securitized bond to interest big investors, a seal of approval is needed from a credit rating agency that measures the level of risk.

In many ways, banks are seeking to replicate the model of subprime mortgage securities, which became popular after ratings agencies bestowed on them the comfort of a top-tier, triple-A rating. An individual mortgage to a home buyer with poor credit might have been considered risky, because of the possibility of default; but packaging lots of mortgages together limited risk, the theory went, because it was unlikely many would default at the same time.

While that idea was, in retrospect, badly flawed, Wall Street is convinced that it can solve the risk riddle with securitized life settlement policies.

That is why bankers from Credit Suisse and Goldman Sachs have been visiting DBRS, a little known rating agency in lower Manhattan.

In early 2008, the firm published criteria for ways to securitize a life settlements portfolio so that the risks were minimized.

Interest poured in. Hedge funds that have acquired life settlements, for example, are keen to buy and sell policies more easily, so they can cash out both on investments that are losing money and on ones that are profitable. Wall Street banks, beaten down by the financial crisis, are looking to get their securitization machines humming again.

Ms. Tillwitz, an executive overseeing the project for DBRS, said the firm spent nine months getting comfortable with the myriad risks associated with rating a pool of life settlements.

Could a way be found to protect against possible fraud by agents buying insurance policies and reselling them — to avoid problems like those in the subprime mortgage market, where some brokers made fraudulent loans that ended up in packages of securities sold to investors? How could investors be assured that the policies were legitimately acquired, so that the payouts would not be disputed when the original policyholder died?

And how could they make sure that policies being bought were legally sellable, given that some states prohibit the sale of policies until they have been in force two to five years?

Spreading the Risk

To help understand how to manage these risks, Ms. Tillwitz and her colleague Jan Buckler — a mathematics whiz with a Ph.D. in nuclear engineering — traveled the world visiting firms that handle life settlements. “We do not want to rate a deal that blows up,” Ms. Tillwitz said.

The solution? A bond made up of life settlements would ideally have policies from people with a range of diseases — leukemia, lung cancer, heart disease, breast cancer, diabetes, Alzheimer’s. That is because if too many people with leukemia are in the securitization portfolio, and a cure is developed, the value of the bond would plummet.

As an added precaution, DBRS would run background checks on all issuers. Also, a range of quality of life insurers would have to be included.

To test how different mixes of policies would perform, Mr. Buckler has run computer simulations to show what would happen to returns if people lived significantly longer than expected.

But even with a math whiz calculating every possibility, some risks may not be apparent until after the fact. How can a computer accurately predict what would happen if health reform passed, for example, and better care for a large number of Americans meant that people generally started living longer? Or if a magic-bullet cure for all types of cancer was developed?

If the computer models were wrong, investors could lose a lot of money.

As unlikely as those assumptions may seem, that is effectively what happened with many securitized subprime loans that were given triple-A ratings.

Investment banks that sold these securities sought to lower the risks by, among other things, packaging mortgages from different regions and with differing credit levels of the borrowers. They thought that if house prices dropped in one region — say Florida, causing widespread defaults in that part of the portfolio — it was highly unlikely that they would fall at the same time in, say, California.

Indeed, economists noted that historically, housing prices had fallen regionally but never nationwide. When they did fall nationwide, investors lost hundreds of billions of dollars.

Both Standard & Poor’s and Moody’s, which gave out many triple-A ratings and were burned by that experience, are approaching life settlements with greater caution.

Standard & Poor’s, which rated a similar deal called Dignity Partners in the 1990s, declined to comment on its plans. Moody’s said it has been approached by financial firms interested in securitizing life settlements, but has not yet seen a portfolio of policies that meets its standards.

Investor Appetite

Despite the mortgage debacle, investors like Andrew Terrell are intrigued.

Mr. Terrell was the co-head of Bear Stearns’s longevity and mortality desk — which traded unrated portfolios of life settlements — and later worked at Goldman Sachs’s Institutional Life Companies, a venture that was introducing a trading platform for life settlements. He thinks securitized life policies have big potential, explaining that investors who want to spread their risks are constantly looking for new investments that do not move in tandem with their other investments.

“It’s an interesting asset class because it’s less correlated to the rest of the market than other asset classes,” Mr. Terrell said.

Some academics who have studied life settlement securitization agree it is a good idea. One difference, they concur, is that death is not correlated to the rise and fall of stocks.

