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You are here: Home / Anderson On Health Insurance / Known unknowns

Known unknowns

by David Anderson|  June 19, 20208:56 am| 22 Comments

This post is in: Anderson On Health Insurance, COVID-19

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Insurers are preparing their 2021 rate filings right now. The dominant response in the ACA individual market filings that I have reviewed at this time is that COVID has minimal impact on rates at this time. Most insurers that are making this statement follow it up immediately with another statement that they are collecting as much data as possible and will change their mind on rate impact when the data changes. This is reasonable as there is a tremendous amount that we don’t know about a novel and new disease.

One of the things that we don’t know is what is the long term consequences of asymptomatic infection? We are fairly confident that asymptomatic infection is the most common disease experience trajectory. But is it a minor annoyance or is it a silent damage causing event?

A new study in NATURE suggests that it might be the later:

3. Over half of patients who were classified as asymptomatic based on the lack of any experienced symptoms showed abnormalities based on lung CT scans, indicating possible damage even in these patients. pic.twitter.com/rGpFzIu5AB

— Carl T. Bergstrom (@CT_Bergstrom) June 18, 2020

What type of medical care is needed due to either direct damage caused by an asymptomatic COVID disease course or excerbations of previously controlled medical conditions?

We don’t know that yet!

Insurers are still trying to price their 2021 products with massive systemic acturial, socio-political and clinical uncertainty.

The ACA markets that I follow have a market design that strongly shifts marketshare towards the most optimistic insurers. Optimistic insurers might be right. They could be horrendously wrong.

I think that a one way risk corridor where the federal government takes on some of the risk of insurers being really really wrong makes sense. The risk corridor could have the federal government pay 80% of the incremental claims if the medical loss ratio for 2021 is over 105%. A company running a 105% MLR for a year is in serious trouble. Its executive team will likely be replaced for that size of money losing wrong guesses. However, it is a survivable one-off event. From a federal perspective, an unlikely to be triggered back-stop potentially saves federal dollars as the premium tax credits may be smaller.

We are not even six months into COVID in the United States. There is a tremendous amount that we still don’t know even as we have to make projections, predictions and pricing offers for the future.

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Reader Interactions

22Comments

  1. 1.

    MattF

    June 19, 2020 at 9:05 am

    Lung damage in asymptomatic patients is a huge ‘uh-oh’.

  2. 2.

    WaterGirl

    June 19, 2020 at 9:09 am

    I’ll see your “uh-oh” and raise you “oh shit”.  Better make that “oh fuck”.

    I have been wondering about repercussions in asymptomatic patients.  This is so not good.

  3. 3.

    JR

    June 19, 2020 at 9:21 am

    Just a note, those are “ground glass opacities” in the CT scan. They indicate lung damage, but aren’t especially prognostic, since they can heal. Of course they might not, either. Without long term studies we will not know. We are living in an experiment.

  4. 4.

    low-tech cyclist

    June 19, 2020 at 9:28 am

    We are not even six months into COVID in the United States.

    It just seems like it’s been a decade or so.

  5. 5.

    Amir Khalid

    June 19, 2020 at 9:35 am

    The Malaysian Health Ministry’s policy has always been that those who test positive for coronavirus are all hospitalised for isolation and treatment, whether asymptomatic or not. The Ministry says that this is not practised elsewhere. I wonder why not.

  6. 6.

    debbie

    June 19, 2020 at 10:27 am

    Is COVID-19 the only cause of  “ground glass opacities” or are they evidence of other diseases?

  7. 7.

    Ohio Mom

    June 19, 2020 at 10:27 am

    Things I just learned. Ohio Dad called me an hour ago from his north Las Vegas hotel; as some of you have read in previous threads, he is a software guy with a new job, automating warehouses (since March).

    He has a little less than two years left before he’s old enough for Medicare, and there were a lot of attractive things about this job (besides the fact he really needed a job).

    Anyway, we weren’t thrilled about this first business trip but when it was scheduled in April, it seemed doable. We found N95 masks, a face shield, and a nonstop flight, the better to avoid milling around an airport between flights.

    Anyway, what we learned through last night’s experience was that Thursday night flights to Las Vegas are filled with groups of tipsy working class friends who got free airplane tickets from the casinos (or maybe they are heavily, heavily discounted?).

    They all seemed to follow the rule about mask wearing, so there’s that.

    I like to think I make an effort to get past my middle-class suburban bubble but this is a clear fail. Growing up in NYC, I knew about the buses to Atlantic City, but did not imagine there was an airplane version to Nevada.

    I will be spending most of the day channeling my nervous energy in a whirl of house cleaning.

  8. 8.

    debbie

    June 19, 2020 at 10:34 am

    @Ohio Mom:

    Ha! You should have seen the line to get into the local casino here! What will be interesting to see will be if there are any issues with “guests” refusing to comply with mandatory masking.

  9. 9.

    Punchy

    June 19, 2020 at 10:34 am

    Ground Glass Opacity is a great band name.

  10. 10.

    scav

    June 19, 2020 at 11:19 am

    As we keep adding symptoms to the disease, these asymptomatic pronouncements get tricky.

  11. 11.

    WaterGirl

    June 19, 2020 at 11:41 am

    @scav: Can you say more about what you mean by that?

  12. 12.

    Sister Rail Gun of Warm Humanitarianism

    June 19, 2020 at 11:53 am

    What’s even scarier is deep in the study.

    In this study, we observed that IgG levels and neutralizing antibodies in a high proportion of individuals who recovered from SARS-CoV-2 infection start to decrease within 2–3 months after infection. In another analysis of the dynamics of neutralizing antibody titers in eight convalescent patients with COVID-19, four patients showed decreased neutralizing antibodies approximately 6–7 weeks after illness onset.

