Understanding the Factors behind Carriers' Decision to Leave the

U.S. Department of Health and Human Services

Assistant Secretary for Planning and Evaluation

Office of Disability, Aging and Long-Term Care Policy

EXITING THE MARKET:

UNDERSTANDING THE FACTORS

BEHIND CARRIERS’ DECISION TO

LEAVE THE LONG-TERM CARE

INSURANCE MARKET

July 2013

Office of the Assistant Secretary for Planning and Evaluation

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) is the

principal advisor to the Secretary of the Department of Health and Human Services

(HHS) on policy development issues, and is responsible for major activities in the areas

of legislative and budget development, strategic planning, policy research and

evaluation, and economic analysis.

ASPE develops or reviews issues from the viewpoint of the Secretary, providing a

perspective that is broader in scope than the specific focus of the various operating

agencies. ASPE also works closely with the HHS operating divisions. It assists these

agencies in developing policies, and planning policy research, evaluation and data

collection within broad HHS and administration initiatives. ASPE often serves a

coordinating role for crosscutting policy and administrative activities.

ASPE plans and conducts evaluations and research--both in-house and through support

of projects by external researchers--of current and proposed programs and topics of

particular interest to the Secretary, the Administration and the Congress.

Office of Disability, Aging and Long-Term Care Policy

The Office of Disability, Aging and Long-Term Care Policy (DALTCP), within ASPE, is

responsible for the development, coordination, analysis, research and evaluation of

HHS policies and programs which support the independence, health and long-term care

of persons with disabilities--children, working aging adults, and older persons. DALTCP

is also responsible for policy coordination and research to promote the economic and

social well-being of the elderly.

In particular, DALTCP addresses policies concerning: nursing home and community-

based services, informal caregiving, the integration of acute and long-term care,

Medicare post-acute services and home care, managed care for people with disabilities,

long-term rehabilitation services, children’s disability, and linkages between employment

and health policies. These activities are carried out through policy planning, policy and

program analysis, regulatory reviews, formulation of legislative proposals, policy

research, evaluation and data planning.

This report was prepared under contract #HHSP23320100022WI between HHS’s

ASPE/DALTCP and Thomson Reuters. For additional information about this subject,

you can visit the DALTCP home page at http://aspe.hhs.gov/office_specific/daltcp.cfm

or contact the ASPE Project Officer, Samuel Shipley, at HHS/ASPE/DALTCP, Room

424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C.

20201. His e-mail address is: Samuel.Shipley@hhs.gov.

EXITING THE MARKET:

Understanding the Factors behind

Carriers’ Decision to Leave the

Long-Term Care Insurance Market

Marc A. Cohen, PhD

Chief Research and Development Officer

LifePlans, Inc.

Ramandeep Kaur, MA

Heller School, Brandeis University

Bob Darnell, ASA, MAAA

Independent Consultant

July 2013

Prepared for

Office of Disability, Aging and Long-Term Care Policy

Office of the Assistant Secretary for Planning and Evaluation

U.S. Department of Health and Human Services

Contract #HHSP23320100022WI

The opinions and views expressed in this report are those of the authors. They do not necessarily reflect

the views of the Department of Health and Human Services, the contractor or any other funding

organization.

TABLE OF CONTENTS

ACKNOWLEDGEMENTS ............................................................................................... vi

EXECUTIVE SUMMARY ................................................................................................ v

I. INTRODUCTION ....................................................................................................... 1

II. PURPOSE ................................................................................................................. 3

III. METHOD AND ANALYSIS ....................................................................................... 4

A. Published Information Sources .......................................................................... 4

B. Survey of Industry Executives ............................................................................ 5

IV. FINDINGS .................................................................................................................. 7

A. Entering the Long-Term Care Insurance Market ................................................ 7

B. Market Evolution .............................................................................................. 11

C. The Decision to Exit the Market ....................................................................... 27

D. Current Market Activity ..................................................................................... 41

E. Factors that Might Lead Companies to Re-Enter the Market ........................... 45

V. IMPLICATIONS ....................................................................................................... 50

VI. CONCLUSION ......................................................................................................... 54

LIST OF FIGURES AND TABLES

FIGURE 1. Primary Motivations for Entering the Market .............................................. 8

FIGURE 2. Initial Business Strategy ............................................................................. 9

FIGURE 3. Evaluation of Most Volatile or Greatest Potential Future

Challenge at the Time of Market Entry..................................................... 10

FIGURE 4. New Sales of Individual Policies .............................................................. 16

FIGURE 5. Number of Insured Lives Covered by Year .............................................. 17

FIGURE 6. Annual Growth in Total Covered Lives..................................................... 18

FIGURE 7. Industry-Wide Actual Annualized Incurred Claims ................................... 20

FIGURE 8. Single Most Important Reason that the Company Left the

Market ...................................................................................................... 30

FIGURE 9. Moody’s Yield on Seasoned Corporate Bonds--All Industries,

AAA and Ten Year U.S. Treasury Note Yield Rate .................................. 32

FIGURE 10. Annual and Cumulative Loss-Ratio .......................................................... 37

FIGURE 11. Industry-Wide Actual Losses to Expected Losses ................................... 38

FIGURE 12. Industry Actual to Expected Annual Incurred Claims:

2009-2011 ................................................................................................ 39

FIGURE 13. Actions taken Prior to Leaving the Market ............................................... 40

FIGURE 14. Level of Concern about Selling the Product if In-Force Rates

had to be Raised ...................................................................................... 41

FIGURE 15. Market Indicators by Company Sales Status 2009 .................................. 45

FIGURE 16. Chance that the Company would begin Selling LTC

Insurance Again ....................................................................................... 46

FIGURE 17. Circumstances under which the Company would Consider

Re-Entering the Market ............................................................................ 49

iii

TABLE 1. Participating Companies ............................................................................... 5

TABLE 2. Characteristics of Policies Selling in the Market: 1990-2010 ...................... 13

TABLE 3. Characteristics of Individual LTC Insurance by Purchase Year .................. 21

TABLE 4. Key Pricing Assumptions in Developing LTC Insurance

Premiums ................................................................................................... 24

TABLE 5. Impact of Alternative Assumptions on Profitability of LTC

Insurance .................................................................................................... 25

TABLE 6. Distribution of Sample by Year of Market Exit ............................................ 28

TABLE 7. All of the Reasons Cited by Exiting the Market ........................................... 29

TABLE 8. Factors Influencing the Decision to Exit the Market .................................... 34

TABLE 9. Summary of Key Industry Parameters: 2000-2010 ..................................... 39

TABLE 10. Experience of 1995 Top Writers of Individual LTC Insurance in

2011 ........................................................................................................... 43

TABLE 11. Distribution of LTC Insurance Companies by Current Market

Status ......................................................................................................... 44

TABLE 12. Factors Potentially Influence the Decision to Re-Enter the Market ............. 47

ACKNOWLEDGEMENTS

We would like to gratefully acknowledge the partial support that we received for the

survey development, analysis, and report writing for this project from the Office of the

Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and

Human Services (HHS), Washington, D.C. and specifically our Project Officer, Sam

Shipley.

We would also like to thank all of the executives from long-term care insurance and

reinsurance companies who participate in this survey and set of unstructured

discussions who shared their views in a candid and honest manner.

As well, a number of individuals both inside and outside HHS provided valuable

input and insights into earlier drafts of this paper. We would like to thank Brian Burwell,

Eileen Tell, Al Schmitz, Jodi Anatole, Malcolm Cheung, Richard Frank and the staff of

ASPE for their important contributions to this report.

Of course any and all errors in this report are the sole responsibility of the authors.

EXECUTIVE SUMMARY

Throughout the 1980s and 1990s a growing number of private insurers began

providing insurance for long-term care (LTC). The market grew rapidly through the

early part of this decade. By 2003, however, growth in annual sales came to an abrupt

end and the market experienced a major decline. Whereas in 2002, there were 102

companies selling policies, by the end of the decade, there were roughly a dozen

companies still actively selling a meaningful number of policies in the market.

The sheer magnitude of the projected growth in the retiree population along with

the significant exposure to financial risk suggests that there still exists a business

opportunity for companies to provide LTC coverage. As well, there has been consistent

public policy effort in the form of state and federal tax incentives, Partnership Programs

across a growing number of states, and public awareness and education campaigns in

support of private insurance. All of this points to a strong desire on the part of public

policymakers that the private insurance market grows and prospers. Yet, this has

clearly not happened, and the question is, why not?

In this study we provide a systematic understanding of the growth and

development of the LTC insurance market with a particular focus on the reasons why

companies both entered and exited the market. We characterize the market and how it

has changed over time in terms of its size, product offerings, consumer characteristics,

regulatory framework, and financial performance. We also focus on firms’ initial

motivations for entering the market, their expectations and experience while in the

market, and ultimately why so many exited the market.

A review of industry data as well as structured interviews with executives and

decision makers from 26 major LTC insurance companies reveals the following key

selected findings:

Market Entry

About half of the companies entered the market because they believed it

represented a profitable opportunity. Others began providing the insurance to

demonstrate market leadership and to provide new products to their sales force

to keep them engaged and committed to selling the company’s other products.

More than half of companies were most concerned with the future claims risk or

the fact that the LTC risk had a “long-tail”.

Few companies were concerned with what turned out to be the two most

significant drivers of future poor financial performance -- the interest rate and

voluntary lapse rate assumptions built into the pricing of the product.

During the first five years after market entry, roughly two-in-five companies

indicated that sales objectives had not been met and half indicated that either

underlying pricing objectives (25%) or initial profitability targets (25%) had not

been met.

Market Exit: Profitability Challenges

The issue of profitability is one of many factors related to why companies

entered the market but it is an absolutely central factor in understanding why

many of these same companies ultimately exited the market.

Product performance and more specifically, not hitting profit objectives was the

most cited reason for leaving the market.

High capital requirement to support the product was cited most frequently as the

single most important reason for market exit.

Other reasons for market exit related to challenges around marketing and sales,

risk management strategies, regulatory policy, and the lack of reinsurance

coverage.

The key drivers of profitability are embedded in the underlying pricing

assumptions used to develop premiums and are a function of company strategies

related to under-writing and claims management, product design, premium

structure, inflation adjustment rates, sales and marketing costs and investment

strategies.

Small variations in actual experience compared to expected performance of each

of the pricing assumptions can have a major impact on product profitability.