“These assets do not have risks that are difficult to estimate and they are not, for the most part, exposed to broader economic risks,” said Joshua Coval, a professor of finance at the Harvard Business School. “By pooling and tranching, you are not amplifying systemic risks in the underlying assets.”

The insurance industry is girding for a fight. “Just as all mortgage providers have been tarred by subprime mortgages, so too is the concern that all life insurance companies would be tarred with the brush of subprime life insurance settlements,” said Michael Lovendusky, vice president and associate general counsel of the American Council of Life Insurers, a trade group that represents life insurance companies.

And the industry may find allies in government. Among those expressing concern about life settlements at the Senate committee hearing in April were insurance regulators from Florida and Illinois, who argued that regulation was inadequate.

“The securitization of life settlements adds another element of possible risk to an industry that is already in need of enhanced regulations, more transparency and consumer safeguards,” said Senator Herb Kohl, the Democrat from Wisconsin who is chairman of the Special Committee on Aging.

DBRS agrees on the need to be careful. “We want this market to flourish in a safe way,” Ms. Tillwitz said.

Blue Double Cross

By PAUL KRUGMAN, NY Times

That didn’t take long. Less than two weeks have passed since much of the medical-industrial complex made a big show of working with President Obama on health care reform — and the double-crossing is already well under way. Indeed, it’s now clear that even as they met with the president, pretending to be cooperative, insurers were gearing up to play the same destructive role they did the last time health reform was on the agenda.

So here’s the question: Will Mr. Obama gloss over the reality of what’s happening, and try to preserve the appearance of cooperation? Or will he honor his own pledge, made back during the campaign, to go on the offensive against special interests if they stand in the way of reform?

The story so far: on May 11 the White House called a news conference to announce that major players in health care, including the American Hospital Association and the lobbying group America’s Health Insurance Plans, had come together to support a national effort to control health care costs.

The fact sheet on the meeting, one has to say, was classic Obama in its message of post-partisanship and, um, hope. “For too long, politics and point-scoring have prevented our country from tackling this growing crisis,” it said, adding, “The American people are eager to put the old Washington ways behind them.”

But just three days later the hospital association insisted that it had not, in fact, promised what the president said it had promised — that it had made no commitment to the administration’s goal of reducing the rate at which health care costs are rising by 1.5 percentage points a year. And the head of the insurance lobby said that the idea was merely to “ramp up” savings, whatever that means.

Meanwhile, the insurance industry is busily lobbying Congress to block one crucial element of health care reform, the public option — that is, offering Americans the right to buy insurance directly from the government as well as from private insurance companies. And at least some insurers are gearing up for a major smear campaign.

On Monday, just a week after the White House photo-op, The Washington Post reported that Blue Cross Blue Shield of North Carolina was preparing to run a series of ads attacking the public option. The planning for this ad campaign must have begun quite some time ago.

The Post has the storyboards for the ads, and they read just like the infamous Harry and Louise ads that helped kill health care reform in 1993. Troubled Americans are shown being denied their choice of doctor, or forced to wait months for appointments, by faceless government bureaucrats. It’s a scary image that might make some sense if private health insurance — which these days comes primarily via HMOs — offered all of us free choice of doctors, with no wait for medical procedures. But my health plan isn’t like that. Is yours?

“We can do a lot better than a government-run health care system,” says a voice-over in one of the ads. To which the obvious response is, if that’s true, why don’t you? Why deny Americans the chance to reject government insurance if it’s really that bad?

For none of the reform proposals currently on the table would force people into a government-run insurance plan. At most they would offer Americans the choice of buying into such a plan.

And the goal of the insurers is to deny Americans that choice. They fear that many people would prefer a government plan to dealing with private insurance companies that, in the real world as opposed to the world of their ads, are more bureaucratic than any government agency, routinely deny clients their choice of doctor, and often refuse to pay for care.

Which brings us back to Mr. Obama.

Back during the Democratic primary campaign, Mr. Obama argued that the Clintons had failed in their 1993 attempt to reform health care because they had been insufficiently inclusive. He promised instead to gather all the stakeholders, including the insurance companies, around a “big table.” And that May 11 event was, of course, intended precisely to show this big-table strategy in action.

But what if interest groups showed up at the big table, then blocked reform? Back then, Mr. Obama assured voters that he would get tough: “If those insurance companies and drug companies start trying to run ads with Harry and Louise, I’ll run my own ads as president. I’ll get on television and say ‘Harry and Louise are lying.’ ”

The question now is whether he really meant it.

