National Center for Policy Analysis (NCPA)
Obamacare Health Insurance COOPs Are Unraveling
Issue
Briefs | Health
No. 163
Thursday, June 04, 2015
by Devon M. Herrick
Many supporters of the Patient Protection and Affordable Care Act (ACA)
wanted a public plan option to compete with the private insurers offering
insurance in the state and federal health exchanges. To placate these
progressives, the ACA created a type of nonprofit health insurance cooperative
that would borrow funds from the government for start-up costs and solvency
reserves.
However, the Consumer Operated and Oriented Plans, or health insurance COOPs,
as they are commonly known, are slipping into insolvency. All but one lost money
in 2014 and one failed spectacularly — singularly forcing about 20 percent of
all COOP enrollees to shop for another plan. Worse yet, many COOPs appear to be
setting artificially low premiums to gain market share, in the process losing
money taxpayers are expected to cover. The latest failure was Iowa-based insurer
CoOportunity Health.
What Are Health Insurance Cooperatives? CoOportunity Health
was not a traditional health insurer. Rather, the organization was a
taxpayer-funded, nonprofit health insurance cooperative established under the
ACA.1 COOPs were a political compromise during the health care
debate, primarily serving as an alternative to the public plan option
many progressives wanted.2
Advocates hoped COOPs would function like nonprofit, enrollee-owned mutual
insurance companies that would do what for-profit insurers supposedly refused to
do — put the needs of people ahead of profits.3 These
member-led plans would provide all the latest patient-centered benefits —
despite little evidence these measures are cost-effective. Proponents hoped
COOPs would outperform established, for-profit insurers and undercut their
premiums. In retrospect, this idea proved naïve.
COOPsf Fundamental Flaws. The COOP program is plagued by
numerous flaws. When COOPs were established, they had no customers and no
historical actuarial data to assist in setting plan premiums. Startup funds and
cash reserves were borrowed from the government, with funds allocated by the
ACA. In any other industry the members of an operating cooperative are the
owners of the entity and provide its capital. Yet, this model does not easily
apply to health insurance cooperatives. The customers of a health insurer are
unlikely to spend, say, an additional $1,000 each to fulfill capital
requirements. Thus, it stands to reason the cooperative business model is
ill-suited to an industry requiring vast amounts of capital mandated by
insurance regulations.4
Making matters worse, COOP proponentsf political agenda overshadowed economic
considerations — dooming what little chance of survival COOPs ever
had.5 For instance, advocates of public health coverage have
long complained that insurance company profits and marketing waste money and
drive up premiums. As a result, COOPs were barred from using federal startup
funds to advertise and market their plans. But without access to equity markets
and advertising dollars, COOPs were doomed to failure. The Office of Inspector
General also feared the member-owned aspect of COOPs would result in low
premiums at the expense of financial viability.
Critics on the Left and the Right. The fact that COOPs had
no competitive advantage seemed to matter little to those supporting the idea.
Yet there were many critics — even among Democrats. Nobel Laureate Paul Krugman
said, gAnd letfs be clear: the supposed alternative, nonprofit co-ops, is a
sham. Thatfs not just my opinion; itfs what the market saysch He continued,
gClearly, investors believe co-ops offer little real competition to private
insurers.h6 Senator Jay Rockefeller (D-W. Va.) expressed the same
sentiment, referring to COOPs as a gcdying business model for insurance,h
arguing gcthere has been no significant research into consumer co-ops as a model
for the broad expansion of health insurance. What we do know, however, is that
this model was tried in the early part of the 20th century and largely
failed.h7
Prospects Going from Bad to Worse. About 500,000 individuals
were enrolled in a health insurance cooperative plan at the beginning of the
fourth quarter in 2014, according to industry data.8 The COOPsf
first-year performance was dismal for many reasons. Membersf first-year claims
were exceptionally high, which also hurt the COOPsf chances for success. They
also had to recruit managers, hire employees, establish protocols and perform
outreach to enroll members despite an exchange system that was working
poorly. Many of these individuals were poor risks. There are logical
reasons for this. Exchange enrollees in the first year of operation were far
less healthy than average. Some individuals were previously uninsured, while
others switched from more costly risk-rated health plans. Healthy individuals
were allowed to keep their pre-ACA (risk-rated) plans through 2014, and in
Iowafs case, until 2016. Thus, individuals paying higher premiums — reflecting
poor health status — were most likely to seek coverage in the exchange.
