In unregulated competitive markets for individual health insurance, risk-rated premiums are observed to differ across subgroups of insured people, which are defined by rating factors such as age, gender, family size, geographic area (because costs of care may be higher or lower in some coverage areas than others) occupation, length of contract period, the level of deductible, health status at time of enrollment, health habits (smoking, drinking, exercising) and, via differentiated bonuses for multiyear no-claim, to prior costs. Some nations that encourage private insurance for health care still seek to prevent insurers from engaging in risk minimizing actions to load the premiums of people with certain high-risk profiles, typically the elderly, the sick, and to some extent, women. To achieve that, financial transfers are needed in order to prohibit any discriminatory practices against these subgroups without increasing costs on insurers. This is done by arranging for a third party to organize a regulatory system of risk-adjusted premium subsidies.
The financial transfers are then channeled via a so-called Subsidy Fund. In European countries such as The Netherlands, Belgium, Germany and Switzerland, the Subsidy Fund is run by a government agency, which assesses risks for individual policy holders. In all countries that apply risk-adjusted premium subsidies in their health insurance market, the sponsor organizes it in the form of risk equalization among health insurers: the risk-adjusted premium subsidies for the insured are channelled to the insurers. In this case, the Subsidy Fund is called a Risk Equalization Fund (REF). An insurer receives a relatively large sum of subsidies via the REF if the risk profile of their members is relatively unhealthy and vice versa.
Although premiums can be rated across many subgroups of insured people, a sponsor may not want to subsidize all observed premium rate variation in practice. The total set of risk factors that insurers use to rate their premiums can be divided in two subsets: the subset of risk factors that cause premium rate variation that the sponsor decides to subsidize, the S(ubsidy)-type risk factors; and the subset that causes premium rate variations which the sponsor does not want to subsidize, the N(on-subsidy)-type risk factors.
Gender, health status and (to a certain extent) age will, in most countries, be considered S-type risk factors. Examples of potential N-type risk factors are a high propensity for medical consumption, living in a region with high prices and/or overcapacity resulting in supply-induced demand, or using providers with an inefficient practice-style. The sponsor determines the specific categorization of S-type and N-type risk factors. When the government takes up the role of the sponsor, this categorization is ultimately determined by value judgments in society. Note that, because the premium subsidies are risk-based, price competition will not be distorted by these subsidies and therefore incentives for efficiency are not reduced.
This system operates in countries such as Australia, Germany, the Netherlands, Belgium, Switzerland, and Ireland. The system of risk equalization plays a crucial role in order to reduce the incentives for risk selection in this new Dutch market of regulated competition. (See Health care in the Netherlands) Dutch insurers are not allowed to risk-rate their premiums. In practice, the sponsor often encounters difficulties to find adequate measures of the S-type risk factors (such as health status) to include in the risk equalization model.
The concept was put in the US healthcare law, passed in 2010, known as the Patient Protection and Affordable Care Act. To achieve its aims, state and federal regulators must construct an effective system of risk adjustment or risk equalization that protects health insurers that attract a disproportionate share of patients with poor health risks and punishes those that cherry pick lower risk groups.
- Stam PJA. Testing the effectiveness of risk equalization models in health insurance. PhD Dissertation. Erasmus University Rotterdam: Rotterdam; 2007.
- Van de Ven WPMM, Ellis RP. Risk Adjustment in Competitive Health Plan Markets. In: Culyer AJ and Newhouse JP (Eds), Handbook of Health Economics, vol.1. Elsevier Science BV: Amsterdam; 2000. p. 755–845.
- Van de Ven WPMM, Van Vliet RCJA, Schut FT, Van Barneveld EM. Access to coverage for high-risks in a competitive individual health insurance market: via premium rate restrictions or risk-adjusted premium subsidies?. Journal of Health Economics 2000; 19: 311-339.
- Van de Ven et al. 2000
- Van de Ven and Ellis 2000, p. 768-769
- Microsoft Word - -HEA8 cover page - new template.doc
- Stam 2007 - Presents research results on the effectiveness of the 2004 Dutch risk equalization model.
- Discussion of US law
- "HHS Officials Explain Risk Adjustment Methodology"
- Regulated competition in the new Dutch health care system
- The purpose of risk equalization, English version
- The purpose of risk equalization, Dutch version
- Testing the effectiveness of risk equalization models, English version
- Testing the effectiveness of risk equalization models, Dutch version