I am a student in the doctoral program at the Duke University Department of Population Health Sciences. I am working towards my my doctorate in Health Services Research with a policy focus. I am fundamentally fascinated by insurance markets, consumer choice and the navigation of complex choice environments. I'm currently RA-ing at the Duke Margolis Center for Health Policy.

I used to be Richard Mayhew, a mid-level bureaucrat at UPMC Health Plan. I started writing here and have not found a reason to stop.

Conflicts of interest: Previously employed at UPMC Health Plan until 12/31/16. I also worked full time as a research associate at the Duke University Margolis Center for Health Policy. I have received direct funding from the National Institute for Healthcare Management, and I have been on projects funded by the Rockefeller Foundation, Kate B. Reynolds Charitable Trust, Gordan and Betty Moore Foundation, Duke University Health System, CMMI, and various value based payment consortiums.

Research Production is here: https://scholar.google.com/citations?user=zof9b4IAAAAJ&hl=en

David Anderson has been a Balloon Juice writer since 2013.

David Anderson

Open Enrollment Ends Tonight

by David Anderson| January 15, 20227:30 am| 2 Comments

This post is in: Anderson On Health Insurance, Open Threads

Good morning Jackals —

For anyone living in a state that uses Healthcare.gov and for people living in most state based market places, OPEN ENROLLMENT PERIOD for health insurance ends tonight at local midnight.

This means that getting health insurance after tonight gets a whole lot harder and less predictable.

Go sign up if you have not already.

Go convince your relative or your neighbor or your neighbor’s relative one last time to sign up.

I’ll be checking in and out of comments all day if you need any help.

Open Enrollment Ends TonightPost + Comments (2)

Ivermectin, Insurers and Hassle Costs

by David Anderson| January 14, 20227:45 am| 18 Comments

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

A new research letter in JAMA Network Open by Chua, Conti and Becker attempts to estimate the cost of spurious and needless ivermectin prescriptions in the United States. They estimate for the commercially insured and Medicare Advantage markets (roughly ~56% to 61% of the population depending on how ACA exchanges are counted) that over $129 million dollars in needless ivermectin prescriptions were filled in 2021. They then make a claim about the economics of insurers:

Findings suggest that insurers heavily subsidized the costs of ivermectin prescriptions for COVID-19, even though economic theory holds that insurers should not cover ineffective care.⁴ Wasteful insurer spending on these prescriptions, estimated at $2.5 million in the week of August 13, 2021, would extrapolate to $129.7 million annually.

I have a problem with this sentence. I think it is too simplistic. Let’s assume that their data applies to 56% of covered lives in the US. That means their population of interest is at least 182 million people. Insurers think in terms of per member per month (PMPM) when they do cost analysis. Taking the Chua et al estimates of $129.7 million dollars in wasteful spending, this is a per member cost of 71 cents per member per year. Assuming full year enrollment this means ivermectin is about $0.06 PMPM.

Setting up a hold that routes to a prior authorization queue is not cost-free. The actual set-up is fairly straightforward but it does require analyst time as well as system validation time. Administering a queue where some of the prescriptions are legitimate and likely need a person at the insurance company to either look at a request with an appropriate diagnosis code or an actual conversation with an in-network PCP. This is not cheap. It won’t take that many conversations to make the cost of running the prior authorization process a break even at best proposition for a short term idiosyncratic spike of a dirt cheap generic being used for an off-label and dumb use.

The business case to deny ivermectin is iffy.

And that business case excludes the almost guaranteed political and media shitstorm that would likely ensue once the first prescription is denied. Insurance companies don’t like being on the front page of a newspaper or a good chunk of the 2nd block of the local 6 o’clock news. Avoiding that shit show is likely worth a few pennies per member per month.

Ivermectin, Insurers and Hassle CostsPost + Comments (18)

Just a few more days

by David Anderson| January 12, 20227:29 am| 7 Comments

This post is in: Anderson On Health Insurance

The ACA Open Enrollment Period for Healthcare.gov ends at 11:59pm on January 15th — that is this coming Saturday.