COOPsf capital was initially made up of funds borrowed from the federal
government. Health COOPs borrowed more than $75 million in startup funds that
must be repaid within 5 years.9 In additions, more than $2
billion in low-interest solvency loans are to be repaid within 15 years.
One measure of a COOPfs financial health is the insurersf capital &
surplus — that is, the amount of capital minus liabilities. The higher the
ratio of debts to capital, the greater the likelihood taxpayers will lose their
investment. This is because COOPs with a high debt ratio will have to repay
taxpayers out of accumulated profits — which virtually none of the COOPs have
earned. As Figure I illustrates, with the exception of Maine Community Health
Options, all COOPs have debts far in excess of their capital.
Surviving on Borrowed Money and Begging for More. By
September 2014, many of the COOPs were hemorrhaging cash and needed emergency
solvency loans. In the last four months of 2014, the U.S. Department of Health
and Human Services (HHS) provided six state COOPs with $355 million in emergency
solvency funding [see Figure II]: 10
- State COOPs receiving emergency funding included Connecticut ($48.4
million), Iowa ($32.7 million), Maine/New Hampshire ($67.6 million) and New
York ($90.7 million).
- CoOportunity received $33 million from HHS in September 2014 — only to
return three months later asking for another bailout.
- HHS denied CoOportunity Healthfs second request, but it did provide two
other struggling health insurance cooperatives with emergency solvency
loans.11
- Wisconsin-based Common Ground Healthcare Cooperative received nearly $23
million more in emergency funds in December after accepting more than $28
million three months earlier.
- The Kentucky Health Cooperative received a $65 million emergency solvency
loan only days prior to the second open enrollment period for the health
insurance exchange in November 10, 2014.
History of Losses. According to industry data, only one of
the 23 COOPs was profitable last year, and a 24th COOP located in Vermont failed
before it even got off the ground.12 The COOP in Vermont was poorly
implemented and did not have adequate resources to qualify for a license to sell
policies in Vermont.13
Some COOPs are close to breaking even, while others are losing money on
multiple fronts. According to third quarter data, more than one-third of COOPs
had medical claims that exceeded premiums. Administrative expenses and claims
adjustment expenses added to these losses. A common complaint about private
health insurers is their administrative expenses are higher than public programs
like Medicare and Medicaid. Many proponents hoped the cooperatives operating in
the exchange system would be able to lower administrative expenses. ACA
regulations cap administrative expenses at no more than 15 percent to 20 percent
of premiums, anticipating medical claims would constitute the other 80 percent
to 85 percent. Yet, more than one-third of the COOPs had general expenses that
either about equaled or exceeded medical claims expenses — some by a huge
margin.14 [See Figure III.]
In total, 23 COOPs lost $244 million through the first
three quarters of 2014, their first year of operation.15 For
every $100 in premiums, the COOPs spent about $117, on average.16
While some of the COOPs are losing money because of their small size, others
appear to have pursued the strategy of losing money to gain market-share at
taxpayersf expense.17
Case Study: CoOportunity Health. Consider the example of
health insurer, CoOportunity Health, which was taken over in December 2014 by
Iowa insurance regulators.18 The cooperative sold policies in
both Iowa and Nebraska, and accounted for one-fifth of all COOP enrollees
nationally. Iowa and Nebraskafs Guarantee Associations — and state and federal
taxpayers — are liable for millions in claims from health care providers the
COOP could not pay. State guarantee associations are designed to protect state
policyholders in the event their insurer becomes insolvent. Guarantee
associations are usually funded by taxes or assessments on all insurers within a
state. This is the first failure, but will undoubtedly not be the last.