Since the late 1990s, all of these major determinants of premium and product

profitability have been going in the wrong direction: interest rates are

significantly lower than what was priced for, voluntary lapse rates are lower than

for any other insurance product, morbidity is somewhat worse than expected and

mortality is actually improving.

Regarding regulatory policy, the most cited factors having a moderate influence

on a company’s decision to exit the market have to do with the ability to obtain

rate increases in a timely manner or at all, as well as having the necessary

flexibility to engage in appropriate risk management activities.

The costs of regulatory compliance and the possibility that such compliance

encumbers product innovation were not seen as factors in the market exit

decision.

vii

Current Market Activity

Fewer than 15 companies are actively selling stand-alone LTC policies in 2012.

As of the end of 2011, policy sales for these companies were well below 1990

levels.

Market concentration has increased over the decade, with the top ten companies

now accounting for slightly more than two-thirds of covered lives and the top five

accounting for more than half of all policyholders.

Given the recent exodus of additional companies from the market, such

concentration is likely to grow.

While there has been variability in cumulative industry claims performance over

the last decade, recent data suggests that performance is deteriorating. Over the

past three years, new incurred claims are 112% higher than what was expected.

In 2010, annual premiums for companies still selling policies in the market totaled

$5.3 billion compared to $4.7 billion for those who exited the market and were

administering “closed-blocks” of business. On a cumulative premium basis,

however, closed-blocks represented 55% of all earned premiums.

By 2010, 55% of policyholders were being serviced by companies who had

exited the market.

Regarding claims, in 2010, closed-block companies represented 53% and 57%

of annual and cumulative total claims costs.

Factors that might lead Companies to Re-Enter the Market

About 42% of respondents affirmed their belief that the “door remained open” to

re-entering the market at some time in the future; however, only one-quarter

indicated that the chance was greater than 25% and the other 75% said that the

chance was very low or that it simply was not going to happen.

There were very few specific policy design changes or regulatory modifications

presented to respondents that would lead companies to definitely reconsider their

decision to exit the market.

The ability to file multiple premium schedules that would be based on alternative

levels of interest rates -- which in part helps to mitigate the investment (interest

rate) risk -- was cited most frequently as a change that would potentially lead to a

reconsideration of the decision.

viii

Expansion of combination-products to include LTC-disability, LTC-critical illness,

or others was viewed as something that might cause companies to think about

getting back into the market.

One-in-three respondents suggested that allowing policies to be funded with pre-

tax dollars also would lead them to potentially reconsider their decision.

In answer to a broad question about factors that would encourage a

reconsideration of the decision to exit the market, product structure changes

were cited most often as likely to have a meaningful influence; many of these had

to do with the level-funded nature of the product, the “long-tail risk”, and the fact

that the product is complicated.

Those citing regulatory requirements pointed to high capital requirements, as well

as a general sense that carriers needed to have more flexibility in product design.

Implications

Changes to the underlying funding structure of products should be considered

with designs that are less interest rate sensitive like term-priced products and

indexation of both premiums and benefits. These approaches make the product

more affordable for consumers and reduce the level of initial reserves that must

be set up by the company, which in turn eases the amount of capital required to

support the product.

Deploying more sophisticated investment strategies designed to hedge against

the inflation and interest rate risks can also help insurers protect underlying

product profitability.

Providing companies with more certainty regarding the anticipated actions of

state insurance departments vis-à-vis requested rate adjustments is also very

important to enhancing the attractiveness of the market.

By taking some of the most risky elements out of the product, high capital

requirements would no longer be justified which would remove a major barrier to

entry and help justify the deployment of capital to support the product.

Solutions to the challenge and cost of selling the product can include linking LTC

insurance to health insurance, simplifying the product, providing more support for

employer-sponsorship of insurance, educating the public about the risk and costs

of LTC, forcing active choice, and implementing targeted subsidies.

Provision of state-based organized reinsurance pools to provide a “back-stop” for

industry experience, may also encourage more suppliers to enter the market.

Conclusions

The lessons learned about pricing and managing the risks associated with LTC

insurance from those who have left the market can help set the industry on a

more solid financial foundation and make entry for new carriers a more attractive

proposition.

Identifying strategies that produce a level of profitability attractive enough to draw

capital into the market is a key to assuring a robust and competitive market of

insurers.

Public policy and regulatory approaches designed to lower the cost of policies,

allow greater product funding-flexibility, support new forms of combination-

products, and encourage strategies that help to minimize risks outside of the

control of companies, could provide needed support for a market “re-set”.

I. INTRODUCTION

Paying for long-term care (LTC) continues to be one of the great financial risks

facing Americans during retirement. Current estimates suggest that the annual costs of

care in a nursing home are roughly $85,000 and that home health care can cost

upwards of $25,000 per year.

Given that one-in-five individuals can expect to spend

more than two years in need of care, this represents a significant financial risk. In 2010,

total spending for LTC was $208 billion or roughly 8% of all personal health care

spending.

For the most, part such care is provided and paid for by families whereas

the largest public payer of LTC services is the means-tested Medicaid program, which

pays more than 40% of costs. Medicaid is one of the fastest growing health programs

in the country, and is creating significant budgetary pressures on the states. Private

insurance covers a small -- less than 10% -- but growing share of LTC expenses.

Throughout the 1980s and 1990s a growing number of private insurers began

providing insurance for LTC, as an alternative to public coverage (i.e., Medicaid) or to

out-of-pocket payments by the elderly and their families. At first, such insurance

policies covered care provided only in a nursing home. Gradually, coverage expanded

to include payments for home care services, assisted living, adult day care, and other

community options. By the mid to late 1990s more than 100 companies were selling

policies to individuals and to individuals in group markets (i.e., employer settings).

Moreover, annual sales increased almost every year throughout the decade. In 1990,

380,000 individual policies were sold; by 2002, 755,000 policies were sold in that year.

In 2003, the pattern of annual increases in sales came to an abrupt end. In fact,

LTC policy sales began to decline rapidly. Between 2003 and 2009 individual policy

sales declined by 9% per year.

Thus, in 2009, fewer policies were sold than had been

sold in 1990. Moreover, while in 2002, there were 102 companies selling policies by

2009, most of these companies had exited the market; that is, they had stopped selling

new policies.

Mature Market Institute (2011). Market Survey of Long-Term Care Costs: The 2011 MetLife Market Survey of

Nursing Home, Assisted Living, Adult Day Services, and Home Care Costs. October.

O’Shaughnessy, CV. The Basics: National Spending for Long-Term Services and Supports. National Health

Policy Forum, 2012. http://www.nhpf.org/library/the-basics/Basics_LongTermServicesSupports_02-23-12.pdf.

Washington, DC.

America’s Health Insurance Plans (2004). Long-Term Care Insurance in 2002. Research Findings, Washington,

DC. June.

LifePlans, Inc. (2012). 2011 Long-Term Care Top Writers Survey Individual and Group Association Final Report,

Waltham, MA. March.

Ibid.

America’s Health Insurance Plans (2004). Long-Term Care Insurance in 2002. Research Findings, Washington,

DC. June.

The sheer magnitude of the projected growth in the retiree population -- from 12

million today to 27 million by 2050 -- along with the significant exposure to financial risk

suggests that a business opportunity exists for companies to provide LTC coverage. As

well, there has been consistent public policy support in the form of state and federal tax

incentives, Partnership Programs across a growing number of states, and public

awareness and education campaigns in support of private insurance. All of this points

to a strong desire on the part of public policymakers that the private insurance market

prospers and grows. Yet, this has clearly not happened, and in fact, the number of

companies actively selling LTC insurance continues to decline at a pace far in excess of

the small number of companies entering the market.

II. PURPOSE

The purpose of this study is to provide a systematic understanding of the growth

and development of the LTC insurance market with a particular focus on the reasons

why companies both entered and exited the market. We will characterize the market

and how it has changed over time in terms of its size, product offerings, consumer

characteristics, regulatory framework, and financial performance. We will also focus on

firms’ initial motivations for entering the market, their expectations and experience, and

ultimately why so many exited the market.

Specifically, we provide information on the following issues or questions:

1. What were the primary motivations and expectations of firms when they began

providing LTC insurance?

2. How has the market changed in terms of product, pricing, consumer profile,

regulatory environment, supplier characteristics, aggregate market

characteristics and performance indicators?

3. What are the primary reasons why companies who actively marketed LTC

insurance ceased selling policies?

4. What would be required for such companies to consider re-entering the market?

By addressing these issues we intend to paint a picture of the industry in terms of its

historical growth and development, as well as its current and future challenges.

III. METHOD AND ANALYSIS

In order to address these issues, we relied on a variety of sources of published

information as well as on new information provided by discussions with insurance

executives from 29 companies who had been in the market and chosen to exit.

A. Published Information Sources

We rely on data and information from America’s Health Insurance Plans (AHIP),

the Life Insurance Marketing and Research Association (LIMRA), industry analyst

reports from Moody’s and Standard & Poors, the academic research literature, and the

National Association of Insurance Commissioners (NAIC) Long-Term Care Experience

Reports for 2000, 2009, 2010 and 2011.

7,8,9,10,11

Reports from this latter source present

the most accurate information on key market parameters regarding premiums, claims,

growth of in-force business, as well as historical performance indicators like actual-to-

expected claims experience and data that enables calculation of measures of volatility

in performance. Almost all companies are required to file detailed data on an annual

basis with the NAIC, and such data is compiled and published in these annual reports.

These reports typically provide country-wide experience for companies. While the

forms are relatively consistent, there have been a number of changes in 2010. The

reports now provide additional information related to lapsation of policies but there is no

longer detailed durational loss-ratio information provided in these reports. Thus, after

2009, one can no longer track the year-by-year loss-ratio (incurred claims divided by

earned premiums) for a specific policy, based on how long that policy has been in-force.

Nevertheless, the data in these reports is extremely valuable and allows us to “size the

market” for companies still selling policies and for companies who exited the market.

An important caveat is that one of the large carriers to exit the market, Penn Treaty

Network America, is currently in rehabilitation status under the auspice of the State of

Pennsylvania. For this reason, the company was not required to provide data to the

National Association of Insurance Commissioners (2001). Long-Term Care Insurance Experience Reports for

2000.Kansas City, KS. November.

National Association of Insurance Commissioners (2010). Long-Term Care Insurance Experience Reports for

2009.Kansas City, KS. November.

National Association of Insurance Commissioners (2011). Long-Term Care Insurance Experience Reports for

2010.Kansas City, KS. November.

National Association of Insurance Commissioners (2012). Long-Term Care Insurance Experience Reports for

2011.Kansas City, KS. November.

