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Pre-Existing Conditions and Fire Insurance

When it comes to health care, I continue to be amazed at the utter nonsense that gets tossed about when the discussion comes to insuring pre-existing conditions. The problem seems to be that no one who understands insurance has anything to say about health care legislation, because the question of why you may not want to guarantee issuance of insurance at a given rate no matter what pre-existing conditions the patient has is really not hard to understand. Consider this little vignette:

Caller: Hi, I’d like to buy some home insurance, please.

Agent: Sure, I’d be happy to help with that.

Caller: Does the insurance cover loss from fire?

Agent: Of course. That’s just one of many coverages you get with our insurance. Can you tell me a little bit about your house?

Caller: It’s three bedrooms, two baths. Worth about $300,000. What will the insurance cost me?

Agent: It depends on a few more pieces of information I have to gather from you, but about <pause> $800 per year.

Caller: That sounds great. Sign me up. Do you need my credit card?

Agent (laughing): Just a moment, sir! I need to get more information to give you an accurate quote. Can you tell me about the condition of your home?

Caller: You mean, right now?

Agent: Um…yes.

Caller: It’s on fire.

Agent: Your house is on fire?

Caller: Yep. Can we speed this up a bit?

Agent: Sir, we can’t insure your house against fire if it’s already on fire!

Caller: Why not? Just because it’s a condition that existed prior to my call?

Agent: Well, yes.

Caller: That’s outrageous! I demand you issue me insurance!

Agent (after conferring with management): Sir, it turns out we can offer you insurance on your home…

Caller: See? I knew you could be reasonable.

Agent: …for $350,000.

See, here’s the thing. Insurance is based on the principle of distributing money in a pool of similar risks from insureds who don’t experience the insurable event to those who do experience the insurable event. If someone enters the pool who has already had the insurable event, it’s simply a transfer – there’s no insurance. Person A needs $100,000 in surgeries, and gets an insurance policy that costs $1,000. Where does the rest of the money come from? It doesn’t come from the insurance company, and I think perhaps people don’t understand that point (and Republicans are truly abysmal at explaining it). The rest of the money comes from other insureds. Consider this situation: rather than get private insurance, you and twenty of your fraternity brothers from college – all about the same age and health – decide to form your own mutual insurance network. Everyone agrees that if anyone gets sick, the whole group will pitch in equally to pay the medical bills of the sick person. Now, suppose one person says “can we take my mom in as well? She has early-onset dementia and was just diagnosed with lung cancer. She’d be glad to join the group and pay an equal share, because fair is fair!” Do you think it is fair that mom pays the same amount?

The insurance company makes money if the money they pay out is less than the money they take in, but they also stand to lose if they underwrite the risks poorly and pay out more than they take in. And insurance companies don’t systematically rip people off by underwriting policies super-conservatively. In fact, the evidence seems to be that insurance companies rather frequently fall prey to pressures to move more product, and underwrite policies too aggressively.

The social-justice question can be separated from the health care insurance question. If you feel that everyone should have their medical bills covered, no matter what, then create a federal umbrella program for high-risk insureds and pay for that program with taxpayer funds. That’s explicit: let the cost of health insurance cover the actual cost of health insurance, which involves conditions the risk pool doesn’t have yet, and represent the welfare or charity – because that’s what it is, of course, when others pick up the expense of those unable to pay – as exactly that. After all, the federal government offers flood insurance to landowners who can’t get insurance at a “reasonable price” because the land floods all the time; that is a similar welfare situation in which taxpayers have decided they are willing to foot the bill because it’s a social good that people live or build on the flood plain. (I’m not sure why, but that’s the import of the federal flood insurance program). So there’s precedent for the government taking over pools that are too risky for private markets.

Again, this isn’t rocket science and it isn’t hard to explain. Why doesn’t someone get on television and explain it? How about a commercial using my script?

Categories: ACA, Analogy, Good One, Insurance, Rant
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