Insurance Agents: Ignored Players In Health Insurance Reform

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1 Insurance Agents: Ignored Players In Health Insurance Reform After reforms, insurance agents in New Jersey still exert a good deal of influence in the individual health insurance market. b y D e b o r a h W. G a rn i c k, K at h e r i n e S w ar t z, a n d K at h l e e n C a rl e y S k w a ra ABSTRACT: In this paper we use the reforms to the individual health insurance market in New Jersey to illustrate the intricate interaction between insurance agents and insurance reform initiatives. Until recently, policymakers who designed reforms to the health insurance market largely ignored the role of agents in selling individual health insurance policies. These reforms have the potential to overturn the agent s traditional role, and agents can influence how the reforms are implemented. In su r an ce a gen ts an d b ro ker s play a key role in the sale of health insurance to the approximately 7 percent of nonelderly Americans who purchase individual policies. 1 Lawmakers at both the state and federal levels have devised reforms to the health insurance industry that are largely silent on agents role in selling insurance in part because of agents political clout. Indirectly, however, these reforms have the potential to curtail agents traditional role. At the same time, agents have enormous power to influence how the reforms are implemented. The reforms to the individual health insurance market in New Jersey illustrate the complex interaction between insurance agents and insurance reform initiatives. New Jersey implemented the Individual Health Coverage Program (IHCP) in August 1993, in response to a federal court ruling that overturned the state s program to finance hospital care for indigent persons and subsidize Blue Cross and Blue Shield of New Jersey as an insurer of last resort. 2 The IHCP requires that insurers participate in the individual health insurance market in New Jersey, either by selling coverage in the individual market or by paying an assessment to fund the reimbursable losses of carriers that do sell such coverage. 3 The types of policies in the individual market are standardized: Carriers can offer only a health maintenance organization (HMO) plan and five indemnity insurance plans with a standard set of benefits. 4 The IHCP also requires guaranteed issue and renewability, community rating, limitations on the use of preexisting condition exclusions, and a minimum loss ratio of 75 percent. 5 With the exception of the requirement that all insurers participate in the IHCP, these regulations for the individual insurance market are similar to legislation being considered in other states Deborah Garnick is a research professor at the Institute for Health Policy, Heller School, Brandeis University, in Waltham, Massachusetts. Katherine Swartz is an associate professor in the Department of Health Policy and Management at the Harvard School of Public Health. Kathleen Skwara is a research associate at the Institute for Health Policy at Brandeis. 1998ThePeople-to-People Health Foundation, Inc.

2 138 STUDY METHODS Information for this study was collected from two major sources. During the fall of 1996 and early winter of 1997 we interviewed more than forty persons at twenty insurance carriers and managed care organizations as well as about a half-dozen New Jersey based health insurance agents and brokers. We also conducted a telephone survey of 1,260 contract holders who purchased new individual health insurance policies between September 1995 and May Among other issues, we asked about their use of various sources of information in making coverage decisions. The survey had a 63 percent response rate, and enrollees were sampled from nine carriers that together represented 77 percent of new contracts. (Only one major carrier declined to participate.) Percentages shown in Exhibits 1 and 2 are weighted to reflect the probability of selection from among the 37,637 policies sold during the eight-month period and to correct for nonresponse bias. It is important to note that for some carriers whose enrollees we surveyed, the only way to buy individual policies is through agents. INSURANCE AGENTS AND BROKERS n TRADITIONAL ROLES. In many states there is a clear distinction between agents and brokers: Agents generally sell products from only one insurance carrier, whereas brokers sell policies for a set of competing carriers. In New Jersey the distinction between agents and brokers is blurred because a single four-year agent s and broker s license can be obtained for $300 from the Department of Banking and Insurance. Almost all carriers in the IHCP in 1996 worked through agents and brokers. Also, about ten major wholesale brokers serve as intermediaries between selling agents and carriers. Typically, the carriers and the brokers have agreed to a target level of sales, for which the wholesale broker receives an override fee of 1 to 3 percent of the premium in addition to the standard commission percentage. In exchange, the wholesale brokers provide a service to the carriers by interacting directly with the selling agents, making sure that applications for coverage are filled out completely, doing mailings, and responding to requests for information. n AGENTS INCOME. Before the IHCP was implemented, agents in New Jersey generally earned commissions of about percent (and in some cases as much as 35 percent) of the health insurance premium for the first year. Commissions for policy renewals were only slightly lower, to discourage agents from switching policyholders to new carriers each year in order to earn higher first-year premiums (a practice known as churning ). Health insurance often is a component of a package of products including life, property, homeowner, disability, automobile, and longterm care insurance. Increasingly, insurance agents and brokers also offer comprehensive financial planning to their clients and are licensed to sell mutual funds, annuities, and other securities. These activities often generate higher commissions than selling health insurance does. Although agents may derive only a small part of their income from the sales of health insurance, they generally offer it so that they can provide their customers with a full spectrum of insurance products and financial services. n SCREENING ROLE. Agents play an important role in the underwriting process in states where regulations do not ensure guaranteed issue and community rating in the individual market. Consumers often have more information about their future health risks than they disclose to insurers on a standard application form. Agents may personally interview applicants and may be able to discern preexisting medical conditions or poor health status. Therefore, insurers do not have to fully investigate an application. But this is a twoway street, too. By using agents, individuals can avoid applying for policies for which they will be turned down, for which the premiums will be prohibitively expensive, or to which the insurer will add a rider that will exclude certain conditions from coverage (for example, chronic back pain). To be sure, this picture is not all positive for consumers. Agents H E A L T H A F F A I R S ~ V o l u m e 1 7, N u m b e r 2

