In two important health policy contexts – private plans in Medicare and the new state-run “Exchanges” created as part of the Affordable Care Act (ACA) – plan payments come from two sources: risk-adjusted payments from a Regulator and premiums charged to individual enrollees. This paper derives principles for integrating risk-adjusted payments and premium policy in individual health insurance markets based on fitting total plan payments to health plan costs per person as closely as possible. A least squares regression including both health status and variables used in premiums reveals the weights a Regulator should put on risk adjusters when markets determine premiums. We apply the methods to an Exchange-eligible population drawn from the Medical Expenditure Panel Survey (MEPS).
McGuire, Thomas G., Jacob Glazer, Joseph P. Newhouse, Sharon-Lise Normand, Julie Shi, Anna D. Sinaiko, and Samuel Zuvekas. "Integrating Risk Adjustment and Enrollee Premiums in Health Plan Payment." Journal of Health Economics 32.6 (December 2013): 1263–1277.