While interim years were available from NAIC, in order to capture the trend over the decade, we focused

exclusively on these years.

NAIC in 2009 and 2010. We solicited such information directly from the company and

this allowed us to include their data with the aggregate NAIC reports.

B. Survey of Industry Executives

The second source of information was discussions with key executives who were

either directly involved in the decision making process relating to leaving the market, or

to those with intimate knowledge about their company’s decision to exit the market. The

instrument was administered in two ways: (1) in-person and telephonic interviews with

executives, and (2) a web-based survey that was sent to those individuals who did not

complete the in-person/telephonic interview. In total, executives from 29 companies

that have exited the market or exited specific market segments over the last 15 years

responded to the survey. Of these companies, three surveys were with executives from

reinsurance companies, and the other 26 from direct writers of LTC insurance. In-

person or telephonic interviews were completed with executives from16 companies and

the other 13 were completed on-line.

Executives from the following companies were interviewed and/or provided

responses to the survey.

TABLE 1. Participating Companies

Ability Re

Aetna

Allianz

American Family Mutual Insurance

Company

American Fidelity Assurance Company

CNA

Conseco

CUNA Mutual

Employers Reassurance Corp

Equitable

Great American Financial

Guardian--Berkshire

Hannover Life Reassurance Company of

America

Humana Insurance/Kanawha

John Hancock Group LTC Insurance

MetLife

Munich Re

Nationwide Financial

Penn Treaty

Physicians Mutual Insurance Company

Principal Financial Group

Prudential

RiverSource Life Insurance Company

Southern Farm Bureau Life

Standard Life and Accident Insurance

Company

Teachers Protective Mutual Life

Transamerica

Union Labor Life Insurance Company

UNUM

a. Note that Transamerica has since re-entered the market and the interview related to the

reasons for the initial decision to exit the market.

Based on an analysis of data for 2010 (and excluding Transamerica, which is now

back in the market), these companies represent slightly more than 95% of the total

earned premium and 90% of covered lives of companies among the top 100 of all

companies who have left the market. Thus, the results of the survey can be generalized

to the population of companies that have left the market.

The survey instrument itself typically resulted in an interview time of between 30

minutes to an hour. All data was captured and put into an analytic database so that

frequencies and cross-tabulations could be completed. Additional information from the

interviewees provided contextual information to many of the responses. This too is

included where appropriate. The survey results that are reported here focus exclusively

on the direct writers of LTC insurance; when appropriate, the issue of reinsurance is

addressed separately and responses from the three participating reinsurance

companies are reported.

Analytic Lens for Understanding Insurer Behavior

A primary focus of this study is to understand why firms have recently left the

market. Therefore, having a frame for understanding such behavior can be helpful in

interpreting the aggregate data as well as company-specific information. We use the

frame of “profit maximization” which posits that firms either enter a market or exit a

market depending on whether they are able to obtain a target return or profit level

commensurate with their expectations. Thus, the basic concept is that companies exist

and make decisions in order to maximize profits.

Clearly, the model of profit

maximization is a simplification of reality and assumes that profits are not the only

relevant goal of the firm. In fact, additional objectives may affect profits indirectly or be

equally as important such as sales maximization, public relations, gaining market share,

increasing the attractiveness of complementary products, acquiring power and prestige,

and other goals more related to managers maximizing their own utility rather than

insurer profit maximization. We do not ignore these other goals and in fact test their

validity by asking direct questions to the executives about the various motivations

underlying their decision making.

We begin by presenting information on why firms entered the market and then

present abridged summaries of key historical developments in the market focusing on

changes in product design, marketing and sales, risk management, consumer profiles,

and the regulatory framework that has developed over the past 30 years.

This is

followed by a discussion of why in recent years most firms have left the market. We

focus on a number of key issues affecting profitability such as pricing strategies, capital

requirements and distribution challenges. We conclude with an examination of the

factors that might influence firms to consider re-entering the market, and present some

specific actions that might encourage them do to so.

This theory of the firm parallels the theory of the consumer which states that consumers seek to maximize their

overall well-being (utility).

It is important to note that the information about firm entry to the market is based primarily on interviews with

companies that have since left the market. The exception is the presentation of some historical information on

Amex Life -- currently Genworth Financial.

IV. FINDINGS

A. Entering the Long-Term Care Insurance Market

LTC insurance has been selling in the marketplace for the better part of 30 years.

Early versions of the insurance were called “nursing home insurance.” This is because

such policies only covered care provided in nursing homes, primarily skilled facilities. In

the late 1970s, early 1980s there were a small number of companies providing such

coverage some of whom included Penn Treaty, Equitable, and Medico. They entered

the market at a time when expenditures on LTC were less than $20 billion which then

quickly grew to $30 billion in 1980 and over $70 billion within a decade.

14,15

Most of the

costs were borne by individuals and their families and already such care represented an

uncovered and potentially catastrophic expense. The problem of LTC financing was

recognized by policymakers who in the late 1980s debated a number of bills aimed at

paying for substantial LTC costs.

This occurred against the backdrop of more than 1.7

million private policies having been sold to individuals during that time.

Most of the firms providing nursing home products in the 1980s also distributed

other types of insurance. All were multi-line companies, the most prominent of which

was the Fireman’s Fund, which then became Amex Life in the late 1980s and G.E.

Capital and Genworth Financial (1990s). These early pioneers were motivated by the

perceived opportunity represented by demographic trends, but more importantly, the

sense that this coverage was not all that different from the Medicare Supplement

policies that were beginning to proliferate in the market. In some sense early nursing

home policies were viewed as a variant of such policies. This view, shaped early

approaches toward pricing, which will be discussed in a subsequent section.

We asked executives in the sample to recount why their company had initially

entered the market. Three of these companies began selling policies in the 1970s, ten

in the 1980s and almost all of the remainder in the 1990s. When these companies

entered the market most (73%) offered a nursing home-only policy -- many having

entered in the 1970s or 1980s -- and slightly more than half (57%) also offered

comprehensive policies covering both nursing home and home care services -- all

companies that entered the market in the late 1980s and early 1990s.

Consistent with our model of firm behavior, Figure 1 shows that almost half of the

companies entered the market because they believed it represented a profitable

Long-Term Care for the Elderly and Disabled (1977). Congressional Budget Office, Congress of the United

States, Washington, DC. February.

Health Care Financing Administration, Office of the Actuary, Data from the Office of National Health Statistics in

Health Care Financing Review, Fall 1994, Volume 16, Number 1.

Among others, these included the Mitchell Bill, which proposed paying for the care of individuals who stayed

more than two years in a nursing home and the Kennedy Bill which proposed paying for front-end LTC costs.

opportunity. However, profit maximization was not the only reason for entering this

market. Many companies felt that such a strategy supported efforts to show market

leadership and to provide new product to their sales force to keep them engaged and

committed to selling the company’s other products. During detailed discussions with

respondents, it was clear that compelling demographics and a perception of increasing

consumer need drove many companies to enter this market to take advantage of an

opportunity that they knew existed, even if they were not completely certain about how

to exploit it profitably. Not shown in the figure is the fact that among these companies

who left the market, 80% had senior management that was either supportive or very

supportive of the decision to initially enter the marketplace.

FIGURE 1. Primary Motivations for Entering the Market

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment of

the market.

NOTE: Numbers sum to more than 100% because respondents could check more than a single

motivation.

Even 30 years later, the need for a product addressing the catastrophic costs

associated with LTC needs persists. The consequence of demographic trends, a lack of

comprehensive public solutions, and an inadequate private market is that LTC remains

the largest unfunded health-related liability faced by elders during retirement. While

demographics and consumer need have remained constant over the period,

perceptions about the actual profit opportunity presented by this market have definitely

changed.

Figure 2 highlights the initial business strategy of companies and demonstrates

that for 40% of the companies that left the market, their initial business strategy was to

grow modestly in order to learn the business and improve their management of the

product over time. Only 16% had aspirations of becoming market leaders.

FIGURE 2. Initial Business Strategy

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment of

the market.

We also asked which business metric was viewed as the most important to

measuring the success of the endeavor during the first five years after market entry.

Slightly less than half (48%) of companies indicated that meeting sales targets was

most important. Profitability and meeting underlying pricing assumptions during the first

few years of sales were cited by fewer than 25% of respondents; this suggests that

there was a realistic understanding that given the long-term nature of the underlying

risk, as well as the relatively high initial costs associated with selling and underwriting

new policies, profit emergence and credible actuarial experience would be relatively

slow in developing. The first measurable goal would be sales.

Most companies tried to differentiate themselves from their competitors through

innovative product design as well as sales incentive plans. Some of the innovation

proved to be confusing for consumers, and in particular, competition related to the

benefit eligibility trigger. Some companies made eligibility for benefits dependant on the

ability to perform varying numbers of activities of daily living (ADLs) and instrumental

activities of daily living. It was nearly impossible for an individual to know which set of

conditions they were likely to meet 20 years into the future to qualify for insurance

payments. Benefit trigger standardization did not occur until the passage of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996. Companies also

expanded coverage for more community services including caregiver support and

respite care, restoration of benefits, transportation services, and other ancillary benefits.

Figure 3 shows how companies evaluated the key risks associated with this

product. More than half of companies were most concerned with the future claims risk

or the fact that this risk had a “long-tail”. In other words, they were not certain how long

an individual with LTC needs would require paid services. A relatively high percentage

of policies had lifetime or uncapped benefit durations, which meant that they would pay

benefits for as long as someone had continued need -- which represented an uncapped

liability to the company.

FIGURE 3. Evaluation of Most Volatile or Greatest “Potential Future Challenge”

at the Time of Market Entry

SOURCE: Survey of executives from 25 LTC carriers who exited the market or exited segment of

the market.

It is somewhat ironic that few companies were concerned with what turned out to

be the two most significant drivers of future poor financial performance -- the interest

rate and voluntary lapse rate assumptions built into the product. Lower than expected

interest rates and voluntary lapse rates have forced almost all companies to seek rate

increases, and this may have contributed negatively to sales as well as to the reputation

of both the product and to a number of companies. As will be demonstrated in a

subsequent section, errors in these assumptions had a major negative impact on

product profitability.

We also asked companies which objectives were not met during the first five years

of market entry. Roughly two-in-five indicated that sales objectives had not been met

and half indicated that either underlying pricing objectives (25%) or initial profitability

targets (25%) had not been met. Thus, fairly early on, for a clear majority of these

companies, the key metrics established to judge whether the initial decision to enter the

market had been a good one, were not being met. Moreover, early undefined goals

may have led to later disappointments.