  13. 13.

    jl

    June 19, 2020 at 12:01 pm

    Isn’t that like some fungal respiratory diseases? Histoplasmosis?

    Seems to me yet another argument to use surveillance, contact tracking and isolation to keep the prevalence low. More and more countries are showing that can be done. The US cannot because it is a wasted hollowed out society with a decayed public sector. Just as much a problem with us as the new bug

    Edit: I read someplace that it has been known that some coronaviruses cause Kawasaki like syndromes in kids. There was a small outbreak bout ten(?) years ago of some kind of coronavirus call ‘New Haven coronavirus’ that produced the syndrome. I also read that the vaccines that have shown best early results use same approach that is used for canine and bovine enteric coronavirus disease.

    Because the US is hopeless feckless mess, it can’t do anything but gape in horror at a solvable problem that is beyond it’s means to solve.

  14. 14.

    Another Scott

    June 19, 2020 at 12:02 pm

    @WaterGirl: The list of symptoms seems to be increasing all the time.

    E.g. https://medicalxpress.com/news/2020-06-clinicians-pink-eye-primary-symptom.html

    HTH.

    Cheers,
    Scott.

  15. 15.

    Edmund Dantes

    June 19, 2020 at 12:06 pm

    @WaterGirl: or the princess bride has a better reference.

    inconceivable. (Asymptotic)

     

    you keep saying that word but I don’t think it means what you think it means. (We keep adding symptoms to the list of stuff asymptotic people have)

  16. 16.

    scav

    June 19, 2020 at 12:20 pm

    @WaterGirl: Sorry, I was off drinking coffee. It’s just that as we discover my symptoms of covid (such as pink eye and the ties) the pool of who as asymptotic changes, so it’s hard to do comparisons between and conclusions from studies done at different times.

  17. 17.

    scav

    June 19, 2020 at 12:33 pm

    @scav: Bother.  The cup of coffee clearly wasn’t enough to catch the typo-automiscorrects in time.  “More symptoms of covid” and “who are” clearly.

    MORE COFFEE!!

  18. 18.

    WaterGirl

    June 19, 2020 at 12:40 pm

    @Another Scott: I am aware that the list of symptoms have greatly increased over time.

    This is the part I have trouble with, where I can come up with more than one version of what he might be trying to say there:

    …these asymptomatic pronouncements get tricky.

    I wasn’t clear, but that’s the part I was inquiring about.

  19. 19.

    WaterGirl

    June 19, 2020 at 12:42 pm

    @scav: I wondered if you were suggesting that perhaps people who thought they were asymptomatic could look back and say “well, I did have pink eye”.  Which would mean that someone we originally thought was asymptomatic might not have been.

    I can see that it’s possible that the % of cases that are asymptomatic could be reduced over time as we add more symptoms.

    But right now, it seems like the % of asymptomatic cases (as compared to all cases) is increasing.

  20. 20.

    jl

    June 19, 2020 at 12:49 pm

    Probably obvious that I’m grouchy from my previous comment, but here in soyboy public health paradise, at least from what I hear on the news and what I see on the local covid-19 dashboards, is that the hold up in a safe and reliable reopen is county governments unable to get up their surveillance, contact tracking and isolation programs up to speed as promised. Areas I’m going to now, compliance with masking is very high, I haven’t seen one instance of ant-masking BS and hardly any flagrant disregard for precautions. So, for whatever reason, yet again, public sector in US cannot deliver as they promise. Mostly likely because of constant attacks on their budgets for decades now. Santa Clara County has admitted they are having resource problems getting their programs up and running,

    Also from news reports I’ve heard, most of the new cases are in nursing homes and worksites. Heard a news report that over 75 percent of new cases are in institutions and work crews at building sites and indoor plants. The rest of us can stay home forever, and that won’t solve those problems. Nursing homes still giving staff inadequate decayed BS for PPE. Unions claiming business being slapdash on safety precautions.

    I find it an outrageous situation.

  21. 21.

    scav

    June 19, 2020 at 1:55 pm

    @WaterGirl: There is that, but here’s a concrete analogy that should hint at the type of problem(s) I was thinking about,  Say we’re trying to evaluate batting average in a population.  Just test everybody.  But if we think actually playing baseball is a disease and we want them out of the pool, so we first eliminate the major leagers and recalculate, get a different number (and a different sized pool, with different other aharacteristics).  But then, O! What about the farm teams? Remove, recalculate, different numbers.  What about playing in college? Ditto.  What about Little League?  Ditto.  So now we’ve got all sorts of batting averages, but how do we compare them?  And the pools are different, so what it we want to say, calculate the relationship of batting average to lifetime income?  Ok, entirely a stretch, but it’s just an example.  The pool including major leaguers and the one without might suggest different relationships, whereas the pools including and not including little leaguers would more likely show a similar relationship.  But when were discussing batting average and income and all, we basically know what’s going on and can predict what’ll happen to the numbers so the change in pool composition doesn’t really matter too much.  But when all we have are the numbers from different pools, it’s harder to reconstruct what are the relationships and assert what the ‘real’ numbers (say of how long an assymptomatic person sheds virus) really are.

  22. 22.

    KRK

    June 19, 2020 at 2:59 pm

    It struck me as I drove into work this morning (no idea what triggered it), that without the ACA’s prohibition on excluding pre-existing conditions, basically no one could ever get new insurance coverage that they could rely on covering major organ ailments, since COVID-19 has been linked to damage in almost all of them. Maybe this is obvious and everyone’s already noted it. But as the Republicans continue their efforts to gut and/or repeal the ACA, I would think it would come up more.

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