Risk pooling in health care

Endnotes Updated on February 22, Originally posted August 1,

Risk pooling in health care

What is a Risk Pool?

Risk pooling in health care

Health insurance risk pools are special programs created by state legislatures to provide a safety net for the "medically uninsurable" population. These are people who have been denied health insurance coverage because of a pre-existing health condition, or who can only access private coverage that is restricted or has extremely high rates.

Each of the state risk pool-type programs is different. Generally, the programs operate as a state-created nonprofit Association overseen by a board of directors made up of industry, consumer and state insurance department representatives.

The board contracts with an established insurance company to collect premiums and pay claims and administer the program on a day-to-day basis.

Generally, there are no exclusions. However, risk pools do have waiting periods for coverage of pre-existing conditions to make sure individuals pay for continual coverage and the program can operate financially sound.

Without waiting periods, the concern is that too many people could forego paying for insurance until they had a high cost claim, and the programs could not function financially. However, under the federal portability legislation, people who have had continuous coverage in the group market, not broken by more than 63 days, can access coverage in risk pools without any waiting periods.

Risk pool insurance generally costs more than regular individual insurance, but the premiums are capped by law in each state to protect the individual from exorbitant costs. The caps range from as low as percent of the average for comparable private coverage in some states, up to percent of the average or more in other states.

Most states offer coverage at less than percent of the average. All state risk pools inherently lose money and need to be subsidized.

Health financing for universal coverage

While the individuals in risk pools pay somewhat higher premiums, roughly 50 percent of overall operating costs need to be subsidized. Subsidy mechanisms also vary from state to state -- some states assess all insurance carriers, HMO's and other insurance providers; others provide an appropriation from state general tax revenue; some states share funding of loss subsidies with the insurance industry using an assessment of insurance carriers and providing them a tax credit for the assessment, or other states have a special funding source, such as a tobacco tax, or a hospital or health care provider surcharge.

It is important to note that risk pools are not created expressly to serve the indigent or poor who cannot afford health insurance. Risk pools are designed to serve people who would not otherwise have the right to purchase health insurance protection.

The indigent can access coverage through state medical assistance, Medicaid or similar programs. However, some state risk pools do have a subsidy for lower income, medically uninsurable people.High-risk pools were, in many cases, the only coverage available pre for people with serious pre-existing conditions who didn’t have access to health insurance from an employer or the government (Medicare, Medicaid, CHIP, etc.).

But they were often underfunded, the coverage was expensive, and plan choices were limited. Risk pooling and redistribution in health care: an empirical analysis of attitudes toward solidarity World Health Report () Background Paper, No 5.

Risk pooling in insurance is a practice where the company groups large numbers of policyholders together to lower the impact of higher-risk individuals by placing them alongside lower risk ones.

The company is able to offer higher risk policyholders more affordable coverage as a result. Risk pooling is a mechanism where revenue and contributions are pooled so that the risk of having to pay for health care is not borne by each contributor individually.

Risk pooling is a form of risk management practiced by the health industry especially insurance companies.

Risk Pooling: How Health Insurance in the Individual Market Works

Risk Pooling in Health Care Finance Kiran Charania April 26, Risk pooling is a mechanism where revenue and contributions are pooled so that the risk of having to pay for health care is not borne by each contributor individually. This report examines risk pooling in health care finance, with particular reference to developing economies.

Pooling is the health system function whereby collected health revenues are.

What is a Risk Pool