CoOportunity Health failed less than a year after it began offering coverage
to the public. It defaulted on $145 million in taxpayer loans and owes enormous
sums to doctors and hospitals. Prior to its first open enrollment, chief
operating officer (COO) Cliff Gold told the Lincoln, Nebraska, Journal
Star that gCoOportunity would be a market disruptor,h and gwefre nonprofit,
we have absolutely no profit motive.h19 Apparently Gold meant his
comments to be taken literally: CoOportunity lost around $163 million in 2014 —
its first year selling health insurance. An attorney hired to help liquidate the
firm says doctors and hospitals are still owed some $100 million. Due to its low
premiums, large network and rich benefit package, CoOportunity Health quickly
enrolled nearly 10 times its projected first-year enrollment — swelling to
nearly 115,000 people at one point. CoOportunity could have made the prudent
decision to charge actuarially sound premiums and to grow conservatively,
considering its lack of reserves and the risks involved. Instead, top executives
pursued the risky strategy of a market disruptor, selling comprehensive coverage
well below its cost — and saddling taxpayers with its losses.
In what is called adverse selection in insurance, sicker-than-average Iowa
and Nebraska residents flocked to CoOportunityfs generous offerings: large
provider networks and rich benefit packages.20 Its premiums were also
lower than most of its competitors.21 This approach was attractive to
Iowa or Nebraska residents with chronic conditions. But it is not so good
for taxpayers who must pay for the losses. CoOportunity didnft just suffer
adverse selection, it played a game of chicken with other insurers when
it purposely designed plans and set premiums it knew would disrupt the market.
Indeed, the Wall Street Journal referred to it as Fannie Med, in
reference to Fannie Mae, the infamous government-supported mortgage insurer
whose risky investment strategy contributed to the 2008 financial crisis that
devastated the U.S. economy.22
CoOportunity executives undoubtedly expected significant first-year
loses. Top management included a former insurance commissioner and a BlueCross
executive.23 Indeed, more established insurers suspected exchange
plan enrollees would be expensive to insure in the first year of operation, and
many insurers decided against selling exchange plans in 2014.
Unfortunately, even nonprofit health insurers must earn a profit to avoid
bankruptcy. The Iowa insurance commissioner shuttered the failing company once
it became clear CoOportunity would not receive another government emergency
solvency loan and its anticipated $126 million bailout would be reduced by about
half.24
What level of premium should CoOportunity have charged enrollees? A
back-of-the-envelope calculation suggests the firm should have billed each
member an additional $100 per month, whereas its losses averaged $1,417 per
member.25 Of course, had the firm charged more, it could not
have grown as quickly. Indeed, if a company is losing money on every customer,
it cannot make up for its losses by increasing its volume of sales.
Hoping for a Taxpayer Bailout. Congress established three
risk-spreading provisions in the ACA for insurers who experience adverse
selection. One is a temporary risk-spreading program, made up of funds collected
from fees and taxes on all insurers, to cover industry losses.In late 2014,
CoOportunity expected the U.S. Department of Health & Human Services (HHS)
to divvy up some of the ACAfs risk adjustment funds, including some $126 million
in risk corridor funds. However, the omnibus spending bill passed in December
2014 limited the risk corridor funds HHS may distribute. In addition, Congress
slashed funding for the COOP program by two-thirds over the past several years
to reduce taxpayersf losses — from $6 billion down to $2 billion. By December
2014, HHS had spent all its money dedicated to emergency solvency loans. When it
became clear that only about half of the $126 million CoOportunity expected to
cover its losses would be forthcoming, state regulators had to shut down the
defunct insurer.
Taken together, these facts suggest CoOportunity executives purposely set
rates low to gain market share — assuming taxpayers would bail out their losses.
The strategic plan was simple: 1) underprice premiums to gain market share; 2)
let taxpayers bail out the losses with emergency solvency loans and
risk-adjustment distributions; 3) increase premiums after the dust settled. This
type of activity should not have been allowed, but it appears to be a common
strategy among health insurance COOPs. Most stakeholders — apparently including
CoOportunity Health — expected taxpayers to bailout struggling COOPs
indefinitely. It is now clear that bailout is not forthcoming.