Since the time when most firms entered the market, the industry has experienced

a number of major changes, many of them directly and indirectly contributing to the

current picture of the industry. These include changes in product, risk management

strategy, sales approaches, and the regulatory and public policy environment. We

summarize these key trends in order to provide an historical view of industry

developments through the first decade of this century.

B. Market Evolution

1. Product Design

As mentioned, LTC insurance -- nursing home insurance -- has been selling in the

marketplace for the better part of 30 years. Thus, it may still be considered a relatively

new insurance product that continues to evolve. The implication is that one might

reasonably expect “wrong turns” along the way, as the product and industry adapts to

new information, changing market conditions, and accumulated actuarial experience.

Through the 1970s and up to the late 1980s, the coverage was linked to the structure of

Medicare coverage. Like many supplemental private health insurance policies, nursing

home insurance focused on what Medicare “did not cover”. Medicare paid for skilled

nursing home care for up to 100 days and private insurance began coverage when

Medicare ceased providing benefits. For this reason, early product configurations had

elimination periods (i.e., deductibles) that were typically defined as 100 days -- the

period of care that Medicare covered -- and the coverage was focused exclusively on

skilled nursing home care resulting from a prior three day hospitalization -- precisely in

line with Medicare policy. If care was initially considered to be “medically necessary”,

private insurance carriers would continue to pay benefits even when the need for skilled

care ceased and only custodial (i.e., maintenance) care was required. Thus, while

these early private policies “keyed off” of Medicare coverage, their innovation was that

they paid for custodial care, where Medicare did not. In essence, this extended

coverage from a limited amount of skilled nursing care (paid by Medicare) to a much

more generous amount of skilled and custodial nursing home care (paid by private

insurance and also by Medicaid for selected populations).

Early Medicaid policy also shaped the conception of LTC as synonymous with

nursing home care.

Over time, LTC -- and now long-term services and supports -- has

come to reflect the reality that the need for care, which is based on functional limitations

and/or cognitive impairment, requires a broader set of service responses. These

include home and community-based care and a variety of residential care settings such

as assisted living, adult day care and others.

Regarding the pricing of early policies, there was little basis on which to develop

an estimate for future morbidity (i.e., the chance that someone would develop a

condition that required use of LTC services) in the context of private insurance. In order

to price these early policies actuaries relied on national data sources like the 1977 and

1985 National Nursing Home Surveys. As they considered home care coverage, they

focused on the 1982, 1984, and 1994 National Long-Term Care Surveys for incidence

and continuance data; again, such data was not directly transferrable to the private

insurance context since it was neither insured data nor was the underlying population

Kemper, Peter (2010). Long-Term Services and Supports. The Basics: National Spending for Long-Term

Services and Supports. Presentation to the National Health Policy Forum, Washington, DC. June 18.

likely to reflect purchasers of insurance. For other pricing parameters, like voluntary

lapse rates and mortality, there was a reliance on the experience of Medicare

Supplement policies and standard mortality tables. For this reason, voluntary lapse

rates priced into initial policies were much higher than what they ultimately turned out to

be. (In fact, there is no other voluntary insurance product in the market that has

experienced lower voluntary lapse rates than what is found in LTC insurance policies.)

Policies were always sold as guaranteed renewable -- they could only be cancelled

for non-payment of premium -- and as level-funded. That is, while the premium charged

varied by age at purchase, once an individual purchased a policy, the premium was

designed to be level for life. Theoretically, an individual buying a policy at age 65 for a

premium of $1,000 per year could be expected to pay that same annual premium

throughout their lifetime, so long as the underlying pricing assumptions employed by the

actuaries were accurate. The level-funded nature of the product persists to this day,

and poses unique challenges to insurers. This will be discussed in a subsequent

section. Finally, almost all policies reimbursed the actual costs of care up to a daily

benefit maximum.

Relatively sluggish sales of LTC insurance policies in the 1980s suggested that the

then current product design was not going to reach a broader part of the public. Selling

insurance to cover something that no one wanted to access, except under the most

extreme of circumstances, did not seem to be an attractive value proposition for fueling

growth in the market. Moreover, Medicare, as well as certain Medicaid plans under

special waivers, began to pay for support services in peoples’ homes. Medicare

covered such services primarily when they were deemed to be medically necessary.

Medicaid also expanded its coverage for home and community-based care but still

severely restricted access to these services.

As agents and brokers came to play a larger role in the LTC product development

process, it was clear that for the coverage to sell, it needed to pay for custodial services

where people desired them most -- in their own homes. This presented a dilemma for

insurers because the primary risk management tool for managing claims was based on

policyholder behavior: no policyholder really wanted to go into a nursing home, and this

served as a brake on potential moral hazard and over-utilization of services. If policies

began covering services in settings that people desired, like the home, this “brake” on

moral hazard would disappear with the potential for making the underlying economics of

the product unsustainable.

It became clear that in order for the market to grow, the product would have to

cover home and community-based services in a manner that enabled insurers to

effectively manage what were viewed to be the primary risks of the product: adverse

selection and moral hazard. This was accomplished in part by changing the basis on

which benefits were paid from a medical necessity model to a functional and cognitive

impairment model. There had been a growing realization, encouraged by professionals

with geriatric experience who entered the industry or consulted with it, that measures of

functional abilities were most closely related to the need for covered services --

including home care.

In the mid to late 1980s and early 1990s, carriers began to provide limited

coverage for home and community-based care -- either through riders or as part of the

underlying basic policy design. They felt comfortable doing so because access to

insurance benefits was made contingent on an insureds inability to perform a certain

number of ADLs or the need for assistance due to a severe cognitive impairment.

These were more easily measurable and predictable benefit eligibility criteria. Also, a

number of third party assessment companies entered the market to assist insurers in

evaluating whether such deficits existed. It is not surprising, therefore, that consumer

demand, coupled with the sense that companies could manage the underlying risk,

fueled rapid growth in market share of comprehensive policies. This is clearly displayed

in Table 2, which highlights the changes in product design over the past 20 years.

TABLE 2. Characteristics of Policies Selling in the Market: 1990-2010

Policy Characteristics

Average

for 1990

Average

for 1995

Average

for 2000

Average

for 2005

Average

for 2010

Policy Type

Nursing Home-Only

63%

33%

14%

Nursing Home & Home

Care

37%

61%

77%

90%

95%

Home Care Only

---

Daily Benefit Amount for

Nursing Home Care

$72

$85

$109

$142

$153

Daily Benefit Amount for

Home Care

$36

$78

$106

$135

$152

Nursing Home-Only

Deductible Period

20 days

59 days

65 days

80 days

85 days

Integrated Policy

Deductible Period

---

46 days

47 days

81 days

90 days

Nursing Home Benefit

Duration

5.6 years

5.1 years

5.5 years

5.4 years

4.8 years

Inflation Protection

40%

33%

41%

76%

74%

Annual Premium

$1,071

$1,505

$1,677

$1,918

$2,283

SOURCE: LifePlans analysis of 8,099 policies sold in 2010, 8,208 policies sold in 2005, 5,407 policies

sold in 2000, 6,446 policies sold in 1995 and 14,400 policies in 1990. Reported in: Who Buys Long-Term

Care Insurance in 2010-2011? A Twenty-Year Study of Buyers and Non-Buyers (in the Individual Market),

AHIP, 2012.

Coverage limited to nursing home or institutional alternatives only has virtually

disappeared from the market. Deductible periods have increased and are roughly equal

to three months of care. Moreover, the percentage of individuals purchasing some level

of protection for increasing LTC costs is about three-in-four with roughly half buying

compound inflation protection.

The average daily nursing home benefit has increased significantly over the period

-- by an annual rate of roughly 4%. Given the mix of home care and nursing home

service use, this is roughly in line with the rate of inflation in these services over the

period; the $153 daily benefit amount in 2010 would cover 70% of the average daily

cost of nursing home, 155% of the daily cost of assisted living, and roughly eight hours

of home care a day seven days a week.

Over the period, there has been a decline in

the number of policies with unlimited benefits, a particularly risky policy design, given

the uncapped liability faced by the insurer. The desire of companies to move away from

this policy design stems in part from pressure by ratings agencies and fewer

reinsurance options.

It represents one of a number of actions insurers have taken to

“de-risk” the product.

Finally, annual premiums have increased significantly over the period, as policy

value has increased and as insurers have a body of credible experience on which to

make changes to a number of key underlying pricing assumptions. Clearly new policies

reflect a more conservative set of pricing assumptions, especially with respect to

interest rates and voluntary lapses. This will be discussed in more detail in a

subsequent section.

2. Marketing and Sales

Like other types of insurance, LTC insurance is sold in a variety of ways and

through a number of distribution channels. Most policies are sold by agents and

brokers directly to individuals. The distribution channel which is growing the most

quickly, however, is the employer group market. Here agents are able to market and

sell group policies to a large number of individuals, each of whom receives an individual

certificate of insurance under a group plan. In 2000, new individual sales accounted for

75% of the market and group sales -- primarily employer-sponsored -- represented only

25% of new sales. By 2010, new individual sales had fallen to 58% of the market and

group channels comprised 42% of new sales.

20,21

While most agents are independent -- this indicating that they can represent and

sell policies from a variety of insurers -- a number of companies do have what are called

“captive agents”. In these companies agents can only sell that company’s specific

policy. Only a very few companies have specialist LTC agents, whose sole focus is

selling LTC insurance policies. Currently there are fewer than 10,000 agents selling any

meaningful number of policies.

Commissions for LTC insurance tend to be “heaped”. This means that first-year

commissions relative to premiums are high -- 40%-60% of premium with some

companies approaching 100% -- and then they tend to drop down to between 5% and

Market Survey of Long-Term Care Costs (2010). The 2010 MetLife Market Survey of Nursing Home, Assisted

Living, Adult Day Services, and Home Care Costs. MetLife Mature Market Institute.

Moody’s: Long-Term Care Insurers Face Uncertain Future (2012). Moody’s Investor Service, Global Credit

Research, New York, NY. September 19.

Cohen, M. (2011). Financing Long-Term Care: The Private Insurance Market. Presentation to the National

Health Policy Forum, Washington, DC. April 15.

It is important to note that a number of companies exiting the market have transferred their group business to

other carriers and in some cases this may be counted as a “sale”, even if individuals purchased their coverage years

beforehand. Thus, some of the 42% of new sales could have been comprised of such takeover activity, which was

particularly prevalent in 2010-2012.