3 who represent multiple carriers can subtly direct their more desirable applicants those with good health status, for example to the carriers who pay agents the highest commission but might not necessarily represent the best deal for the consumer. IMPACT OF INSURANCE REFORMS In New Jersey the role of agents changed overnight when the IHCP was implemented. Each of the five IHCP reforms highlighted below is directly related to the New Jersey legislature s overall goal of reducing the number of uninsured by making it easier to obtain individual health insurance. 7 The impact of the legislation on how agents conducted business and on their income from commissions was immediate. Indeed, the agents anticipated some of the consequences of the reforms, which led them to lobby against the legislation before it was passed. n MINIMUM LOSS RATIO. A minimum loss ratio of 75 percent (the requirement that carriers pay at least 75 percent of premium revenues for covered benefits) contributed to an immediate and sharp decline in the commissions offered to agents. Under the IHCP regulations, commissions to agents are counted in the 25 percent of premiums that are allowed for administrative expenses (which include costs of capital reserves, a premium tax of 2.5 percent, operating costs, reinsurance, and management-of-care costs). When commissions are combined with these other costs, insurers can no longer afford to pay their previous agent commission rates of 10 to 15 percent. Shortly after the IHCP was implemented, most carriers lowered agent commission rates to between 4 and 5 percent. Some insurers reported that agents did not have initial concerns about the lower commissions, in part because they believed that the combination of standard policies and guaranteed issue would make their jobs easier. They would need to spend less time per policy sale, and the total volume of sales would rise. But a number of carriers have been vocal in their denunciation of the lower rates they have had to pay their agents, suggesting that the fees did not permit an agent to support a family. Significantly lower commission rates have contributed to the dramatic decline in the number of agents selling health insurance in New Jersey. Since many agents also sell other products to individuals and health insurance to small groups, however, the decline is difficult to quantify. At the national level, other factors have contributed to a decline in the number of agents: a declining field force of life insurance agents and more employers in the small-group market offering managed care options to their employees, coupled with the fact that HMOs, which have increased their market share relative to indemnity plans, do not use agents as frequently. 8 Also, the fact that banks can now offer financial planning advice has meant that agents face increased competition. n TRANSPARENT PRICING. The standardization of benefit packages meant that consumers need for agents and brokers advice and information was potentially lower than before the 1993 reforms. Choice among insurers no longer depended on which insurers would cover particular individuals but rather on the consumer s evaluation of the quality of the insurer s services, the insurer s reputation, and the price of coverage. Community rating of premiums made the pricing of standard plans transparent because the monthly premium for individuals now depended only on their insurance unit (single, couple, one adult with children, and family) and their choice of insurance plan. n DEDUCTIBLE TRANSFERS. Effective January 1995 a deductible credit provision was added to the IHCP regulations, allowing a person to transfer coverage from one carrier to another during a calendar year without having to satisfy a new deductible. Any deductible or portion thereof paid to the prior carrier now is credited toward the deductible of the succeeding carrier. This change was intended to remove a financial barrier that kept consumers from switching carriers in the middle of a calendar year in response to premium increases. But the change also created more work 139