The medical-industrial complex has called the president’s bluff. It polished its image by showing up at the big table and promising cooperation, then promptly went back to doing all it can to block real change. The insurers and the drug companies are, in effect, betting that Mr. Obama will be afraid to call them out on their duplicity.

It’s up to Mr. Obama to prove them wrong.

Out-of-Network Payment Practices

NY Times Editorial, Published: April 7, 2009

There has been a justifiable cloud in recent years over the way the insurance industry decides how much to pay for the services of doctors who are outside a company’s network. The procedures are rendered suspect by conflicts of interest and look as if they have been manipulated to shortchange patients by hundreds of millions of dollars over the past decade.

A tough settlement negotiated between New York’s attorney general, Andrew Cuomo, and the UnitedHealth Group early this year will clean up much of the mess — not only in New York but in other states as well. Still, there are loose ends that need attention, so it is helpful that the Senate commerce committee has held two hearings to explore the need to expand and secure what Mr. Cuomo has achieved.

The hearings were a useful reminder of how badly the industry behaved in using a UnitedHealth subsidiary to calculate the “reasonable and customary” charges by physicians in a particular region. When patients leave the network, insurers typically pay about 70 percent of these charges and the patient pays the remaining 30 percent — plus any additional amount charged by a doctor above the supposedly reasonable charge.

Linda Lacewell, who led Mr. Cuomo’s investigation, testified that the industry engaged in fraudulent and deceptive practices to understate the “reasonable and customary” rate and thus keep its reimbursements low. Although the industry denies any such wrongdoing, UnitedHealth agreed to cough up $350 million to settle a class-action suit and agreed to shift responsibility for the calculations to an independent nonprofit organization. Eleven insurers, including some of the largest, have agreed to help finance the new database and use its findings wherever they operate.

That should go a long way toward cleaning up dubious practices, and New York is working on a new regulation to codify what insurers must do. But New York’s settlement won’t reach all insurers in all states. The Senate commerce committee will need to explore what further steps may be required to force insurers to use either the new database or some other measure that is reliable and free of conflicts of interest. All insurers should enable customers to determine, in advance, how much they will have to pay for services outside their network.

Medicare’s Too Costly Private Plans

NY Times Editorial

Private health insurance plans were supposed to bring better care and lower costs to elderly patients covered by Medicare. Instead they have increased the cost and complexity of the program without improving care, according to new analyses published by the respected journal Health Affairs. Congress clearly has more work to do to remove unjustified subsidies that prop up many of the most inefficient private plans.

Back in the 1980s, private plans — known as health maintenance organizations — were seen as a savior for Medicare. They could provide the same or better services as traditional fee-for-service Medicare, but because of managed care they could do it at a lower cost. Over the years Congress brought other, less managed private plans into Medicare, and in 2003 the Republican-dominated Congress substantially increased government payments to private plans.

Medicare currently pays the private plans — now called the Medicare Advantage program — 13 percent more on average than the same services would cost in the traditional fee-for-service program. Some of the added payments are used to provide extra benefits for enrollees, like reduced cost-sharing or reduced premiums for such extra benefits as vision and dental care.

The added value averages more than $1,100 a year per patient. Not surprisingly, that makes them attractive to individuals and employers seeking coverage for retirees. It has fueled an explosive growth in enrollments. Almost a quarter of all Medicare beneficiaries, more than 10 million people, are enrolled in private plans.

The managed-care plans still arguably do a better job than traditional Medicare at coordinating care and eliminating duplicative services. Unfortunately, the fastest growth has occurred in private-fee-for-service plans, which do very little to coordinate care. They simply piggyback on the traditional Medicare program, relying on the same doctors and hospitals while using their subsidies to offer cost savings or extra benefits to enrollees.

As these plans have proliferated, Medicare’s costs to cover the subsidies have risen — with the taxpayers and the beneficiaries in traditional Medicare picking up the tab. The many competing plans have also increased Medicare’s bureaucratic burden and costs. And there is no sign that these plans provide better quality of care. Congress started this year to reduce the unjustified subsidies. But a lot more needs to be done. President-elect Barack Obama called during the campaign for eliminating the excessive subsidies and paying private plans only what it would cost to treat the same patients under traditional Medicare.

That would anger millions of enrollees as well as the insurance companies that use the subsidies to attract hordes of new customers. But it is only fair to treat all Medicare beneficiaries equally. Eliminating the subsidies could provide savings to help finance broader health care reform.