15% of ongoing renewal premiums.

This compensation structure does cause

significant first-year cash flow challenges for companies. Moreover, it delays the timing

of profit emergence as companies may be in a loss position for the first year after a

policy is sold.

The 1990s were characterized by companies competing for the allegiance of large

distribution forces by paying higher commissions to attract and encourage them to

represent and sell their, rather than competitors’, policies. This led to a situation where

the costs of the product increased and market share shifted rapidly between companies

as agent groups focused on selling the product that paid the highest commissions. The

higher commissions did not appear to draw enough new agents into the market to

effectively increase overall market size significantly over the past decade.

It is often said by industry participants that LTC insurance is not “bought” by

consumers, but rather, it is “sold” to consumers. Challenges related to individuals’ lack

of understanding about future risk, an incorrect belief that government will pay for LTC,

confusion about products, belief that other products already address the risk, its cost in

relation to the value that people believe it has, and a lack of belief in the underlying

value proposition have all contributed to the overall challenge of growing the market.

23,24

Even in the presence of such challenges, however, two-thirds of surveyed individuals

from the general population age 50 and over in 2010 indicated that they were aware of

companies that offer this insurance, and about 40% had been approached or had

considered purchasing it.

It often takes agents 2-3 visits to close a sale. Still agents are critical in the

process and are viewed very positively by buyers; in a study of buyers in 2000, more

than 90% reported that the agent they had dealt with was knowledgeable, explained the

product well, and helped them select a policy that met their needs. Moreover, after a

spouse, agents were seen to be the most important in individuals’ decision to purchase

a policy.

In terms of overall sales and market penetration, the first half of the 1990s

represented the fastest growth over the 20 year period and coincided with the

proliferation of policies covering home care and nursing home care. The precipitous

Note that for life insurance first-year commissions are commonly above 100% and the dollar value of annuity

commissions is often greater than the value of LTC commissions. Thus, LTC commissions are not out of line with

other voluntary insurance products.

Stevenson, D., Cohen, M., Tell, E. and Burwell, B. (2010). The Complementarity of Public And Private Long-

Term Care Coverage. Health Affairs, 29:1. January.

Brown, J.R., Coe, N.B., and Finkelstein, A. (2007). Medicaid Crowd-Out of Private Long-Term Care Insurance

Demand: Evidence from the Health and Retirement Survey. In J.M. Poterba, Ed., Tax Policy and the Economy, Vol.

21, pp.1-34.

Based on analysis of 500 individuals age 50 and over surveyed in 2010, 2005, and 2000 as well as 1,000

individuals age 55 and over surveyed in 1995 as reported in Who Buys Long-Term Care Insurance in 2010-2011? A

Twenty-Year Study of Buyers and Non-Buyers (in the Individual Market), AHIP, 2012.

Long-Term Care Insurance 2000: A Decade of Study of Buyers and Non-Buyers. The Health Insurance

Association of America, July 2000.

decline in sales in the early part of this century coincides with a growing number of

companies exiting the market, the general declines in the stock market which affected

demand, and the significant price increases in new policies offered by insurers.

Figure 4 shows sales patterns for new individual policies over the past 20 years.

FIGURE 4. New Sales of Individual Policies

(thousands)

SOURCE: LifePlans analysis based on AHIP, LIMRA and LifePlans sales surveys, 2011.

Clearly, as policies became more attractive to consumers in the 1990s, the market

grew significantly both in terms of covered lives and insurance premium. It is also worth

noting that during the 1990s, there were minimal changes in the underlying pricing

assumptions of policies. In fact, between 1990 and 2000, the average value in policies

-- as measured by changes in average value of policy benefits -- increased more quickly

than the average premium during the period.

This trend foreshadowed a later criticism

and concern with LTC policies expressed by ratings agencies that early designs of

policies offered benefits that were too generous relative to factors like actual benefit

utilization.

29,30

Note that the decline in sales in 1994 coincided with the Clinton health care reform debates which included

provisions for expanded home and community-based care. This was seen to depress demand as potential buyers

waited to see whether or not the legislation would pass.

Authors calculations based on policy design data from more than 10,000 policies in 1990, 1995 and 2000 as

reported in Who Buys Long-Term Care Insurance in 1994? Profiles and Innovations in a Dynamic Market (2005).

Health Insurance Association of America, Washington, DC, and Who Buys Long-Term Care Insurance in 2005? A

Fifteen Year Study of Buyers and Non-Buyers (2006). America’s Health Insurance Plans, Washington, DC.

Bazer, L. (2012). An Outsiders View: The State of the LTCI Industry--Long Term Care from a Rating Agency

Perspective. Presentation at the 12th Annual Intercompany Long Term Care Insurance Conference, Las Vegas,

March. Moody’s: Long-Term Care Insurers Face Uncertain Future (2012). Moody’s Investor Service, Global

Credit Research, New York. September 19.

Figure 5 shows that in 2010, the total number of individuals with LTC insurance

coverage was 7.3 million. This does not represent all people who have ever had

policies, only those who still have them. Changes in covered lives reflect both growth in

annual sales as well as changes in the number of policyholders who maintain their

coverage over time.

FIGURE 5. Number of Insured Lives Covered by Year

(thousands)

SOURCE: NAIC Experience Reports, 2011.

Figure 6 shows the annual change in covered lives over the period. As shown,

between 1992 and 2000 there was tremendous variation in the growth rate of covered

lives and after 2003, there has been a relatively steady yet small annual increase in

covered lives. Given the aging of the individuals with policies, this suggests that the

growth in sales throughout the decade has declined or been relatively flat.

30 Meyer, D. (2012). Why Get in? Why Get out? Ratings Agency Perspective on Long-Term Care. Fitch

Ratings, presentation at the 12th Annual Intercompany Long Term Care Insurance Conference, Las Vegas, March.

FIGURE 6. Annual Growth in Total Covered Lives

(thousands)

SOURCE: LifePlans analysis of NAIC data, 2010.

3. Risk Management

For first generation policies sold in the 1970s and 1980s, insurers were convinced

that because nursing homes were viewed as places of last resort to receive care, there

would be little moral hazard because it was well known that most people viewed nursing

home residency as a “dreaded event”. Not surprisingly, little attention was paid to

underwriting and claims management for these early policies. So long as an applicant

was not already in a nursing home, they could apply for coverage and would likely be

issued a policy. Given that the average age of new buyers at the time was 68, most

carriers still expected to see significant claims activity only 10-15 years in the future.

As companies began to market and sell comprehensive coverage they well

understood that the aversion to using nursing homes was no longer an impediment to

moral hazard; hence, companies felt a need to invest in more robust approaches to

managing the two primary risks associated with product performance that were

completely under their control: underwriting to guard against adverse selection, and

claims management, to protect against moral hazard.

In the early 1990s, insurers began to employ more vigorous approaches to the

underwriting of policies; these approaches focused on two broad dimensions: (1)

medical criteria; and (2) tools and requirements gathering. Regarding medical criteria,

the three domains on which companies focused their attention were the medical,

functional, and cognitive status of individuals. Risk managers tried to better identify

factors that put the individual at immediate or near term need for the services that were

being insured for, namely, human assistance required to compensate for an individual’s

inability to perform ADLs due to functional deficits or to cognitive issues. Diagnoses

were viewed as markers for current or future manifestations of functional need. Data

mining, as well as more comprehensive reviews of the medical literature resulted in the

development of detailed medical underwriting guides by companies. The information in

these guides was considered proprietary, since the ability to perform more effective risk

selection was seen as a competitive advantage for a company. At the same time,

cognitive testing was adopted in the early 1990s and became a standard business

practice. The availability of third party assessment companies serving the industry

significantly enhanced the ability of insurers to perform their risk management functions

both for underwriting and for claims management.

Companies also invested in more robust information gathering. The most common

tools included information provided from the application, telephone interviews, medical

records or attending physician statements, medical exams, in-person assessments and

pharmacy databases. Many of these tools are in use today. An analysis of underwriting

practices across the industry suggested that over the last decade, as companies have

been able to link their up-front underwriting strategies with back-end claims experience,

there has been a marked shift toward more conservative underwriting practices.

2009, underwriting rejection rates across the industry were at 19.4%. For applicants

under age 45, declination rates are below 10% whereas for those over age 80, rates

increase to more than two-in-five.

Regarding claims, insurers focused on managing three major types of risks

associated with a claim: (1) the incidence risk, which is the risk that someone becomes

disabled and requires LTC services covered by the policy; (2) the intensity risk, which

focuses on the level of service and associated expenditure required to compensate for

the individual’s functional or cognitive deficits; and (3) the continuance risk, the amount

of time that an individual would require paid services. Companies typically deploy --

through third party vendors -- nurses into the homes of claimants to measure whether

the benefit eligibility trigger has been met and these same nurses are also involved in

the development of care plans. These benefit assessments are fairly standard across

the industry, especially when someone is claiming home care or assisted living benefits.

For nursing home care, many companies rely on nursing notes or the Minimum

Dataset Survey to obtain the information necessary to adjudicate a claim. The latter is

an assessment that must be completed on all nursing home residents. Companies also

conduct regular follow-up with claimants to assure that they remain eligible for benefits

under the terms of the insurance contract. Over the last decade insurers have invested

significant resources into claims management systems and are far more active in terms

of helping claimants navigate the LTC system and get services in place.

Tolerating Risk: A Look at LTC Underwriting Strategies. Behind the Data, Issue 2, January 2011. LifePlans,

Inc., Waltham, MA.

Ibid.

U.S. Department of Health and Human Services, Office of Disability, Aging and Long-Term Care Policy (2008).

Private Long-Term Care Insurance: Following an Admission Cohort over 28 Months to Track Claim Experience,

Service Use and Transitions. Final Report. Washington, DC. April.

http://aspe.hhs.gov/daltcp/reports/2008/coht28mo.htm.

This investment is clearly warranted given the rapid growth in claims payments.

Figure 7 shows the growth in new claims over the period. The average growth in

annual incurred claims over the period is 13%. Although not shown in the figure,

through 2010, companies reported paying out on a cumulative basis over the last two

decades slightly less than $50 billion in incurred claims; on an annual basis, the liability

covered from private LTC insurance is roughly $6 billion, which is less than 5% of total

expenditures on LTC services in the United States.

FIGURE 7. Industry-Wide Actual Annualized Incurred Claims

SOURCE: NAIC Experience Reports, 2011.