Conclusion. The spectacular failure of CoOportunity Health
was a wakeup call to other health insurance cooperatives, state insurance
commissioners, the U.S. Department of Health & Human Services, Congress and
taxpayers. But it wonft be the last COOP that goes broke, owing taxpayers large
sums of money.
Going forward, state insurance regulators and other government regulatory
bodies need to be on the lookout for COOPs that employ strategic plans premised
on losing money while gaining market share — expecting taxpayers to bail them
out. This strategy will likely play out again and again until most of the COOP
health insurers lose all their taxpayer financing and go bankrupt.
Devon M. Herrick is a senior fellow with the National Center for Policy
Analysis.
Notes
- Devon M. Herrick, gConsumer Oriented and Operated Plans: An Idea whose
Purpose has Come and Gone,h Statement before the Committee on Oversight &
Government Reform Subcommittee on Energy Policy, Health Care and Entitlements
and the Subcommittee on Economic Growth, Job Creation and Regulatory Affairs,
hearing on gHealth, Health Insurance CO-OPs: Examining ObamaCarefs $2 Billion
Loan Gamble,h February 5, 2014.
- James T. OfConnor, gComprehending the compromise: Key Considerations in
Understanding the CO-OP as an Alternative to the Public Plan,h Milliman, Inc.,
June 26 2009; available at
http://www.milliman.com/insight/healthreform/Comprehending-the-compromise-Key-considerations-in-understanding-the-co-op-as-an-alternative-to-the-public-plan/;
and Julia James et al., eHealth Policy Brief: The CO-OP Health Insurance
Program,f Health Affairs, updated January 23, 2014, available at
http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=107.
- Department of Health and Human Services, 45 CFR Part 156 [CMS–9983–F] RIN
0938–AQ98, gPatient Protection and Affordable Care Act; Establishment of
Consumer Operated and Oriented Plan (CO–OP) Program,h Federal
Register, Vol. 76, No. 239, December 13, 2011, pages 77,392 – 77,415.
Available at
http://www.gpo.gov/fdsys/pkg/FR-2011-12-13/pdf/2011-31864.pdf.
- Tim Worstall, gCoOportunity Health Isnft an Obamacare Problem, Itfs a
Cooperative Problem,h Forbes, December 29, 2014. Available at
http://www.forbes.com/sites/timworstall/2014/12/29/cooportinuty-health-isnt-an-obamacare-problem-its-a-cooperative-problem/.
- Jerry Markon, gHealth Co-Ops, Created to Foster Competition and Lower
Insurance Costs, Are In Danger,h Washington Post, October 22, 2013.
Available at
http://www.washingtonpost.com/politics/health-co-ops-created-to-foster-competition-and-lower-insurance-costs-are-facing-danger/2013/10/22/e1c961fe-3809-11e3-ae46-e4248e75c8ea_story.html.
- Paul Krugman, gObamafs Trust Problem,h New York Times, August 20,
2009. Available at:
http://www.nytimes.com/2009/08/21/opinion/21krugman.html.
- gRockefeller Decimates Co-ops in Letter to Baucus and Grassley,h Daily
Kos, September 16, 2009. Available at
http://www.dailykos.com/story/2009/09/16/782985/-Rockefeller-Decimates-Co-ops-in-Letter-to-Baucus-and-Grassley.
- See gBriefing: Losses Persist at Majority of Health Co-ops,h
BestWeek (AM Best), January 15, 2015. Available at
http://www3.ambest.com/bestweek/purchase.asp?record_code=232698&URATINGID=2625286&altsrc=0&fs=0&altnum=0&b=0&tl=7&c=N.
- Scott E. Harrington (University of Pennsylvania), gThe Financial Condition
and Performance of CO-OP Plans,h Robert Wood Johnson Foundation, Data Brief,
February 2015, page 2.
