California Cracking Down on Latest Health Insurance Scam

Let our journalists help you make sense of the noise: Subscribe to the Mother Jones Daily newsletter and get a recap of news that matters.

As you may recall, the health insurance market doesn’t work well if companies are allowed to cherry pick their customers. If that’s allowed, companies will all chase after the youngest, healthiest customers, leaving the older ones high and dry — and there are plenty of ways of doing this. It’s not a matter of only signing up companies that can prove their workforce has an average age of 28; it’s a matter of targeting certain kinds of companies, or shaping your plans so they appeal to a younger cohort. Apparently the latest version of this scam involves selling group health policies to small companies that are supposedly self-insured:

Some insurers are chasing after much smaller customers with new plans designed to limit employer payouts for big claims using what’s called stop-loss policies. This guarantees that businesses won’t be responsible for anything over a certain amount per employee, perhaps as low as $10,000 or $20,000, with the rest paid by an insurer. Regulators and health-policy experts say this arrangement undercuts the notion of self-insurance since employers aren’t bearing much of the risk, and it allows companies to circumvent some state insurance rules.

“This is not real self-insurance. This is clearly a sham,” said Mark Hall, a professor of law and public health at Wake Forest University who has studied the small-business insurance market. “Regulators have good reason to be concerned about the potential harm to the market.”

Self-insurance is attractive for many reasons, particularly the prospect of lower costs. It’s exempt from state insurance regulations such as mandated benefits, granting employers the flexibility to design their own benefit package and the opportunity to reap some of the savings from employee wellness programs. A federal law, the Employee Retirement Income Security Act, or ERISA, governs self-funded plans. Some aspects of the Affordable Care Act do apply to self-insurance, such as the elimination of caps on lifetime benefits and some preventive care at no cost.

Yeah, it’s a scam. Self-insurance is for companies big enough that they can count on losses evening out. Small companies can’t do it because a single million-dollar cancer could wipe them out.

So what’s the answer? Easy! Sell small companies on the idea of “self insuring,” but only up to $10,000 per employee. After that, the insurance company pays the bill. The advantage to employers is that they get to evade the usual insurance regulations. The advantage to insurers is that small companies tend to be young companies.

Needless to say, an insurance policy with a $10,000 deductible is still an insurance policy. Likewise, these shiny new self-insurance plans are still insurance policies. They look, walk, and quack like ducks. They’re ducks. An HHS spokesman says they will “provide more clarity” about their legality soon. Hopefully that clarity will be an outright ban.

THE TRUTH IS...

what drives Mother Jones' team of 50-plus journalists. The truth is powerful, as evidenced by how hard those with something to hide, or profit to gain, seek to discredit it. The truth, stated boldly and reported meticulously, is what draws so many readers to Mother Jones.

And the truth is, going into the final 4 days of the year we still needed to raise $TK to hit our $350,000 goal and start 2021 on track. It's nerve-wracking, wondering if the big spike we normally see at the end of December is going to be another thing that doesn't go as planned in 2020, or worse, if, now that Donald Trump is set to leave the White House (for longer than a taxpayer-funded golf trip to a property he owns), folks might be pulling back from fighting for the truth and a democracy and think the hard work is done.

It's not, and if you can right now, please consider a year-end donation to support our team's fearless nonprofit journalism so we can close that big fundraising gap and finish the year strong, ready for all that's ahead in 2021. Whether you can give $5 or $500, it all matters in keeping us charging hard, and we'd be grateful.

payment methods

THE TRUTH IS...

what drives Mother Jones' team of 50-plus journalists. The truth is powerful, as evidenced by how hard those with something to hide, or profit to gain, seek to discredit it. The truth, stated boldly and reported meticulously, is what draws so many readers to Mother Jones.

And the truth is, going into the final 4 days of the year we still needed to raise $TK to hit our $350,000 goal and start 2021 on track. It's nerve-wracking, wondering if the big spike we normally see at the end of December is going to be another thing that doesn't go as planned in 2020, or worse, if, now that Donald Trump is set to leave the White House (for longer than a taxpayer-funded golf trip to a property he owns), folks might be pulling back from fighting for the truth and a democracy and think the hard work is done.

It's not, and if you can right now, please consider a year-end donation to support our team's fearless nonprofit journalism so we can close that big fundraising gap and finish the year strong, ready for all that's ahead in 2021. Whether you can give $5 or $500, it all matters in keeping us charging hard, and we'd be grateful.

payment methods

We Recommend

Latest

Sign up for our free newsletter

Subscribe to the Mother Jones Daily to have our top stories delivered directly to your inbox.

Get our award-winning magazine

Save big on a full year of investigations, ideas, and insights.

Subscribe

Support our journalism

Help Mother Jones' reporters dig deep with a tax-deductible donation.

Donate