NOTE: The growth in incurred claims in and of itself does not translate to underlying profitability

or performance for the industry, nor does its relationship to changes in earned premiums (which

are not shown in Figure 4) relate directly to profitability. Profitability is related in part to the actual

relationship between claims and premiums over the life of a policy.

4. Consumers of Long-Term Care Insurance

Roughly seven million individuals have a LTC insurance policy. The LTC

Financing Strategy Group estimated that penetration among individuals who are

considered to be suitable purchasers (i.e., have incomes in excess of $20,000 and are

not currently eligible for Medicaid) is 16% of the over age 65 group and about 5% of the

age 45-64 age group.

The profile of individuals purchasing LTC insurance has

changed dramatically over the last 20 years. As products have become more

comprehensive and costly, the proportion of middle income buyers of insurance has

declined. Table 3 summarizes key characteristics of buyers in the individual market.

The average age of buyers continues to decline, and most purchasers are working,

married college-educated and have significant levels of income and assets. In the

group market, the average age is roughly 46 years. Not shown in the table is the fact

that most people purchase the insurance to protect current consumption patterns (e.g.,

LTC Financing Strategy Group, 2008. Washington, DC.

maintain standard of living, avoid dependence, maintain affordability of services) rather

than to protect assets.

TABLE 3. Characteristics of Individual LTC Insurance by Purchase Year

Socio-Demographic

Characteristics

1990

1995

2000

2005

2010

Average Age

70 and over

42%

49%

40%

16%

Percent Female

63%

61%

55%

57%

54%

Percent married

68%

62%

70%

75%

72%

Median Income

$27,000

$30,000

$42,500

$62,500

$87,500

% Greater than $50,000

21%

20%

42%

71%

77%

Median Assets

N.A.

$87,500

$225,000

$275,000

$325,000

% Greater than $75,000

53%

49%

77%

83%

82%

Percent College-Educated

Percent Employed

N.A.

23%

35%

71%

69%

SOURCE: Who Buys Long-Term Care Insurance in 2010-2011? A Twenty-Year Study of Buyers and

Non-Buyers (in the Individual Market), AHIP, 2012.

One of the ways policymakers have worked to expand the private insurance

market to reach middle income adults is to support Partnership Programs. These

programs -- which represent a partnership between state Medicaid programs and the

private insurance industry -- are designed to enable individuals who purchase qualified

LTC insurance policies to access Medicaid benefits without having to spend down their

assets to Medicaid levels, if and when their LTC insurance benefits are exhausted. A

growing number of states -- upwards of 45 by the end of 2012 -- have implemented

such programs.

Even so, few people age 50 and over -- less than 25% -- actually

know whether or not their state has a Partnership Program. However, the Program

does hold appeal: fully 45% of a random sample of individuals over age 50 indicated

that they would be likely to purchase a policy if their state participated in a Partnership

Program.

For individuals who have been approached by agents and choose not to buy a

policy, most cite cost as the primary impediment to purchase. Other far less prevalent

reasons typically include the difficulty of choosing a policy, a lack of confidence in

insurers to pay benefits as stated, and the desire to wait to see if better policies come

on the market.

5. Regulatory Framework and Public Policy

The first reported interest in developing a regulatory framework for private LTC

insurance was in 1985 when a series of conferences between legislators, regulators

and industry representatives were held; there was also growing interest in Congress in

Authors’ analysis of data summarized in AHIP Study of Buyers and Non-Buyers of Private LTC Insurance in

2010, Washington, DC.

Website on Partnership Programs: http://w2.dehpg.net/LTCPartnership.

Who Buys Long-Term Care Insurance in 2010-2011? A Twenty-Year Study of Buyers and Non-Buyers (in the

Individual Market), AHIP, 2012.

Ibid.

the area of nursing home insurance.

As a result of a sustained effort, NAIC adopted

the first Model Act in December 1986, followed by the first model regulation in 1987.

Many states adopted these model regulations. In fact, by 1989, more than two-thirds of

states had adopted the NAIC model act and/or regulation.

The model regulations

became the reference point for companies developing or modifying policies they were

selling -- or intended to sell -- in the marketplace. The model regulation provides

guidance and requirements related to many issues affecting the product including

capital requirements, pricing, marketing and sales, agent licensing and education, and

consumer protections, to name but a few.

In December 1988, the first attempt aimed at modifying insurance contracts

occurred. The regulation included prohibitions against prior hospitalization

requirements as a condition for receipt of institutional benefits and in 1989, the same

requirement was eliminated for home care benefits. It was not until 1995, however, that

a new section -- Section 27 -- was added to the Act that provided for standards on the

conditions under which insurance benefits would be paid. Regulators, consumer

representatives and the industry expressed widespread support for greater

standardization.

In 1998, the Senior Issues Task Force (which was part of the NAIC) was charged

with the task of reviewing the LTC Insurance Model Act and Regulation for compliance

with the HIPAA of 1996. Among other things, HIPAA set benefit eligibility standards for

tax-qualified LTC insurance policies. The federal requirement -- detailed in Section 213,

7702B and 4980C of the Internal Revenue Code -- was that benefits would be triggered

when the insured could not perform at least two of five ADLs, or had severe cognitive

impairment and six ADLs were specified in the Act. In 2000, an update to the Model

Regulation was completed which added a new section -- Section 28. The purpose of

this section was to assure that standards for qualified LTC insurance policies were

consistent with HIPAA.

Finally, there have been a number of changes at the NAIC level related to the

pricing of policies. Until the early part of this decade, insurers needed to certify that

policies were priced to achieve a 60% lifetime loss-ratio. This meant that at a statutory

interest rate (of 3.5%-4.5% depending on state) the policy had to pay out 60% in

benefits (claims payments) to consumers. As pricing became inadequate and insurers

had to increase rates, insurers had to certify that the pricing took into account

“moderately adverse conditions” and the minimum loss-ratio requirement was removed.

The intent was to assure that companies would not under-price their policies and that

premiums would be more stable over the life of the policy. To this day, the NAIC

remains the focal point for the regulation of LTC insurance.

The passage of HIPAA conferred favorable tax treatment to LTC policies that met

a series of standards set out in the law, the most important of which related to benefit

National Association of Insurance Commissioners (2009). Long-Term Care Insurance Model Act, Legislative

History, 640-21. October.

Ibid, 2009.

eligibility standards. HIPAA clarified the treatment of premiums for qualified plans as

medical expenses for individuals deducting medical expenses beyond 7.5% of their

gross income and by not taxing LTC insurance benefits up to certain limits. In addition

to standardizing policies, the law helped to signal to the market, that LTC insurance was

something that should be considered by the public. It appeared as a line item on every

federal income tax return.

On the other hand, few individuals actually purchasing the insurance would benefit

from the favorable tax treatment. This is because a policyholder would have to have

taxable income, very high medical expenses, and itemize expenses (rather than take

the standard deduction.)

The law did encourage states to begin to provide tax

deductions and exemptions for the purchase of insurance. In fact more than half the

states provide tax incentives for the purchase of LTC policies, and most of these are

linked to qualified policies.

Even so, there is little evidence that such policies have led

to a discernible effect on LTC insurance take-up rates. This is not too surprising given

that the value of incentives is fairly low compared to the costs of the policies

themselves.

There are a number of clear trends in the development of the industry in the 1990s

that laid the groundwork for many of the market exits that occurred in the subsequent

decade. These included the development of more comprehensive policies without

commensurate adjustments to premiums, pressure from agents to add benefit features

that served to confuse consumers and make the purchase decision more difficult, and a

likely underinvestment in risk management given the unknown nature of the morbidity

risk. While there was a rapidly developing regulatory infrastructure, many insurers felt

that the NAIC model act imposed requirements that added to the cost of the product

without a commensurate level of actual consumer benefit. Finally, tax benefits were

considered to be more ephemeral than real and were seen to have little impact on the

overall level of demand. Taken together, these factors all resulted in challenges to the

underlying profitability of the product, which is discussed in more detail below.

6. Long-Term Care Insurance Pricing and Profitability

The issue of profitability is one of many factors relating to why companies entered

the market but it is an absolutely central factor in understanding why many of these

same companies ultimately exited the market. Clearly, there was a belief that LTC

insurance could be priced and managed in a way that assured reasonable returns to

companies. The key drivers of profitability are embedded in the underlying pricing

assumptions used to develop premiums and are a function of company strategies

related to underwriting and claims management, product design, premium structure,

Baer, D. and O’Brien, E. (2010). Federal and State Income Tax Incentives for Private Long-Term Care Insurance.

AARP Public Policy Institute. Washington, DC.

Stevenson, D., Frank, R. and Tau, J. (2009). Private Long-Term Care Insurance and State Tax Incentives.

Inquiry 46:305-321. Fall.

Wiener, J.M., Tilly, J., and Goldenson, S.M. (2000). Federal and State Initiatives to Jump Start the Market for

Private Long-Term Care Insurance. Elder Law Journal 8(1):57-99.

inflation adjustment rates, sales and marketing costs and investment strategies. Table

4 shows the key assumptions underlying the pricing of LTC insurance.

TABLE 4. Key Pricing Assumptions in Developing LTC Insurance Premiums

Pricing Parameter

Description

Typical Assumptions

Morbidity

The claims that are expected to be paid out

based on the specific benefit design of the

policy.

SOA Experience reports

National public data sources

Insured Experience.

Mortality

The underlying mortality table employed to

determine how long individuals who have

policies are expected to live and pay

premiums and collect benefits.

Annuitant mortality tables (e.g.,

1994, 2000).

Interest Rate

Because the product is level-funded, there is

a great deal of pre-funding occurring at early

durations of policy ownership and this is the

rate or return assumed on invested premiums

and risk-based capital (RBC).

1990s: 5% - 8%

2000s: 3% - 5%

Current: 2% - 4%

Voluntary Lapse

Rates

Not all individuals will hold their policies until

death. For a variety of reasons people may

cease paying premiums. High voluntary

lapse rates lead to lower premiums because

premium reserves from a lapsed policy are

retained by the company without related

future claim expenses.

1990s : 8% first year declining

to 4%

2000s: 6% first year declining

to 3%

Current: 4% first year declining

to 0.5%

Underwriting

Selection Effect

A group that is underwritten tends to be

healthier than a non-underwritten group and

this has a positive impact on the morbidity.

Claims reductions factors

typically wearing off within 5-7

years of policy issue.

Acquisition Costs

and Administration

These are the costs associated with

“producing” and servicing the policy and

include marketing and sales expenses

(commissions), underwriting, claims

management, ongoing policyholder billing

and premium collection and other

administrative expenses.