4 140 without further compensation for agents. The following example shows the impact of switching plans on an agent s earnings from commissions and on the agent s work. If a person enrolls and stays with one plan for a year, the agent earns a commission of 3 percent say, $15 per month on a policy costing $500 per month (or $180 per year). If the enrollee switches plans once, however, the agent must submit two applications and still will earn about $180 per year if the new carrier also pays a 3 percent commission. Of course, the second and subsequent applications may be simpler than the first if agents store information in their computer systems. While the agent may have worked harder to put together an application prior to the 1993 reforms, individuals who had been accepted for coverage were probably less likely to switch to new plans in the prereform market because they would have needed to repeat the medical underwriting process and restart preexisting condition limits. n OTHER SOURCES OF INFORMATION. The legislation implementing the IHCP also created an administrative structure to run it. The IHCP, which has an executive director and one assistant director, is overseen by a nine-member board of directors, which includes representatives of the insurers and consumers. 9 This board also created consumer aids to provide a direct link to carriers, so consumers can obtain information or purchase insurance directly; to assist consumers comparison shopping among carriers; and to educate insurance agents about individual health coverage options available in New Jersey. To help accomplish these goals, the board set up a toll-free telephone line and put together The New Jersey Individual Health Benefits Plans Buyers Guide, which includes a table of the premiums for each of the standardized plans offered by each carrier selling individual coverage in New Jersey. Telephone numbers of the carriers sales offices also are provided. In September 1996 the IHCP board published a revised version of the buyers guide and a summary brochure in a reader-friendly format. The new guide shows examples of the out-of-pocket expenses for the same person in an indemnity plan and in an HMO. The guide also tells consumers: You may also decide to consult a licensed insurance producer (sometimes called an agent or broker) who can help you make an informed decision, at no additional cost to you. However, some carriers do not offer coverage through agents, so you would have to contact those carriers directly. The IHCP buyers guide reflects a national trend toward encouraging consumers to independently assess information and make decisions about individual insurance coverage and toward direct marketing to individuals. 10 As part of its continuing effort to make the IHCP buyers guide more accessible, the IHCP board recently contracted with a new advertising group to make the individual health insurance program more visible to consumers. n DISTINGUISHING POLICY TYPES. Before New Jersey implemented the individual health insurance reforms in 1993, the distinction between individual health insurance policies and small-group policies was often blurred. Self-employed persons were sold one-life group policies (for themselves and any family members) in the small-group market and were viewed as favorable clients by indemnity insurers that specialized in baby groups that is, groups of six employees or fewer. Significantly, several insurers reported that before the reforms half of their sales in the small-group market were of one-life policies, although they did not sell coverage in the individual market before the 1993 reforms. 11 The individual market reform legislation in New Jersey, however, put insurance policies covering one-life groups squarely into the purview of the individual insurance market. Thus, agents who were used to selling one-life policies to self-employed individuals in the small-group market had to serve the one-life segment under the rules of the individual market after August CONSUMERS USE OF INFORMATION In our survey of contract holders who purchased new individual health insurance poli- H E A L T H A F F A I R S ~ V o l u m e 1 7, N u m b e r 2

5 cies between September 1995 and May 1996, we asked about their use of three sources of information: agents, the IHCP buyers guide, and telephone calls or mailed information from carriers. About 71 percent of respondents reported having used an insurance agent, 50 percent used information obtained directly from carriers through the mail or telephone conversations, and only 13 percent used the buyers guide. Among those using agents to purchase individual health insurance, 70 percent reported using agents representing multiple carriers. Only a third of all respondents reported that agents were their sole source of information, while another third reported multiple sources of information (most often a combination of an agent and carriers information), and only 10 percent reported using none of the sources we asked about (Exhibit 1). The proportion of policyholders who used agents in the purchase of individual coverage did not vary significantly by their education (Exhibit 2). Policyholders were more likely to use an agent if they were between the ages of thirty-five and fifty-four, did not have a family member with poor health status, or were selfemployed. Moreover, more enrollees whose previous insurance was an individual policy reported using agents (82 percent), compared with those whose previous insurance was group coverage, or were uninsured, or were unsure of their previous status. This is consistent with the carriers and agents unhappiness with the shift of one-life policies from the small-group to the individual market. Also, policyholders with indemnity plans were much more likely than those with managed care plans to report agents as a source of information (80 versus 27 percent). AGENTS INFLUENCE ON INSURANCE REFORM Although agents were seriously affected by the New Jersey reforms, they also have played an active role in the implementation and evolution of the regulations, largely through their continued role in interpreting the insurance market and their concerted lobbying efforts. n INTERPRETING THE MARKET. Interpretation occurs when agents present individuals with a subset of the plans available to them in the individual insurance market. Agents may not tell people about the lowestcost plans if the carriers for such plans do not pay commissions, or they may question the quality of the lowest-cost plans in particular or of managed care plans in general. Thus, public perceptions of the affordability of individual health insurance options are affected by the limited information that they receive from agents and brokers. Some screening of individuals by agents for carriers may con- 141

