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October 14, 2011

Many younger, healthy people may not purchase health insurance when the health care reform law requires them to in 2014 because paying penalties under the law will be much cheaper, several Wall Street health care industry analysts said Oct. 12 at a conference at the Center for Studying Health System Change’s Wall Street Comes to Washington Conference meeting in New York.

According to a senior analyst who covers the managed care industry for Citi Investment Research and Analysis, the mandate to purchase health insurance in 2014 is so weak that it may not force a large portion of the younger and healthier population to purchase insurance.

The Patient Protection and Affordable Care Act requires most people to buy health insurance or pay a penalty, which starts at $95 a year in 2014 and increases afterward. The individual mandate is the basis for constitutional challenges by many states and other opponents of the law. In contrast, buying health insurance will cost several thousand dollars a year. Further, under PPACA, health insurers must sell policies to uninsured people if they get sick. From a financial perspective, it may not make sense for someone to buy insurance under the structure that is set currently.

Excise taxes that will be imposed on health plans in 2014 under PPACA, as well as increased costs that will be imposed on younger people to lower costs for older people, will mean that for young people, premiums may quite a bit in excess of the penalty and there won’t be any incentive for them to participate in the system.

The situation may likely lead to situation called adverse selection where sicker people buy insurance but healthier people do not and this may further lead to increased costs for the health insurance plans going forward.

There is some possibility, however, that other measures could be enacted to reduce adverse selection if the U.S. Supreme Court rules the individual mandate is unconstitutional. For example, people who do not buy coverage initially could be required to pay more if they buy policies later, or they might be forced to wait for a lengthy time period before being allowed to buy coverage, he suggested.

In addition, another effective inducement to get healthy or younger people to buy coverage would be to allow insurers to underwrite people for medical conditions if they do not buy coverage initially. People would have to pay more for such coverage.

Almost all insurers are planning to be involved in health insurance exchanges for individuals and small groups in 2014. Insurers such as Aetna Inc. and CIGNA Corp., which have little involvement in the individual and small group markets, are preparing for this. Large insurers most likely don’t have a choice but to participate in the exchanges as this may be the only significant opportunity for any type of member growth.

Plans offered in the exchanges will be much less profitable than commercial plans because the plans will need to be standardized and there will be more emphasis on price competition.

The plans are expected to be similar to Medicaid plans in the sense that the federal government will provide what the essential benefits are that need to be covered.

One of the big open questions is whether employers will continue to provide coverage. Large employers are likely to move to defined contribution plans, under which they give lump sum payments to employees, who could buy their own coverage or who could buy coverage through an exchange.  

In addition, it is forecast that the largest employers will not drop coverage until they see other large employers do so. It would be significantly cheaper for large employers to pay the $2,000 per employee penalty under PPACA for not providing coverage than to pay for health insurance. But that could result in the federal government paying significantly more in subsidies, which could lead Congress to raise penalties.

For small employer, however, the situation is quite different. As the PPACA is currently modeled, there is a high possibility that large numbers of small employers will completely discontinue health care coverage. 10.14.2011. HRM Partners.

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