Sales costs typically greater than

60% of first year premiums and

then leveling out at lower levels.

Ongoing policyholder

administration and claims

management as a fixed per

policy fee or percent of premium.

Profit

This is the amount of load or additional

charge put into the product to assure an

adequate return for the insurer.

Profit measures including pre-tax

profits, post-tax profits, internal

rate of return (IRR), pricing to

lifetime loss-ratio.

Small variations in actual experience compared to expected performance of each

of the pricing assumptions can have a major impact on product profitability. In order to

demonstrate this, we developed a LTC insurance pricing model that allows us to

evaluate the impact of small changes in various pricing assumptions on overall product

profitability. Table 5 shows these impacts. Baseline profitability is defined as the

addition of a 10% margin on the premium that is generated to cover the present value of

all claims and expenses. Thus, the pre-tax profit margin is set at 10% of the premium.

What this model shows, for example, is that if a company assumed that it would be

able to earn 6.5% on its reserves, and instead, earned 5.5%, then depending on age,

premiums would have to increase between 5% and 10% to maintain the initial 10% level

of profitability as defined above. Again, depending on age, if the actual interest rate

earned on reserves was 5.5%, compared to the priced interest assumption of 6.5%,

then the profit margin would vary between 0.5% and 5.2%. This represents declines in

the margin of between 48% and 95%.

TABLE 5. Impact of Alternative Assumptions on Profitability of LTC Insurance

Change in

Profit Margin

(no change

in premium)

Profit Margin

(no change

in premium)

Required Change

in Premium Level

to Maintain

10% Profit Level

Premium

Needed to

Maintain

10% Profit Level

Age

Lapse

Interest

Morbidity

Mortality

BASE CASE

10.0%

$713

Standard

6.50%

Standard

10.0%

$1,379

10.0%

$2,149

-95%

0.5%

10%

$781

Actual

5.50%

Standard

-67%

3.3%

$1,472

-48%

5.2%

$2,252

-208%

-10.8%

21%

$861

Actual

4.50%

Standard

-142%

-4.2%

14%

$1,575

-100%

0.0%

10%

$2,364

-339%

-23.9%

34%

$955

Actual

3.50%

Standard

-224%

-12.4%

22%

$1,688

-156%

-5.6%

16%

$2,485

-492%

-39.2%

49%

$1,064

Actual

2.50%

Standard

-315%

-21.5%

31%

$1,813

-216%

-11.6%

22%

$2,614

102%

20.2%

-10%

$640

Better

6.50%

Standard

75%

17.5%

-7%

$1,276

54%

15.4%

-5%

$2,034

-52%

4.8%

$750

Worse

6.50%

Standard

-39%

6.1%

$1,433

-30%

7.0%

$2,213

90%

19.0%

-9%

$649

Actual

6.50%

Lower

Standard

94%

19.4%

-9%

$1,250

96%

19.6%

-10%

$1,943

-90%

1.0%

$777

Actual

6.50%

Higher

Standard

-94%

0.6%

$1,509

-96%

0.4%

10%

$2,355

22%

12.2%

-2%

$697

Actual

6.50%

Standard

Higher

23%

12.3%

-2%

$1,347

21%

12.1%

-2%

$2,104

TABLE 5 (continued)

Change in

Profit Margin

(no change

in premium)

Profit Margin

(no change

in premium)

Required Change

in Premium Level

to Maintain

10% Profit Level

Premium

Needed to

Maintain

10% Profit Level

Age

Lapse

Interest

Morbidity

Mortality

-25%

7.5%

$731

Actual

6.50%

Standard

Lower

-25%

7.5%

$1,414

-22%

7.8%

$2,196

SOURCE: LifePlans Long-Term Care Insurance Pricing Model, 2012.

Assumptions: 5 year policy; $100/ day; 10% margin; 60% minimum loss-ratio.

Better claims = 10% lower than priced; Worse claims = 10% higher than priced.

Better mortality = 10% higher than priced; Worse mortality = 10% lower than price.

Better lapse = 1 percentage point higher than priced; Worse = 1 percentage point lower than priced & year 7+ ultimate lapse rate of 0.25% versus 0.75%.

As shown, a percentage point difference in the underlying interest rate assumption

has a very major impact on underlying profitability. Moreover, the impact is most

pronounced at the younger ages. As well, even small errors on multiple assumptions

can lead to major changes in the product’s underlying profitability. Finally, the

assumptions are subject to a wide degree of volatility given changes in the provider

landscape, trends in disability rates, macro-economic policy vis-à-vis aggregate interest

rates, and other factors. Thus, it is not surprising that given the level-funded nature of

this product, along with the long-tail morbidity risk, the product is viewed as inherently

more risky than other insurance products, and regulated in a way that requires greater

levels of capital to support it.

Noteworthy is the fact that since the late 1990s, all of these major determinants of

premium and product profitability have been going in the wrong direction: interest rates

are significantly lower than what was priced for, voluntary lapse rates are lower than for

any other insurance product, morbidity is somewhat worse than expected and mortality

is actually improving. For these reasons, the prior decade saw a major exodus of

companies from the market, as returns on the product have been significantly below

expectation. More recently, major ratings agencies have highlighted the poor profit

results of companies and issued reports cautioning about the future of the industry.

C. The Decision to Exit the Market

With few exceptions, most companies that stopped selling LTC policies did so over

the past decade. Table 6 shows the distribution of companies by market exit year. It

shows that more than half of companies in the sample have exited the market (or

specific market segments) in the past eight years. The largest number of companies

exited the market in 2003 and 2010.

There does not seem to be any discernible difference between those companies

that chose to exit the market earlier rather than more recently. Most companies made

the decision to exit the market within a year of considering such a strategy and roughly

a quarter within six months. Thus, once these companies seriously began re-evaluating

the desirability of remaining active in the market, it did not take long for them to make a

final decision to leave the market.

Moody’s Investor Services. (2012). Special Comment: Long-Term Care Insurance: Sector Profile. September 18.

TABLE 6. Distribution of Sample by Year of Market Exit

Year of

Market Exit

Sample

1996

Principal Financial Group

2001

Nationwide

2002

American Fidelity Assurance Company

Standard Life & Accident Insurance Company

2003

American Family Mutual Insurance Company

CNA

Conseco

RiverSource Life Insurance Company

Union Labor Life Insurance Company

2004

Medico

Teachers Protective Mutual Life

2005

Humana Insurance/Kanawha

Transamerica (re-entry 2010)

2006

Aetna

Southern Farm Bureau Life

2008

Penn Treaty

2009

UNUM Individual

2010

Allianz

CUNA Mutual

Equitable

Great America Financial

John Hancock (group market)

MetLife

2011

Guardian--Berkshire

2012

Prudential, UNUM Group

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment

of the market and analysis of NAIC Experience Exhibit Reports from 2000, 2009, 2010 and

2011

We asked executives to highlight all of the reasons why the company left the

market (Table 7) and the single most important reason for doing so (Figure 8). In broad

terms the reasons can be related to profit, risk, internal management, sales and

distribution, public and regulatory policy, or other issues posing challenges to

companies.

As shown, product performance, that is, not hitting profit objectives was the most

cited reason for leaving the market. Incorrect assumptions about two underlying pricing

assumptions -- voluntary lapses and interest rates -- have had a lot to do with this and

have been key drivers behind the need of many companies to increase rates on

products. The concern about the ability to obtain needed rate increases from state

insurance departments was the second most cited reason for market exit. Slightly more

than half of respondents also cited high capital requirements as a reason for exiting the

market. It is noteworthy that only a single company cited an unfavorable public policy

environment specifically as a reason for exiting the market.

TABLE 7. All of the Reasons Cited for Exiting the Market

Reasons

Percent

Responses

Profit Issues

Product performance--not hitting profit objectives

69%

Product performance not hitting profit objectives

quickly

High capital requirements

54%

Risk Issues

Concern about ability to get rate increases if

necessary

62%

New evaluation/assessment of the risk of product

and market

50%

Lack of confidence in ability to manage risk

42%

Could not get reinsurance or partner with whom to

share risk

19%

Internal Management Issues

Reputation Risk

23%

Pressure from Rating Agencies

23%

Pressure from Board of Directors

New Senior Management not interested in the

product

39%

Sales and Distribution Issues

Too difficult to sell (consumer-related)

27%

Distribution issues (agent-related)

23%

Intense competition

15%

Regulatory/Public Policy Issues

New regulatory requirements

19%

Unfavorable public policy

Other (please specify)

50%

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment

of the market.

Figure 8 highlights the point that a high capital requirement to support the product

was cited most frequently as the most important reason for market exit. Product

performance is the second most cited reason. Some of the other reasons cited include

a concern that a continued focus on LTC insurance detracted from other core products,

that tax qualification guidelines inhibited certain innovative product designs, and others.

In terms of classifying these reasons into major categories, slightly less than half are

related to profitability, about a quarter to risk issues and a quarter split out across the

other reasons.

It is important to note that some of the reasons -- particularly those related to

changes in the outlook of upper management -- are likely “intermediate” factors. That

is, if senior management wanted to exit the market, it was likely related to the fact that

business objectives were not being met, or they had a different evaluation of the risk,

etc. In some cases, it likely required a new CEO to take a fresh look at the business

which led to a market exit.

FIGURE 8. Single Most Important Reason that the Company Left the Market

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment of

the market.

Concerns related to capital requirements and rate increases may represent

something unique about the structure and regulatory requirements relating to LTC

insurance that have a major impact on profitability. LTC insurance is a guaranteed

renewable product which means that as long as an individual pays premiums, the

insurance company must continue to honor the coverage. Premiums are not

guaranteed, although they are designed to be level-funded over the life of the policy.

This means that if the actual experience of any of a number of underlying pricing

assumptions (claims, interest rate, mortality, voluntary lapse rates, etc.) varies from

what was anticipated, the financial viability of the product can be threatened, unless

there is an adjustment to rates.

Rate adjustments can only occur with the permission of individual state insurance

departments. Rate increases would typically be sought for policies that have been in

the market for enough time to gain credible experience. This means that policyholders

would typically be older and more likely to be on fixed incomes at the time that a

company might be seeking a rate adjustment. Given the sensitivity around increasing

rates for older policyholders, it is not surprising that companies are concerned about

their ability to raise rates; in fact, many companies have experienced significant

challenges obtaining the level of rate increases that they request, even when such

increases may be actuarially justified. For example, a company may request (and

require) a 35% rate increase, yet be allowed to adjust premiums by only 15%. This

does not mean that regulators have ignored requests for rate adjustments. With few

exceptions, most companies have increased rates on some if not all of their policy

series, and clearly the increases have been significant.