After the Open Enrollment Period, getting individual market health insurance gets a whole lot harder. After January 15th, you need a Qualifying Life Event (QLE) to open up a Special Enrollment Period to get coverage. A QLE is a major change in your life like a birth, death, marriage, move or loss of coverage.

As of this morning, the ACA markets are running at a record volume with over 13 million sign-ups. Get signed up by Saturday and save yourself some headaches.

Just a few more daysPost + Comments (7)

Antigen testing and administrative burden

by David Anderson| January 11, 202210:02 am| 53 Comments

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

The Biden Administration now requires insurers for fully insured plans to reimburse individuals for up to eight tests per month. Dr. Valerie Lewis of UNC makes an excellent point last night:

It’s good that insurance will now cover 8 home tests/month. It’s bad that this involves reimbursement (which is arduous). And much worse, ~28M Americans have no insurance (concentrated in states that didn’t expand Medicaid) so can’t get tests reimbursed. https://t.co/y9RVLmFub3

— Valerie A. Lewis, PhD (@valeriealewis) January 11, 2022

Reimbursement is an administrative burden nightmare. Receipts will be required. ~~There may be requirements for prescriptions.~~ Cash needs to be fronted and then payments will be received via check or direct deposit several weeks to months later.

This is an obstacle course that will lead to predictable and disparate fall-off from people either trying and failing to get reimbursed or looking at the obstacle course and saying “fuck it.” We know that administrative burden is most heavily borne by individuals with low incomes, complex lives, low education and likely to be heavily minoritized (in an international and American contexts). People like my wife and I who are overly educated professionals who are good at navigating complex bureaucracies because this is what we do for a living and have been trained to do for our entire lives will figure out how to get reimbursed. People earning $20,423 and have a kid at home because school is closed because seventy percent of the teachers are either sick, in isolation or on quarantine and whose boss is demanding that they come in for an extra overnight shift tomorrow are far more likely to not succeed in getting a $50 or $100 reimbursement check approved — if they could ever afford to front the $50 or $100 to buy a few boxes of tests.

Antigen testing is primarily intended to provide public externalities. There are a few treatments which are reliant upon early identification where the gains of an early positive test can be captured by the individual taking the test. However, the primary purpose for antigen testing is to identify people without symptoms early enough so that future chains of infection can be broken before other people are infected.

Reimbursement is an attempt by the government to pay for some of the externalities that we want and need to generate. However given the administrative burden, take-up will be fairly light and non-uniform.

Antigen testing and administrative burdenPost + Comments (53)

Sickle cell, CRISPR, cures and policy

by David Anderson| January 10, 20228:37 am| 55 Comments

This post is in: Anderson On Health Insurance

Earlier this week, Tom Levenson linked to an excellent article by NPR on the promise of CRISPR technology for either long term symptom alleviation or cures for some people who have sickle cell anemia:

“I’m doing great,” Gray, now 36, said during a recent interview from her home in Forest, Miss. with NPR, which has had exclusive access to chronicle her experience for more than two years….doctors taking cells out of her bone marrow, and editing a gene in the cells in their lab, using the revolutionary gene-editing technique known as CRISPR….

The hope was the edited cells would produce a protein known as fetal hemoglobin, alleviating the symptoms of sickle cell…

And it appears to have worked, for Gray and other patients. Doctors have now treated at least 45 patients with sickle cell and a related condition known as beta thalassemia, and reported data indicating it’s working for at least 22 of them.

Sickle Cell Anemia is a genetic disease that is the result of two recessive genes expressing themselves so that red blood cells are bent instead of round. A single copy of the gene provides protection against malaria while both copies of the gene produce pain and lack of function.

Last week, the Duke Margolis Friday virtual lunch seminar had a speaker go over some of their new research on sickle cell. The TLDR from that talk is that sickle cell cures are a very nasty policy problem.

