Healthcare Insurers’ Incentives to Get Worse and Worse

Under the current system virtually all employers and group insurers have perverse incentives to attract the healthy and avoid the sick. Once people have enrolled, the incentives are to overprovide to the healthy (to encourage them to stay) and underprovide to the sick (to encourage them to leave).

Managed Competition in the Healthcare Exchanges

The problem with managed competition under the Affordable Care Act is that the pressures to act on the incentives will be much more intense. In the health insurance exchanges, health plans will be forced to charge the same premium, regardless of health status, and potential enrollees will be able to easily compare premiums. In this way, the insurers will be forced to aggressively compete on price.

To the degree that a plan succeeds in attracting an above-average share of healthy enrollees or a below-average share of sick enrollees, its average cost will be lower than that of competing plans. That means it will be able to charge a lower premium than other plans and enjoy a competitive advantage in the health insurance exchange.

There are provisions to offset some of the expected perversity with so-called “risk adjustments.” Yet no system of risk adjustment works well. Currently, the Medicare Advantage program has the most sophisticated risk adjustment mechanism—employing as many as 60 or 70 variables. However, studies show that the system predicts individual health costs very poorly and the health plans are still able to game the system and attract an above-average healthy enrollment. [1,2]

A Better Alternative: Creating a Market for the Care of the Sick

Instead of requiring insurers to ignore the fact that some people are sicker and more costly to insure than others, we should adopt a system that compensates them for the higher expected costs—ideally, making a high-cost enrollee just as attractive to an insurer as a low-cost enrollee. At a minimum, this means that when individuals switch health plans, they always move at market prices, not artificial prices.

For more on the Affordable Care Act and its consequences, please see my Independent Institute book, Priceless: Curing the Healthcare Crisis.


1. Jason Brown et al., “How Does Risk Selection Respond to Risk Adjustment? Evidence from the Medicare Advantage Program,” National Bureau of Economic Research, NBER Working Paper 16977, April 18, 2011,

2. Robert O. Morgan et al., “The Medicare-HMO Revolving Door—The Healthy Go in and the Sick Go Out,” New England Journal of Medicine 337 (1997): 169–175,

[Cross-posted at Psychology Today]

John C. Goodman is a Research Fellow at the Independent Institute, President of the Goodman Institute for Public Policy Research, and author of the Independent books, Priceless: Curing the Healthcare Crisis and A Better Choice: Healthcare Solutions for America.
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