Where Does the Health Insurance Premium Dollar Go?

By Uwe Reinhardt, Ph.D.
The JAMA Forum, April 25, 2017

In early March, America’s Health Insurance Plans (AHIP), the national association of private US health insurers, released an interesting report that presents, for insured patients younger than 65 years, financial statistics for 2014 of commercial and nonprofit health insurance companies.

According to the report, “Where Does Your Premium Dollar Go?,” an average of 79.7 cents per premium dollar is spent by insurers on health care proper and 17.8 cents on the insurers’ “operating costs,” leaving only 2.7 cents per premium dollar as profits.

The nearly 80 cents per premium dollar that insurers report to spend on medical expenses are known in insurance jargon as the “medical loss ratio (MLR),” because it is the portion of premiums collected health insurers “lose” to physicians, hospitals, and other entities who offer health care.

The Affordable Care Act (ACA) mandated an MLR of at least 85% for large insurance companies and of at least 80% for smaller carriers. By their own admission, insurers selling policies for individually purchased health insurance before the ACA went into effect tended to have MLRs in the 55% to 65% range. Should a repeal of the ACA entail elimination of the mandated minimum MLRs, the market might well revert again to these extraordinarily low payouts of premiums for health care.

As already noted, the AHIP reports that insurers had an average profit margin (net profits divided by premium revenue) of only 2.7%. The number seems low, perhaps because it is a simple average. Profit margins for the larger US health insurers, for example, actually were much higher  than just 3% in recent years, with 4.7% for Aetna, 7.0% for Cigna, and 4.6% for United Health Group in 2015 and 3.5% for Anthem in 2014. (These numbers, however, also include the Medicare Advantage program for older people.)

But even a profit margin of 5% belies the frequent assertion that private health insurers divert huge fractions of their premiums to their own profits. Much more troublesome is the 18 cents per premium dollar reported to cover the insurers’ “operating costs.” These include the cost of marketing, determining eligibility, utilization controls (eg, prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care workers and facilities.

These operating costs are about twice as high as are the overhead costs of insurers in simpler health insurance systems in other countries. A 2010 study comparing per capita health spending in Canada and the United States, for example, found that administrative costs in 2002 accounted for 39% of the total per capita spending difference between the 2 countries.

Also worthy of note is that the 18 cents per premium dollar that insurers report as their “production costs” exclude 2 additional forms of administrative overhead. First, the number excludes the value of the time US patients must spend dealing with insurers, mainly over enrollment and over claims. It can be very time-consuming. Second, the insurers’ cost naturally excludes also the sizeable outlays that physicians, hospitals, and other health care workers and facilities make to negotiate prices for health care and to argue over medical bills.

A Costly “Coding War”

A “must read” in this regard is a recent article by Elizabeth Rosenthal, MD, “Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much.” Rosenthal describes a costly “coding war” in which physicians, hospitals, and others who treat patients seek to maximize their profits by hiring legions of consultants who know how to “upcode” procedures in their medical bills. For their part, insurers hire legions of coding consultants who know how to protect insurers from such upcoding. Rosenthal vividly describes how individual patients can get mauled in the process.

We can think of the extraordinarily high overhead imposed on insured individuals and patients in the United States as the price they seem to be willing to pay for the privilege of choice among health insurers and, for each insurer, among multiple different insurance products. US consumers seem so fanatic about this choice that to keep it, they have been willing to give up their erstwhile freedom of choice among physicians, hospitals, and other clinicians and health care facilities. Citizens of most other countries have made that trade-off in exactly the opposite direction.

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The last paragraph sums up today’s message: “We can think of the extraordinarily high overhead imposed on insured individuals and patients in the United States as the price they seem to be willing to pay for the privilege of choice among health insurers and, for each insurer, among multiple different insurance products. US consumers seem so fanatic about this choice that to keep it, they have been willing to give up their erstwhile freedom of choice among physicians, hospitals, and other clinicians and health care facilities. Citizens of most other countries have made that trade-off in exactly the opposite direction.”