The first big thing is that the disease is very heavily racialized. African Americans are tremendously more likely to have the right combination of genes than people who identified as white.

Secondly, individuals with sickle cell are highly likely to be insured by Medicaid. Medicaid is a joint federal-state program. ACA Medicaid expansion has the federal government pay 90% of the costs and the states 10% while legacy Medicaid has the feds paying between 50% and 75% of the costs and states paying the remainder. The mostly former Confederacy states that have not (yet) expanded Medicaid under the ACA have a disproportionate share of individuals with sickle cell anemia.

Third CRISPR is expensive even in the context of US healthcare costs. A million dollar treatment cost is well within the realm of plausible and in some discussions that would be considered cheap. According to the NPR article, success is only happening in about half of the trial population. So there might be cases where a million dollars is spent for limited gains while other people can have massive improvements in quality and quantity of life for the same million dollars.

It is likely that a sickle cell cure will be cost effective under traditional health economics regimes. It is almost certain that a CRISPR based treatment will be a massive cash flow shock. Costs are incurred in the first period and the benefits are distributed to the individual over a twenty, thirty or forty year follow-on period. The Hep-C antivirals are a good analogy for a technological shock that is very cost-effective over a reasonable time horizon that is also a huge cost shock to the current payer period.

Several of my colleagues are thinking hard about how to structure contracts and payment arrangements that deal with massive expenditures with group level benefits but uncertainty and variance at the individual level. But no matter what, this is both very promising and one hell of a nasty policy problem.

Sickle cell, CRISPR, cures and policyPost + Comments (55)

Comment letter on the Georgia 1332 Waiver

by David Anderson| January 7, 20229:30 am| 16 Comments

This post is in: Anderson On Health Insurance

The Centers for Medicare and Medicaid Services (CMS) recently asked the public for further comments on the Georgia 1332 waiver application for the Georgia Access Model (GAM) portion of the waiver. Georgia wants to shut down Healthcare.gov in the state and not replace it with a state based marketplace. Instead, private entities will be responsible for outreach, assistance and advertising while the state handles income verification and subsidy determination. The state believes that this will increase enrollment. The GAM waiver was approved in November 2020 but CMS is concerned that the underlying realities of the without waiver baseline have significantly changed so that the with waiver application will not meet the relevant guardrails.

Commenting is an act of active citizenship. Federal agencies seek public input all the time. Most of the time it is to fulfil the notice and comment requirements of the Administrative Procedures Act where the agency needs to build a paper trail that the decisions that they are making are neither arbitrary nor capricious. Other times, it is to gain insight on pressing matters of import. Regulations.gov is usually the central repository of ongoing federal requests and responses to comments during the rule-making process. Most comments that are vaguely responsive come from small groups of very interested in the outcome stakeholders who are willing to argue vehemently over punctuation as a comma instead of a semi-colon might be worth tens of millions of dollars. Public comments from the public that is well informed, specific and relevant adds different views into the rule-making process.

I, along with Drs. Rebecca Myerson of the University of Wisconsin and Dr. Coleman Drake of the University of Pittsburgh, writing in our personal capacities submitted the comment below regarding the Georgia 1332 Waiver last night. We outlined some of our current research and other relevant and reasonably recent research that may shed some insight on the questions that HHS and CMS are asking about.

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Comment letter on the Georgia 1332 WaiverPost + Comments (16)

January 6, 2022

The Honorable Xavier Becerra
Secretary of Health and Human Services
200 Independence Ave, SW Washington, DC 20201

Re: Georgia Access Model Request for Comment

Dear Secretary Becerra,

We are health policy scholars writing in response to the November 9, 2021 Request for Comment on the Georgia Access Model Section 1332 waiver proposal to share timely research that is relevant to your decision-making regarding this waiver proposal. Our statements here do not speak for our employers, funders, or any other entity, organization or individual. We address the current literature on the following subjects:

• The impact of changes in federal law and policy on the Georgia Access Model’s compliance with Section 1332’s statutory coverage guardrail given the impact of inertia, zero-premium plan availability, and extended open enrollment periods for plan effectuation.
• The impact of changes in federal funding for the navigators in the federally facilitated exchanges; specifically, new data indicate cuts to the navigator program affect reductions in coverage.
• The lack of substitutability between public vs. private sector forms of outreach. Several studies suggest that private entities such as insurers do not fill gaps in key means of outreach and assistance, such as television ads, when there is reduced public sector activity.