- gLoan Program Helps Support Customer-Driven Non-Profit Health Insurers,h
Center for Consumer Information & Insurance Oversight, Centers for
Medicare & Medicaid Services, updated December 16, 2014. Available at
http://www.cms.gov/CCIIO/Resources/Grants/new-loan-program.html
- Paul Demko, gCo-op Insurers Receive Additional Federal Loan Dollars to
Boost Solvency,h Modern Healthcare, December 23, 2014. Available at
http://www.modernhealthcare.com/article/20141223/NEWS/312239973.
- Data through the third quarter, 2014. See gBriefing: Losses Persist at
Majority of Health Co-ops,h BestWeek (AM Best), January 15, 2015.
Available at
http://www3.ambest.com/bestweek/purchase.asp?record_code=232698&URATINGID=2625286&altsrc=0&fs=0&altnum=0&b=0&tl=7&c=N.
- Richard Pollock, gVermont Insurance Regulator Delivers Setback to
Obamacare CO-OP,h Washington Examiner, May 30, 2013. Also see Dale
Schaft (Information Management Officer), gVermont Health CO-OP Fails State
Insurance Standards,h Vermont Department of Financial Regulation, May 22,
2013.
- Scott E. Harrington (University of Pennsylvania), gThe Financial Condition
and Performance of CO-OP Plans,h Robert Wood Johnson Foundation, Data Brief,
February 2015, page 6.
- Dan Mangan, gObamacare CO-OPs Try to Swim—Not Sink—as Red Ink Persists,h
CNBC.com, January 26, 2015. Available at http://www.cnbc.com/id/102364418. See
also gBriefing: Losses Persist at Majority of Health Co-ops,h BestWeek (AM
Best), January 15, 2015.
- Scott E. Harrington (University of Pennsylvania), gThe Financial Condition
and Performance of CO-OP Plans,h Robert Wood Johnson Foundation, Data Brief,
February 2015, page 6.
- gFannie Med Implodes: An ObamaCare-funded Insurer in Iowa is Sent to the
Morgue,h Wall Street Journal, December 28, 2014. Available at
http://www.wsj.com/articles/fannie-med-implodes-1419812352.
- Anna Wilde Mathews, gState Regulator to Shut Down Insurer CoOportunity
Health,h Wall Street Journal, January 23, 2015. Available at
http://www.wsj.com/articles/state-regulator-to-shut-down-insurer-cooportunity-health-1422052829.
- Richard Piersol, gNonprofit Health Insurer Intends to be Market
eDisruptor,fh Lincoln Journal Star, March 30, 2013. Available at
http://journalstar.com/business/local/nonprofit-health-insurer-intends-to-be-market-disruptor/article_b28c3da1-d9aa-5d55-8787-5593d8229300.html.
- Trudy Lieferman, gWhy Did CoOportunity fail? The insurance CO-OPfs
Struggles Raise Questions about the Efforts to Foster Competition,h
Columbia Journalism Review, January 19, 2015. Available at
http://www.cjr.org/united_states_project/why_did_cooportunity_fail.php.
- Steve Jordon, gInsurance Agents Stung by CoOportunity Healthfs Collapse,h
World-Herald, January 9, 2015. Available at
http://www.livewellnebraska.com/consumer/insurance-agents-stung-by-cooportunity-health-s-collapse/article_17362220-7df5-5ff7-ba5b-3d05ddbfbbd3.html.
- gFannie Med Implodes: An ObamaCare-funded Insurer in Iowa Is Sent to the
Morgue,h Wall Street Journal, December 28, 2014. Available at
http://www.wsj.com/articles/fannie-med-implodes-1419812352.
- Tony Leys, gCoOportunity Health Falters, Taken Over by State,h Des
Moines Register, December 30, 2014. Available at
http://www.desmoinesregister.com/story/news/2014/12/24/cooportunity-health-taken-iowa-insurance-division/20856151/.
- Anna Wilde Mathews, gState Regulator to Shut Down Insurer CoOportunity
Health,h Wall Street Journal, January 23, 2015. Available at
http://www.wsj.com/articles/state-regulator-to-shut-down-insurer-cooportunity-health-1422052829.
- For example, a loss of $163,000,000 in 2014 divided by approximately
115,000 members equals a loss of about $1,417 per member enrolled.