Problems with MSP Enrollment

April 10, 2007

A Technical Look at MSP Eligibility Lists

Erin Airton and I debated each other on the Rafe Mair show on 600 AM for two years, and now I occasionally sit opposite her and Rafe on the CBC Early Edition's political panel during Moe Sihota's absences. I did that on April 9th when we discussed the concerns I've raised regarding apparent inaccuracies in the MSP eligibility lists. To Airton's credit, she looked at the 2001 and 2006 tables produced by the Ministry of Finance and immediately commented on the disproportionate growth in the number of singles, something I had ignored. This motivated me to explore some of the intricacies of how data is categorized by MSP, as opposed to the census.

The table below summarizes the number of contracts in units 1, 2 and 3 as shown in the tables provided by the Ministry of Finance. The use of the terminology "contracts" and "units" is a holdover from the days in the 1960s when medical coverage was administered by CU&C and MSA (which since merged to form Pacific Blue Cross). If you have dental or extended health coverage, you will be familiar with rates set by those units, and the Medical Service Plan premiums remain based on that scheme.

	unit 1 (single)	unit 2 (couple)	unit 3 (family)	total contracts
2001	1,016,378	538,130	464,667	2,019,175
2006	1,335,885	611,227	476,111	2,423,223

In 2001 there were 1.016 million unit 1s, and in 2006 there were 1.335 million, an increase of 31.4%.

It would be useful if the unit status (family size) shown in the Ministry of Finance tables could be verified through comparison to census data. A census was conducted in 2006, but tabulations on "marital status" and "families and households" won't be released until September 2007. It is surprisingly difficult to find data on family status; definitions are tricky. Statistics Canada's CANSIM Table 051-0010 provides estimates of population, by marital status, age group and sex, Canada, provinces and territories. In BC the number of singles age 20 or over who were never married plus the number of divorced singles was 877,520 in 2001, and 1,029,729 in 2006, an increase of 17.4%. While those categories don't exactly match the MSP criteria for not being a dependent (age 18 or younger, or 19 to 24 and attending school or university full-time), the differences can't possibly account for the difference between a 31.4% increase for unit 1s according to the Ministry of Finance and a 17.4% increase for singles according to Statistics Canada. Something is clearly amiss with the MSP data.

A moment's reflection makes it apparent that comparisons to indicators of marital status are unproductive because unit status is a fiction used by the government for the collection of premiums.

Unit 1 refers to coverage for one person. The words "one person" are important and should not be confused with "single person". Unit 2 refers to coverage for one person and one dependent, which may be a spouse or child. Unit 3 refers to coverage for three or more persons. Unit is not a true indication of family status. For example, a couple, whose employer pays their premiums, may elect to each be covered as unit 1 paid by their respective employers. Similarly, a family of four could have one adult whose MSP premium is paid by an employer as unit 1, and a second adult whose employer pays unit 3 premiums for that adult and two children. In other words, unit status in the MSP data reveal how premiums are collected, but that status reveals nothing about family size.

While waiting for an answer to a freedom of information request for the number of individuals enrolled with MSP by level of premium subsidy, it is possible to use the unit data to refine the estimate of the apparent error in MSP eligibility lists. The 2001 table indicated that 4,096,677 people were covered by MSP. Since unit 1s have one person and unit 2s have 2, we can calculate that 2,004,039 individuals were in unit 3s, or an average of 4.313 people per contract. If we use the 2006 table and add the number of unit 1s plus 2 times the number of unit 2s plus 4.313 times the number of unit 3s, we get an estimate of 4,611,734 people, which is 301,234 more than the population of BC. Alternatively, we can work backwards and ask what the average number of people per unit 3 contract would have to be in order to make MSP enrollment equal the province's 2006 population (answer: 3.68). So the question of over-enrollment boils down to whether there are more than an average of 3.68 people per family of 3 or more (unit 3) on the MSP eligibility lists. We may get an answer to these questions when the government responds to my April 6th freedom of information request.

April 9, 2007

Abbott Responds on MSP Eligibility Lists

CBC Radio News has reported that Health Minister George Abbott's response to concerns raised about hundreds of thousands of people inappropriately being on MSP eligibility lists is that the numbers reported on StrategicThoughts.com are correct but the interpretation is wrong. Abbott claimed that the 2001 figures were too low. There are two problems with Abbott's response. First, the 2001 figures were provided by the Ministry of Finance in February 2002, under his government. Second, the number of people reported in the 2001 figures (4,096,677) is almost identical to the population of the province in 2001 (4,078,400), as it should be in a universal Medicare system.

A real answer to the questions raised about MSP eligibility lists will have to wait for a response to the freedom of information request submitted on April 6th. It took almost four months and an appeal to the Office of the Freedom of Information and Protection of Privacy Commissioner before the government finally produced the table with the 2006 data. Hopefully, it won't take four months or longer and more appeals before the government comes clean with the information requested for the number of people on MSP eligibility lists as of December 31, 2006, and for any documents that discuss concerns regarding errors in the MSP eligibility lists.

April 8, 2007

Too Many People on MSP Eligibility Lists

To give the Campbell government the benefit of the doubt, Medical Service Plan eligibility lists may have "only" 600,000 more people on them than there are people in the province (not 800,000 as stated in Friday's article).

The table below contains figures from tables provided by the Ministry of Finance, and population figures from BC Stats. The question is what number should be entered in the blank cell. Note that the term "contract" is used in the Ministry of Finance table to refer to singles, couples (two people, one of whom could be a child or a spouse), and families of two or more. The term is a holdover from the 1960s when insurance principles applied to the plan for covering payments to physicians.