Inertia, Zero-premium Plan Availability and Extended Open Enrollment Periods

We believe that baseline without waiver enrollment levels from Georgia’s waiver application are materially different for Plan Year 2022 (PY2022), the last pre-waiver year, than the application assumed. While Georgia’s waiver would not go into effect until Plan Year 2023, this difference will significantly alter the calculations needed to satisfy the federal deficit neutrality and coverage guardrails. Many 2022 enrollees will re-enroll in 2023, even as subsidies decrease with the sunsetting of American Rescue Plan Marketplace subsidies.

Georgia, in its October 9, 2020 waiver application (Table 4.1), estimated that PY2022 would have a total enrollment of 386,792 in all QHP market segments. For PY2020, the Summary Report on Permanent Risk Adjustment Summary Report – HHS Risk Adjustment Program-State Specific Data, Appendix A, indicates that there were 437,475 member years between the individual and catastrophic market. For PY2021, CMS reports, via the OEP State Level Public Use File, that 517,113 individuals effectuated coverage during the 2021 Open Enrollment Period, including 379,105 returning subscribers on the Marketplace. More individuals enrolled off-exchange.

The 2022 Open Enrollment Period is ongoing. The presence of enhanced premium subsidies provided through the passage of the American Rescue Plan (ARP), increased navigator funding and increased federal advertising support, and the COVID pandemic likely will lead to enrollment levels that are greater than 2021 Open Enrollment Period enrollment in Georgia. Premiums net of subsidies (i.e., net premiums) are highly important to households deciding whether to enroll for the first time. Since 2018, net premiums for the least expensive plans have dramatically declined due to states’ decisions, including Georgia’s, to “silver load” the value of Cost-Sharing Reduction benefits into silver plans’ premiums (1).The net premium for the least expensive plan available to subsidized buyers significantly decreased, especially in low competition and rural markets, even as the net premium for the least expensive plan available to non-subsidized buyers increased (2).

At this time, Georgia’s enrollment for the 2022 OEP is 653,590, 69% higher than the waiver projected (3).These data suggest Marketplace enrollment is growing rapidly in Georgia under the new policy regime affected by the Biden Administration and Congress (4). Higher levels of without-waiver enrollment are thus likely to alter calculations regarding the impact of Georgia’s proposed waiver on budget neutrality and coverage, calling Georgia’s original assumptions and analysis into question.

The ARP has increased both the scale and scope of premium tax credits. The applicable percentage that households must pay each month for the benchmark plan has temporarily decreased such that: (1) households earning under 150% Federal Poverty Level (FPL) have a choice between two zero-premium silver plans with CSR benefits; and (2) households earning over 400% FPL only need to pay 8.5% of their Modified Adjusted Gross Income (MAGI) for a benchmark plan.

Georgia, in their August 26, 2021 response letter states that these “provisions of the ARP cited by the Departments are also irrelevant to the Georgia Access Model’s compliance with statutory guardrails and STCS because the cited ARP provisions expire before the Georgia Access Model even goes into operation in 2023.”

This statement assumes that individuals and households actively choose to purchase or not purchase health insurance each and every year. This is incorrect.

