Yesterday, Gin & Tonic rightly called me out for a big assumption:
is extremely attractive assuming deep and well functioning individual markets
Quite an assumption there.
I think that I have an understated assumption that the health insurance markets are far less functional of a market compared to most other insurance product markets unless there is a massive regulatory thumb on the scale. I think and believe that the big differentiator of health insurance compared to home, auto, fire and life insurance is the combination of politically and economically strong counter-parties and very localized monopolies with significant barriers to entry.
Next week, my wife and I are closing on a new house. We’ve spent most of this week chasing down all the final threads of paperwork. My wife had to take care of the homeowner’s insurance policy. She was able to look at several national carriers that operate in North Carolina. They all offer functionally similar coverage. The big differentiator is customer service and bundling discounts. She chose to go with Allstate because we get our auto insurance through them so the bundled discount is significant and the friction cost of setting up another bill and keeping track of it is not worth any marginal savings.
If a triggering event occurs for the home owner’s policy, they will send an adjuster and then write a big check. After the check is deposited into our account, we then get to go argue with local general contractors to fix whatever the problem was. The same basic story applies for an auto insurance policy. The local auto repair market and the local home repair markets are fairly fragmented, price-taking markets with modest information asymmetry. Almost all general contractors and mechanics will take a personal check and all of them will take cash. The counter-party/doer barrier to entry for new insurers to enter a region is reasonably small for home and auto insurance. It is very small for life insurance as a check is written and accepted for deposit in any US bank.
Health insurance is more complex. There is massive informational uncertainty and asymmetry. I can evaluate reasonably well if my roof has been repaired but I am guessing for a while if my knee will be right after an intervention. I, as a patient, have a harder time evaluating quality as well. I can assess whether or not the check cleared the bank. I can assess whether or not Joe’s Autobody did a good job of replacing my right front fender. I have a harder time determining if a hospital/doctor/pharmaceutical intervention fixed the underlying problem, masked the symptoms or alleviated the worst of the situation without making things go back to the status quo pre-event.
Health insurers build a network of preferred contracted providers. When something goes wrong that triggers a health insurance claim, that claim comes through the contracted network. I think this is a significant barrier to entry when there are locally concentrated medical markets. An insurer can only get a good price on services with either massive government shoulder throwing as in Medicaid, Medicare and Medicare Advantage, or by being able to steer large populations to preferred rate providers and away from not-preferred entities. Building a network is a chicken and an egg problem. An insurer gets good pricing with a big membership base. They get a big membership base because they have good pricing on a good network. It is a natural neck deep moat for dominant local insurers against new entries. New entries, as we saw with co-ops in the ACA, have a hard time getting competitive pricing on their provider networks until they can build up the membership base. This means selling loss leaders for several years and lighting a lot of money on fire.
This is true for the individual market. This is true for large group markets. It is not as true for Medicare Advantage as price setting regulations in Medicare sets a ceiling of roughly 110% of Medicare Fee for Service as a pragmatic anchor point in pricing. Medicare Advantage has other start-up challenges in risk adjustment but building a non-exorbitantly priced network while having a low membership base is not one of those challenges.
I think that I assume that local/regional health insurance markets that don’t have significant price regulations are not the most functional markets. They reward size and incumbency so new entries need to be able to climb over some very large hurdles. I think this is less true in the individual market as the decision making agent is an individual with only family needs in mind and more true in large group where the decision making agent is someone in HR with a strong budget and a moderately strong scream constraint to work against.
Brachiator
Thank you for this excellent explanation and commentary.
One other thing about auto repair and health care. A person might accept an adequate or just good enough auto repair, something that keeps a car running but which does not restore it to mint condition.
With health care most people want the best possible care and full restoration of their health, if possible.
wkwv
Thank you Mr. Anderson. Reminds me of the microeconomics test question- “Assume a spherical cow…”.
Ruckus
@Brachiator:
Also the entry to an auto mech job is much smaller than to medicine, because while fixing your car may or may not be easy, it is a relatively easy task to learn, the costs of entry to the repairperson are far, far less and as you point out the desired results can be different and still satisfactory. Also you take your car to a mechanic and he replaces parts and the car runs. Medicine is often far trickier to diagnose, and a full repair is often not available, especially as we age. Also a car is fully replaceable. OK, a number of humans should be fully replaced…… I think you know who I mean.
Gin & Tonic
Now I see that when you’re talking about “deep and well-functioning” you’re talking from the perspective of the insurer, not the insured. But the individual market for health insurance is a small fraction of the group market, which is another informational assymetry that works to the detriment of the insured and as a dis-incentive to entry for the insurer. Leaving aside the AAA or AARP or similar groups, the property-casualty market is weighted *much* more heavily to the individual purchaser. The individual purchaser of health insurance is buying a more complex product with far fewer providers and has no means of applying pricing pressure. This may be a “good” market for the insurers to operate in, but nothing like “deep and well functioning” in any normal way of looking at things.
Yarrow
@Brachiator:
Sure but that isn’t always possible so many times people are happy just to stop things from getting worse or to be better than they were.
@Ruckus:
You are generally correct but even with medicine some lower level jobs (entry level tech jobs, lower level nursing jobs) don’t take that much training and are key parts of the medical system. Medicare and other insurers are offloading office visits to nurse practitioners because they’re cheaper. They are well trained but are not doctors. Sometimes that’s better, sometimes you need to see the doctor.
StringOnAStick
@Yarrow: “Sometimes that’s better, sometimes you need to see a doctor” .
There’s the tricky part, how do you know? I’ve had NP’s and PA’s get it right when MD’s had completely missed it. I’ve also had an ENT convince me to have a surgery that made my moderate hearing loss turn into severe (I refused to let him touch the other ear). Everything I’ve ever let an orthopedic doctor talk me into has led to osteoarthritis, except one surgery. I used to be completely trusting of MD opinions, not so much anymore.
Eric Keller
UPMC is trying to take over in our local market. Our GP just sold his practice to them. Geisinger had previously tried this but failed. I knew an insider there, they had the idea that they could take over the management of Penn State University Park insurance. Which is pretty much everyone with insurance in this market.
Yarrow
@StringOnAStick: Yeah it’s a tough call. When you find a good practitioner it’s great. Otherwise, who knows. I guess that’s why they say doctors are “practicing” medicine. It’s not black and white a lot of the time. It takes interpretation.
Ruckus
@Yarrow:
The VA works this way. You are assigned a primary and this person is a LP, NP, or along the same line. You get sent to another clinic, say cardio for more extensive workups. You always see a resident first even then.
It seems to work well most of the time.