	2001	2006	increase
contracts	2,019,175	2,423,223	20.0%
people	4,096,677	?????
population	4,078,400	4,310,500	5.7%

The ratio of people to contracts in the 2001 MSP table is 2.0289. If the number of contracts in 2006 is multiplied by that ratio, it suggests there were 4,916,444 people covered by MSP in 2006. That is 605,944 more than the population of the province. The government may quibble over the numbers, but the fact that the number of contracts increased by 20% while the population increased by less than 6% indicates a problem.

The problem with MSP eligibility lists came to light when the Ministry of Finance produced a table in response to my freedom of information request for an update to their 2001 table, which was produced in February 2002 as part of the background information when the government increased premiums by 50%. Unfortunately, the updated table did not include the column showing the number of people covered. A new freedom of information request has now been submitted asking for the number of people and also asking for any documents that discuss the problem with MSP's inflated eligibility lists.

April 5, 2007

Problems with MSP Enrollment

An examination of data provided as a result of a freedom of information request shows why the Ministry of Finance may have been reluctant to make the information available. Since December I've been trying to get a table that shows the number of families that receive various levels of Medical Service Plan premium assistance. The table, provided this week, contains some interesting information with respect to premium assistance, but it suggests that there are 800,000 more people on the MSP eligibility lists than there are people in the province!

Just over one third, 34.4%, of BC families receive some assistance with their MSP premiums. Remember that BC and Alberta are the only provinces to use the premiums (which are a regressive form of taxation) to finance Medicare; the other provinces use more efficient and more progressive forms of taxation. Also recall that the Campbell government increased MSP premiums by 50% in 2002.

The Ministry of Finance finally responded to my freedom of information request with a table that shows the number of "contracts" (families and unattached individuals) receiving premium assistance, by level of assistance and rate category (0, 1 and 2 or more dependents). It also shows the number of contracts that pay full premiums. When the Campbell government raised premiums, they produced a similar table for premium assistance rates in 2001 (prior to the rate increase). The old table and the updated table are both available here in pdf format (just click on these links).

The adjusted family income levels, which determine the level of assistance a family is entitled to, depend on age and family composition. Adjusted family income is calculated by adding net income (from line 150 on the income tax form) for the applicant and any spouse, and from that total deducting $3,000 for each person in the family over age 65 and for each child. That means a family income of less than $28,000 is adjusted to a net family income of $34,000 for a couple, if both are over age 65. In order to receive any amount of premium assistance in 2001, a family needed an adjusted family income of less than $20,000. In February 2005 government increased the income levels needed to qualify for premium assistance to $28,000, and in March 2005 it moved the implementation date for the changes from August 1st to July 1st, 2005.

In 2001, 686,231 contracts received some level of premium assistance; in 2006 this rose to 832,936 contracts, an increase of 146,705 contracts. The table provided by the Ministry of Finance with the 2006 data did not report the number of individuals, but the 2001 table indicated that on average there were 1.5 individuals in the average contract receiving premium assistance, and 2.3 individuals in the average contract not receiving premium assistance. In other words, contracts with good family incomes had more dependents. If the dependent ratio for contracts remained the same between 2001 and 2006, the 146,705 additional contracts that received assistance would include 222,000 individuals. The government news release said 215,000 more individuals would benefit from the increased premium assistance levels, so that estimate appears to be roughly accurate. That also illustrates the validity of projecting the number of individuals using the ratio of individuals to contracts from the 2001 data.

The tables show 2,019,175 contracts enrolled with MSP in 2001, and 2,423,223 in 2006. That's an increase of 20.0% over 5 years, almost four times the rate of population growth. The proportion receiving premium assistance hasn't changed much between 2001 and 2006 even though the eligibility criteria changed; 34.0% received assistance in 2001 when the maximum adjusted family income was $20,000, and 34.4% received assistance in 2006 when the maximum was $28,000.

The number of contracts who paid full premium in 2001 was 1,332,944; it was 1,590,287 in 2006. That's an increase of 19.3%.

The table with the 2001 data indicates that 4,096,677 individuals were covered by MSP in 2001; BC Stats reports that the provincial population was 4,090,659 in the fourth quarter of 2001. That's close enough to call it equal; in other words, the data released by the Ministry of Finance in February 2002 (for 2001) appears consistent with population figures. The population increased by only 5.4% between the fourth quarter of 2001 and the third quarter of 2006. How can it be that the number of contracts covered by MSP increased by 20.0% over that period?

An alternative way to compare the two tables is to take the ratio of individuals to contracts in 2001 and apply those ratios to the number of contracts in the 2006 table to project the number of individuals covered in 2006. That calculation yields an estimate of 4.913 million, but the 2006 census reported BC's population as 4.113 million. That suggests BC has 800,000 more people enrolled for MSP than there are people in the province! Either the data provided by the Ministry of Finance is wrong, or there is a serious problem with the enrollment data for the Medical Services Plan. Maximus was contracted by the government to administer MSP enrollment starting in 2003. There is an urgent need to review whether additions and deletions to MSP eligibility lists have been properly made, since inappropriate names on the edibility list can lead to millions of dollars in incorrect payments. Since MSP enrollment lists are also used for Pharmacare, and since the Minister of Finance indicated that MSP premium assistance lists will be used to determine extended eligibility for the homeowner grant, it is urgent to correct errors in those lists.