The current, without-waiver enrollment environment is highly supportive. Researchers have also found that the presence of zero-premium plans substantially increases re-enrollment(5). Furthermore, the recent Executive Order issued on December 13, 2021 directing agencies to further reduce administrative burden—the costs, barriers, and frictions required of individuals to enroll and maintain eligibility for benefits—will, once implemented, likely sustain and increase enrollment as administrative frictions have been shown reduce enrollment and decrease health plan choice quality(6). Finally, the extended open enrollment period through January 15, 2022 will likely lead to many individuals who had wanted to enroll in insurance with a January 1, 2022 start date but had not been able to do so having a second opportunity to enroll with a February 1, 2022 start date. Research using the Colorado state based marketplace has found that this population is notable in its size and comparatively lower income(7).

The individual’s decision to enroll in a Qualified Health Plan is complex. Political identification, elite messaging, advertising, administrative burdens including time and hassle costs to enroll, affordability and quality of benefits all contribute to whether a household enrolls in a Qualified Health Plan(8–10). Changing the structure of health insurance enrollment as specified in the with-waiver modeling, for Georgia Marketplace enrollees may thereby decrease overall enrollment by creating a new system for enrollees to learn and navigate. This decrease will likely be magnified unless it is accompanied by robust advertising and outreach to assist returning enrollees. Prior evidence discussed below suggest that private insurers will not step in to fill gaps in public outreach that will likely be necessary to accommodate the transition away from the Marketplace (see below).

These behavioral frictions in the context of high enrollment are likely to lead to high, persistent enrollment in a without-waiver universe under current law.

Navigators
Federal funding for the public sector navigator program in Georgia increased from $700,000 in 2020 to more than $2.5 million in 2021. The 2021 funding constituted the first 12 months of a 36-month period of performance, so that level of funding for the current navigator grantees is expected to continue through August 26, 2024. Access to these funds for the navigator program would be lost under the Georgia Access Model.

Navigator programs were designed to facilitate enrollment in qualified health plans by providing consumers with fair, accurate, and impartial information about health insurance, the health insurance marketplaces, and insurance affordability programs such as subsidies in the marketplaces (11). Many navigator grantees proposed to target their services to specific underserved populations in their statements to CMS. In 2017, for example, the Georgia Association for Primary Health Care targeted rural consumers, veterans, Latino consumers and other minoritized racial or ethnic groups, the self-employed, and women with children, and the Georgia Refugee Health and Mental Health targeted refugee and international/limited English speaking populations (12).

Matching these stated goals, the navigator program has been linked with improvements in the coverage rate for underserved populations. A recent study examined changes in coverage before vs. after the 80% cut in funding for the navigator program under the Trump administration, comparing across counties in federally facilitated marketplace states that had more vs. fewer navigator programs prior to the cuts. Cuts to the navigator program were associated with drops in the coverage rate among lower-income adults, adults under age 45, Hispanic adults, and adults who speak a language other than English at home (13).

There is also the possibility that cuts to the navigator program could affect affordability of coverage, although data on this question are sparser. Data from California also suggested that consumers assisted by private sector insurance agents or insurer-employed enrollers overpaid for their coverage – e.g., enrolled in a marketplace plan that provided less coverage at a similar or higher price than another available plan – at slightly higher rates than consumers assisted by public sector assisters, although it is not clear whether this difference is statistically significant (14).

Television Advertising and Navigators
Individuals and households need information to make significant financial choices. Many individuals have low health insurance literacy and are unable to identify and differentiate key insurance concepts like “premium” and “deductible” (15–17). Information can be provided to consumers through a variety of channels including broadcast advertising through federal, state, and private channels and navigators.

Government sponsored television advertising has been positively associated with increases in the proportion of people who report looking into purchasing marketplace coverage or ultimately enrolling in marketplace coverage (18). Consumer engagement with the marketplace (e.g., views of the marketplace website and calls to the call center) significantly declined in Kentucky when government sponsored advertising was abruptly decreased after the governorship of the Commonwealth changed parties (19). The association between advertisements and marketplace enrollment outcomes can vary based on the advertisement sponsor (20). Aizawa and Kim found that private sponsored marketplace advertisements differed from government advertisements in the content included and geographic areas targeted, consistent with the possibility that privately sponsored advertisements were designed to achieve a different objective from publicly sponsored advertisements (21). Private insurers profit when they are able to insure individuals whose net of risk adjustment costs are lower than their net of risk adjustment premiums (22); profit maximization informs advertising strategy, e.g., targeting of individuals with low disease severity relative to their risk adjustment score (23).