6 EXHIBIT 2 Use Of Agents To Purchase Individual Policies, By Age, Education, Health Status, And Previous Insurance 142 Education Less than high school High school and some college College degree or more Other Policyholder age a years years years 55 years or older Health status a No one with poor health status Someone with poor health status Employment a Self-employed Not self-employed Previous insurance a Uninsured Individual coverage Group coverage Do not know Type of carrier a Managed care plan Indemnity insurer Number , Percent using an agent SOURCE: Authors survey of new enrollees (N = 1,260) in the Individual Health Coverage Program. NOTE: Eight policyholders who responded that they did not know if they used an agent are excluded from this exhibit. a Differences between categories in use of agent are significant at a.001 level using a chi-square test. 71% tinue if agents still direct their more favorable clients, those who are younger or healthier, to specific carriers. 12 n POLITICAL INFLUENCE. Agents continue to use their standing in the community to shape state health care reform. Insurance issues in general are increasingly complex, and agents are in a strong position to explain the potential effects of regulatory changes to legislators. Agents have a strong incentive to do so because seemingly minor changes in regulations have the potential to affect their income and responsibilities. Indeed, agents influence has been documented in New Hampshire, where in 1994 they helped to defeat health care reform legislation, and in Florida, where they preserved their role in the reformed health insurance system. 13 At the local level, agents also can influence public perceptions of health insurance reforms through their day-to-day contacts with the local business community. Agents do not, however, have an entirely uniform view of the reforms to the individual health insurance market in New Jersey. While some are lobbying to scrap the reforms entirely and to try alternative approaches, others are lobbying to leave the program largely intact and to make only incremental changes. POLICY IMPLICATIONS The reforms of New Jersey s individual health insurance market are similar to those proposed by many other states. Some policy analysts may believe that agents no longer need to play a direct role in selling health insurance to H E A L T H A F F A I R S ~ V o l u m e 1 7, N u m b e r 2

7 individuals because such reforms often include standardized plans and direct information sources for consumers. But we found that few enrollees had actually used the IHCP buyers guide despite its useful policy and premium information. The large volume of calls to the toll-free information number in New Jersey suggests that many people have requested the guide but did not report using it. Not surprisingly, agents believe that consumers continue to need help with understanding their options for coverage and recognizing the importance of purchasing health insurance. Indeed, for many people who have limited experience in making choices based solely on written materials, agents may provide a vital link to a complex system of health insurance coverage. In designing state health insurance reforms, it is crucial to recognize that resources are needed for both direct marketing to individuals and for selling plans through agents. Because clear evidence does not yet exist as to which approach is more cost-effective, a mix of improved information for consumers and agents selling plans may prove to be the optimal way to provide full information to individuals so that larger numbers will purchase health insurance coverage. Research for this paper was supported by Grant no from the Robert Wood Johnson Foundation. The authors are grateful for discussions with Kevin O Leary (former executive director of the IHCP board), Ellen DeRosa (assistant director of the IHCP board), and representatives of insurance companies selling agents. Richard Strouse, Barbara Carlson, John Hall, and Karen Cybulski of Mathematica Policy Research fielded the survey of enrollees. Patrick Wang provided expert computer programming, and Michele King and Allison Dimond provided administrative assistance. NOTES 1. U.S. General Accounting Office, Private Health Insurance: Millions Relying on IndividualMarket FaceCost and Coverage Trade-Offs, GAO/HEHS-97-8 (Washington: GAO, November 1996). 2. New Jersey Individual Health Insurance Reform Act, N.J.S.A. 17B, 27A-2 et seq.; and J.C. Cantor, Caring for the Uninsured and Underinsured: Health Care Unreform, The New Jersey Approach, Journal of the American Medical Association (22/29 December 1993): Insurer and carrier are used interchangeably in this paper to refer to health plans that provide a defined set of benefits for a monthly premium as well as to indemnity insurers. 4. Standard plans are also a key feature of the 1990 Medigap reform legislation. This is described in L.A. McCormack et al., Medigap Reform Legislation of 1990: Have the Objectives Been Met? Health Care Financing Review (Fall 1996): K. O Leary, Individual and Small Employee Health Insurance Markets Progress Report: August 1993 April 1996, available online at 6. G. Claxton and L. Levitt, Reform of the Individual Health Insurance Market (Fairfax, Va.: Lewin Group, August 1996). 7. K. Swartz and D. Garnick, Regulating Individual Health Insurance Markets: Be Wary of Unintended Consequences (Working paper, Heller School, Brandeis University, Waltham, Massachusetts, January 1998). 8. W.H. Zultowski, An Agent in the Distribution Revolution Decade, Journal of the American Society of Chartered Life Underwriters and Chartered Financial Consultants (May 1994): The board includes four members appointed by the governor (including employer, organized labor, and consumer representatives), four elected by carriers (health services corporation, insurer, and HMO representatives), and the commissioner of banking and insurance (or designee). The board holds monthly public meetings to make decisions and establish rules that govern the operations of the individual insurance market. 10. For example, see U.S. Department of Health and Human Services, Checkup on Health Insurance Choices, AHCPR Pub. no , available at Small-group reforms also were passed in New Jersey in 1993, but implementation was delayed until January R. Pear, Health Insurers Skirting New Law, Officials Report, New York Times, 3 October 1997, 1, S. Armstrong, The Producers Lobby: Insurance s Vox Populi, Best s Review (October 1994):

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