What Is Adverse Selection in Health Insurance?

There are large numbers of people who are more likely than others to get illnesses and diseases over the course of their lives. Also, many people who are sick already apply for health insurance policies. With a wide variety of people who are high-risk, companies can experience adverse selection.

What Is Adverse Selection In Health Insurance?

Adverse Selection is when sick or high risk people buy insurance policies, but healthier people do not. It can have numerous effects on an insurance company, and companies also run the risk of people who are sick or purchasing more health insurance overall, or investing in more robust plans. If they do this, while people who are more healthy buy less coverage, it can have the side effect of a health insurance provider having a higher risk of paying out more money than it predicted. This results in higher premiums, which can often result in even more adverse selection. With increased premiums, healthier people are more likely to opt-out of buying health insurance coverage. If the process continues unchecked, health insurance carriers are more likely to become unprofitable and go out of business.

With a process that can potentially escalate and continue to get worse and worse, health insurance providers have to be careful with how they charge people for policies. They can take numerous steps to help prevent adverse selection from having a negative impact on their business and their clients.

How Does Adverse Selection Work In Health Insurance?

Healthy people are often questioning why they should get health insurance policies. If a policy costs $250 a month, and they only go to the doctor two or three times a year, they are spending more money on a health insurance plan than they would on healthcare expenses overall. It can seem like this is a fantastic way to save money. The chances are smaller that a healthy person will need expensive healthcare, like surgery, emergency room admittance, specialists, or other types of services. Less healthy people, however, will look at a $250 a month premium and know they are getting a fantastic deal. Even after paying the deductible, this person, who may have heart disease or diabetes, as an example, might be saving a lot of money on their healthcare costs.

Health insurance companies need people who are paying more for their health insurance than the amount that they are paying out to those people. Health insurance is a fantastic way for people to get peace of mind, and it is essential to remember that emergencies can happen unexpectedly. This can cost people who do not have health insurance coverage a lot of money, regardless of whether they are healthy or not. Adverse selection is important for health insurance carriers to pay attention to because if they are losing money on each person paying for a policy, they will either need to raise rates or they will go out of business. Insurance companies rely on their financial strength, meaning their ability to play claims, and order to stay solvent.

Many countries around the world have different ways that they have decided to deal with adverse selection. Some leave it up to the individual insurance providers to prevent adverse selection from happening. There are numerous ways health insurance providers can discourage adverse selection. Beyond that, many governments put forth regulations to prevent health insurance providers from using some of these methods when they are deemed to be unfair.

In unregulated insurance markets, health insurance providers use underwriting to try and avoid adverse selection. During this process, an underwriter goes over each applicant’s medical history, as well as prior claims they have made, demographics, and the lifestyle choices and habits of each person who applies. The information is utilized to determine the risk a person has to the insurance company, which then determines prices. In some cases, insurance companies may decide not to sell a health insurance plan to someone who poses a significant enough risk. They may also charge them higher rates overall as another option.

Moral Hazard in Health Insurance

The idea that people who are insured will take on more risk, and use more services as well, if they are not covered, is called moral hazard. The concept that a person who is insured will accept riskier health situations, and in return, use more healthcare, is something that some professionals say increases healthcare costs.

Affordable Care Act Effect On Health Insurance Companies

The Affordable Care Act was designed to help insurance companies prevent adverse selection but also limits some of the things that health insurance providers do on their own to limit it from happening. The requirement to maintain coverage that was part of the Affordable Care Act was one way that the government looked to prevent adverse selection, which is known to increase health insurance rates. This was part of the Affordable Care Act until 2018, with people having to pay a tax penalty if they did not maintain health insurance coverage. The idea was to encourage younger people, who tend to be more healthy, to purchase healthcare coverage and help balance the system.

The ACA also provides subsidies to help people who have moderate incomes for health insurance coverage. By utilizing the health insurance exchanges, people are more likely to enroll in a healthcare plan. Some professionals have credited this portion of the Affordable Care Act as the reason that the ACA compliant markets have not faced hardship. The idea is that premium subsidies grow to keep up with the premiums, helping to keep healthcare affordable for people who are eligible for subsidies, regardless of how much the retail prices go up.

The Affordable Care Act also put in place limited enrollment windows, and coverage does not take effect immediately. Beyond that, there is a tobacco surcharge and a 3 to 1 rating ratio for older applicants. The Affordable Care Act put many systems in place to try and deal with adverse selection and keep health insurance accessible for more people overall.