Privately sponsored television advertising is not a substitute for the absence of navigator funding that is proposed by the Georgia waiver application. A current working paper has found no relationship between changes in navigator funding and privately sponsored advertising volume for private insurance (24). This null finding was robust to multiple specifications and placebo tests.

Overall, private insurers and related entities with financial incentives—such as web-brokers, agents, and brokers—have a fundamentally different set of goals than federal and state governments. In the context of the Georgia Access Model, the assumption that private outreach will either replace or substitute for publicly funded outreach to marginalized populations is unlikely to be accurate. We are especially concerned that, based on the evidence noted above, reliance on solely private outreach could result in less outreach and marketing to people with chronic conditions, people who are low-income, and other marginalized populations.

Sincerely,

David Anderson MSPPM
Department of Population Health Sciences
Duke University

Dr. Rebecca Myerson PhD
Assistant Professor
Department of Population Health Sciences
University of Wisconsin-Madison

Dr. Coleman Drake PhD
Assistant Professor
Department of Health Policy and Management
University of Pittsburgh

References
1. Anderson D, Abraham JM, Drake C. Rural-Urban Differences In Individual-Market Health Plan Affordability After Subsidy Payment Cuts. Health Aff (Millwood). 2019 Dec 1;38(12):2032–40.
2. Drake C, Abraham JM. Individual market health plan affordability after cost-sharing reduction subsidy cuts. Health Serv Res. 2019;54(4):730–8.
3. Marketplace Weekly Enrollment Snapshot: Week 6 | CMS [Internet]. 2021 [cited 2022 Jan 6]. Available from: https://www.cms.gov/newsroom/fact-sheets/marketplace-weekly-enrollment-snapshot-week-6
4. Anderson DM, Griffith KN. Increasing Insurance Choices In The Affordable Care Act Marketplaces, 2018–21. Health Aff (Millwood) [Internet]. 2021 Nov 1 [cited 2021 Nov 21];40(11):1706–12. Available from: https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2020.02058
5. McIntyre AL, Shepard M, Wagner M. Can Automatic Retention Improve Health Insurance Market Outcomes? [Internet]. National Bureau of Economic Research; 2021 Apr [cited 2021 Jun 21]. Report No.: w28630. Available from: https://www.nber.org/papers/w28630
6. Ericson K, Layton T, McIntyre A, Sacarny A. Frictions vs. Premiums Impeding Take-up of Subsidized Health Insurance Coverage: Evidence from a Field Experiment. In Preparation;
7. Drake C, Cai S-T, Anderson D, Sacks DW. Financial Transaction Costs Reduce Benefit Take-Up: Evidence from Zero-Premium Health Plans in Colorado [Internet]. Rochester, NY: Social Science Research Network; 2021 Mar [cited 2021 Apr 7]. Report No.: ID 3743009. Available from: https://papers.ssrn.com/abstract=3743009
8. Anderson D, Shafer P. The Trump Effect: Postinauguration Changes in Marketplace Enrollment. J Health Polit Policy Law [Internet]. 2019 [cited 2019 Jul 9]; Available from: https://read.dukeupress.edu/jhppl/article/doi/10.1215/03616878-7611623/139047/The-Trump-Effect-Postinauguration-Changes-in
9. Trachtman S. Polarization, Participation, and Premiums: How Political Behavior Helps Explain Where the ACA Works, and Where It Doesn’t. J Health Polit Policy Law [Internet]. 2019 Dec 1 [cited 2019 Dec 11];44(6):855–84. Available from: https://read.dukeupress.edu/jhppl/article/44/6/855/139739/Polarization-Participation-and-Premiums-How
10. Herd P, Moynihan DP. Administrative Burden: Policymaking by Other Means. New York: Russell Sage Foundation; 2018. 360 p.
11. Department of Health and Human Services. Patient Protection and Affordable Care Act; Exchange Functions: Standards for Navigators and Non-Navigator Assistance Personnel [Internet]. 45 CFR Part 155 2013. Available from: https://www.govinfo.gov/content/pkg/FR-2013-04-05/pdf/2013-07951.pdf
12. Centers for Medicare and Medicaid Services. In-Person Assistance in the Health Insurance Marketplaces: Navigator Grant Recipients [Internet]. 2019 [cited 2021 Apr 30]. Available from: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/assistance
13. Myerson R, Li H. Information Gaps and Health Insurance Enrollment: Evidence from the Affordable Care Act Navigator Programs [Internet]. Social Sciences Research Network; 2021 Nov. Available from: http://dx.doi.org/10.2139/ssrn.3966511
14. Rasmussen P, Anderson D. When All That Glitters Is Gold: Dominated Plan Choice on Covered California for the 2018 Plan Year. Milbank Q [Internet]. 2021 Jul; Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/1468-0009.12518
15. Kim J, Braun B, Williams AD. Understanding Health Insurance Literacy: A Literature Review. Fam Consum Sci Res J [Internet]. 2013 [cited 2019 Jul 24];42(1):3–13. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/fcsr.12034
16. Tipirneni R, Politi MC, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost. JAMA Netw Open [Internet]. 2018 Nov 16 [cited 2021 Apr 6];1(7):e184796–e184796. Available from: https://doi.org/10.1001/jamanetworkopen.2018.4796
17. Yagi BF, Luster JE, Scherer AM, Farron MR, Smith JE, Tipirneni R. Association of Health Insurance Literacy with Health Care Utilization: a Systematic Review. J Gen Intern Med [Internet]. 2021 May 23 [cited 2021 May 25]; Available from: https://doi.org/10.1007/s11606-021-06819-0
18. Gollust SE, Wilcock A, Fowler EF, Barry CL, Niederdeppe J, Baum L, et al. TV Advertising Volumes Were Associated With Insurance Marketplace Shopping And Enrollment In 2014. Health Aff (Millwood) [Internet]. 2018 Jun 1 [cited 2021 Oct 11];37(6):956–63. Available from: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.1507
19. Shafer P, Franklin Fowler E, Baum L, Gollust S. Television Advertising and Health Insurance Marketplace Consumer Engagement in Kentucky: A Natural Experiment. J Med Internet Res. 2018 Oct 25;
20. Shafer PR, Anderson DM, Aquino SM, Baum LM, Fowler EF, Gollust SE. Competing Public and Private Television Advertising Campaigns and Marketplace Enrollment for 2015 to 2018. RSF Russell Sage Found J Soc Sci [Internet]. 2020 Jul 1 [cited 2020 Dec 28];6(2):85–112. Available from: https://www.rsfjournal.org/content/6/2/85
21. Aizawa N, Kim YS. Public and Private Provision of Information in Market-Based Public Programs: Evidence from Advertising in Health Insurance Marketplaces [Internet]. Rochester, NY: Social Science Research Network; 2020 Aug [cited 2021 Oct 11]. Report No.: ID 3675247. Available from: https://papers.ssrn.com/abstract=3675247
22. Geruso M, Layton T, Prinz D. Screening in Contract Design: Evidence from the ACA Health Insurance Exchanges. Am Econ J Econ Policy. 2019 May;11(2):64–107.
23. Aizawa N, Kim YS. Advertising and Risk Selection in Health Insurance Markets. Am Econ Rev [Internet]. 2018 Mar 1 [cited 2021 Oct 22];108(3):828–67. Available from: https://pubs.aeaweb.org/doi/10.1257/aer.20151485
24. Myerson R, Anderson D, Baum L, Franklin Fowler E, Gollust S, Shafer P. Cuts to navigator funding were not associated with changes to private sector advertising in the ACA marketplaces [Internet]. University of Wisconsin-Madison working paper; 2021 Dec. Available from: https://drive.google.com/file/d/1uoQt0PeplBjNrxrtBS2OFGoGHpzYhajs/view

Actuaries rule the world (Mortality edition)

by David Anderson| January 6, 20227:45 am| 19 Comments

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

An Indiana life insurer has made some news earlier this week when they reported their claims experience for the second half of 2021. Life insurers pay out claims when people die. People usually die fairly predictably on the basis of age, gender, previous medical history and geography. Spikes are either due to one-off catastrophic events (plane crashes) or something weird and notable.

The head of Indianapolis-based insurance company OneAmerica said the death rate is up a stunning 40% from pre-pandemic levels among working-age people…

Davison said the increase in deaths represents “huge, huge numbers,” and that’s it’s not elderly people who are dying, but “primarily working-age people 18 to 64” who are the employees of companies that have group life insurance plans through OneAmerica.

“And what we saw just in third quarter, we’re seeing it continue into fourth quarter, is that death rates are up 40% over what they were pre-pandemic,” he said.

“Just to give you an idea of how bad that is, a three-sigma or a one-in-200-year catastrophe would be 10% increase over pre-pandemic,” he said. “So 40% is just unheard of.”

Most of the claims for deaths being filed are not classified as COVID-19 deaths, Davison said

A couple of points need to be made.

This is reflected of the Delta wave and not Omnicron.

Death categorization is a very inexact science. Death determination is often made by coroners. Coroners are often elected positions with frequently low to no training requirements. Reporting to the CDC for inclusion in the WONDER database is slow in pre-COVID times (the dataset is good through 2020 at this time).

However life insurers have a far simpler problem. They pay out a claim on a verified death of a covered life. They fundamentally care about dead/not dead as the unit of meaning. Further details are needed to verify that the coverage actually applies to the claimed death, but the fundamental questions are simple: Active policy? dead or alive?

Life insurance companies don’t care that some county coroners “doesn’t do COVID deaths.” Their actuaries know that they are paying a lot of claims for a population that tends to not have a lot of deaths leading to claims. Much like climate change, insurers will respond to the evidence in front of their actuaries’ noses that something big is happening that will cost them a lot of money if new trends continue.

Actuaries rule the world (Mortality edition)Post + Comments (19)

So it was an October Surprise A Day, like an Advent calendar but for crime.

Historically it was a little unusual for the president to be an incoherent babbling moron.

Just a few bad apples.

Not all heroes wear capes.

I’d like to think you all would remain faithful to me if i ever tried to have some of you killed.

Technically true, but collectively nonsense

‘Forty-two’ said Deep Thought, with infinite majesty and calm.

If senate republicans had any shame, they’d die of it.

Pessimism assures that nothing of any importance will change.

Proof that we need a blogger ethics panel.

Optimism opens the door to great things.

It was, in fact, named Jelly.

Let there be snark.

The willow is too close to the house.

Our job is not to persuade republicans but to defeat them.

I see no possible difficulties whatsoever with this fool-proof plan.

Usually wrong but never in doubt

Since when do we limit our critiques to things we could do better ourselves?

When I decide to be condescending, you won’t have to dream up a fantasy about it.

Red lights blinking on democracy’s dashboard

Let’s delete this post and never speak of this again.

Sadly, there is no cure for stupid.

Americans barely caring about Afghanistan is so last month.

The math demands it!

Open Enrollment Ends Tonight

Ivermectin, Insurers and Hassle Costs

Just a few more days

Antigen testing and administrative burden

Sickle cell, CRISPR, cures and policy

Comment letter on the Georgia 1332 Waiver

Actuaries rule the world (Mortality edition)