The failure to hit profitability targets as a reason to leave the market was pervasive

in the interviews with executives. Therefore it is important to understand what is meant

by profitability and how it is measured in evaluating the success of a product. Profit can

be defined differently by companies and the application of various standards affects

premium levels. Some of the more common profit standards include: (1) a pre-tax

measure (e.g., 10% of gross premium); (2) a post-tax measure (e.g., 5% of some level

of the RBC allocated to support the product); (3) pricing to a specific lifetime loss-ratio

standard (e.g., 60% at a conservative earnings or interest assumption); or (4) an IRR

(e.g., 15%). Even when all other assumptions are held constant, use of an alternative

profit standard can yield significant differences in premiums. For example, for a 62 year

old, everything else held constant, using a 10% pre-tax standard compared to a 15%

IRR calculation leads to a premium that is roughly 10% lower.

The post-tax profit

measure focuses on a target rate of return on RBC -- which is the level of capital that a

company is required to allocate to support the product.

The calculation behind the level of capital required to support insurance products

was set by the Risk-Based Capital for Insurers Model Act which went into effect in

1992/1993 for life and health companies. A company’s RBC is monitored by both state

regulators and A.M. Best or other rating agencies. State regulators use an RBC model

that is developed and maintained by the NAIC. The purpose is to require companies to

measure their capital allocation compared to a standard risk-based calculation of

needed capital.

In essence, the idea is to determine the minimum capitalization that is

appropriate to a company’s risks. While the exact formula will depend on the specific

type of insurance, in general there are four risk areas that are typically considered: C1 is

credit risk; C2 is pricing risk; C3 is interest rate risk, and; C4 is other business risks.

The key risks that are the focus of LTC insurance include C2 and C3.

At the core of the NAIC model is a formulaic approach to developing a “Company

Action Level (CAL)” of capital and then generally relating actual capital to this CAL. For

example, if a company’s CAL is $100M and its actual capital is $400M it would have a

400% RBC ratio. Regulators monitor this ratio and various actions generally result if

this ratio falls below certain target levels.

For many years, the RBC level on the C2

(i.e., pricing risk) had been to establish a level equal to 5% of claim reserves, plus $25

million of the first $50 million in premiums and 15% on all additional premium beyond

that. The formula now reflects a lower percentage (10% instead of 25%) applied to

California Department of Insurance Website relating to rate histories of LTC insurance companies.

http://www.insurance.ca.gov/0100-consumers/0060-information-guides/0050-health/ltc-rate-history-

guide/index.cfm.

Helwig, D. (2005). The Basics of Long-Term Care Insurance, New Orleans Life Spring Meeting, May 22-24,

Record, Volume 31, Number 1, Society of Actuaries.

Meilender, B. (2003). Risk Based Capital, 2003 Valuation Actuary Symposium, San Diego, CA. September 11-

12, 2003. Session 37 PD, Society of Actuaries, 2004.

Charsky, D., FSA and Nelson, R., FSA (2012). Personal Communication. December 28.

premiums and an additional component related to claims. The intent was to hold higher

levels of RBC as claims increased and to match the level of required capital to the

actual pattern of risk in the product.

Again, the capital requirements for LTC insurance are high relative to other

products such as health and life insurance. High capital requirements are due to the

long-term nature of the coverage and other “unknowns” which make the product

inherently more risky. Thus, the actual required capital is very high per dollar of earned

premium or reserves because of the perceived product risk, the long-term nature of the

guaranteed renewable coverage, and the fact that rating action impacts are muted as

policyholders continue to age.

Also, and in particular, with respect to policies with

inflation protection, the capital strain is often large in the early years of a policy because

sales commissions, underwriting and issue, taxes, and administrative expenses are

large relative to earned premium. For that reason, it is not uncommon for companies to

show financial losses in the first 2-3 years after a policy is sold and then show ever

increasing reserves for many years and continued losses. While claims may be low

during these initial years, expenses are high and for inflation policies, reserves high.

Thus, at the very least, for the product to be profitable over its lifetime, it must generate

returns that take account of the initial 1-3 years of expense-associated losses.

FIGURE 9. Moody’s Yield on Seasoned Corporate Bonds--All Industries, AAA and

Ten Year U.S. Treasury Note Yield Rate

Personal communication with Don Charsky, FSA President of Ability Re and Ray Nelson, FSA Senior Actuary at

Ability Re.

This would not be a major issue if the actual or expected returns on capital were

strong. However, that has rarely been the case. In addition to voluntary lapses being

lower than anticipated (resulting in premiums being lower than necessary), interest rates

have also been lower than anticipated, resulting in earnings on invested reserves that

are lower than anticipated. More specifically, an analysis of rates of return on Triple A

(AAA) corporate bonds and U.S. Treasure Notes over the last two decades highlights

why so many companies exited the market in the last 7-10 years -- yields on both types

of investments have experienced very major declines.

Between 1992 and 2002,

yields on Corporate Bonds were typically above 6.5% whereas in 2003, they began a

precipitous decline such that by 2010, they had fallen to below 5%. For Treasuries,

yields dropped to below 4%. The vast majority (85%) of companies that exited the

market did so from 2003 through 2010, which correlates closely to this decline in yields.

In addition to absolute declines in returns on invested capital, when carriers point

to required capital as a reason for exiting the market, they are also viewing constrained

capital in light of expected returns from other lines of business. If profits do not emerge

at either the rate or levels expected, then economic pressures will lead companies to

allocate such capital to products offering higher returns. The high “hurdle rate” needed

to justify the allocation of capital to the LTC insurance product line is particularly

sensitive to the interest rate environment, given the level-funded nature of the product.

While for most companies the primary motivations for leaving the market were

related to high capital requirements and the seeming inability to meet profit objectives,

many factors converged and played a role in the decision. Some of these were related

to challenges around marketing and sales, risk management strategies, regulatory

policy, the lack of reinsurance coverage and others. Executives were asked to indicate

whether a specific factor “Strongly influenced the decision to leave the market”,

“Somewhat influenced the decision to leave the market” or “Did not influence the

decision to leave the market at all”. Table 8 on the following page summarizes results.

There are a number of important points to be made about the data presented in

Table 8. First, consistent with prior results, the factors cited most often as having the

strongest influence on the decision to exit the market included high capital requirements

and pressure to reallocate capital to other more profitable business lines due to

profitability challenges. As well, roughly one-in-three respondents indicated that the

level-funded nature of the product made it particularly susceptible to investment risk

(i.e., interest earnings), and there were few ways to successfully mitigate this risk.

Note that not all companies hold assets in AAA bonds, but many of them do. In general and across various asset

classes in which companies typically invest, returns have declined over the period.

TABLE 8. Factors Influencing the Decision to Exit the Market

Factor

Strongly

Influenced

the Decision

Somewhat

Influenced

the Decision

Did Not

Influence

the Decision

Marketing and Sales

The required commission schedules to

attract agents made the product very

expensive.

---

19%

81%

It was difficult to recruit agents to sell the

product.

84%

The amount of agent training required by

regulations was excessive.

84%

LTC insurance was too difficult to sell.

15%

77%

Marketing of and education about the

product became too costly.

---

15%

85%

Risk Management

Finding experienced actuaries became

difficult.

12%

80%

Finding underwriters and claims

adjudicators who knew about LTC

insurance risk became difficult.

---

15%

85%

Underwriting and claims management

tools were not adequate to manage the

risk.

---

19%

81%

In a rapidly changing service environment

it became difficult to enforce original

provisions of the policy.

---

24%

76%

Denying claims became too much of a

reputation risk.

---

11%

89%

It became too difficult to mitigate

investment risk.

28%

24%

48%

There was too much bad publicity

regarding rate increases.

---

27%

73%

The costs associated with managing the

product became too high.

15%

43%

42%

Morbidity was worse than expected.

---

50%

The incidence of fraudulent claims was too

high.

---

92%

Regulatory Policy

Regulations encumbered product

development/innovation and sales.

15%

70%

Regulations encumbered the ability to do

adequate risk management.

27%

35%

38%

The cost of regulatory compliance became

too high.

15%

19%

66%

State insurance departments would not

approve necessary rate increases (at all or

in a timely manner).

23%

31%

47%

We were concerned that the NAIC or state

insurance department would pass a model

regulation that would be applied to policies

retroactively.

12%

19%

69%

Availability of Reinsurance

It was difficult to acquire high value

reinsurance coverage.

15%

31%

54%

Requirements of the reinsurer were too

stringent for us.

15%

12%

73%

TABLE 8 (continued)

Factor

Strongly

Influenced

the Decision

Somewhat

Influenced

the Decision

Did Not

Influence

the Decision

Capital Costs and Profits

Capital requirements became too high

50%

15%

35%

High capital costs caused constant

pressure to reallocate capital to products

with more rapidly emerging profits

31%

12%

58%

Emergence of profits was too slow

35%

15%

50%

Level funding made the product too

dependent on interest earnings

35%

31%

34%

Other Factors

We were concerned that a negative rating

on LTC insurance business would

negatively affect other business lines

23%

38%

39%

Public policy was unsupportive of the

product

---

15%

85%

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment

of the market.

Second, issues relating to marketing and sales were not cited frequently as having

a major or even moderate influence on the decision. Third, finding skilled staff for

underwriting, claims and actuarial analysis has not played much of a role in the decision

nor have issues related to enforcing policy provisions in the context of a changing

provider landscape. In contrast, half of respondents indicated morbidity experience was

worse than they had anticipated and this influenced their decision to exit the market. On

a cumulative basis, most of these companies actual claims experience was better than

what was anticipated; that is, the actual-to-expected loss-ratio was less than 100%.

However, more recent claims experience suggested that claims costs were increasing

at a rate higher than expected, and that this did not bode well for projected future

profitability. (See Figure 11.)

Clearly, all of the activity related to risk management has costs which must be

absorbed or built into the underlying pricing of the product. As morbidity experience has

deteriorated for a growing number of companies, it is not surprising that companies are

investing significant resources in risk management -- not sales -- activities. Roughly

two-in-five respondents indicated that the costs associated with managing the product

have become too high and this has been one of the factors that has led them to exit the

market.

Regarding regulatory policy, the most cited factors having a moderate influence on

a company’s decision to exit the market have to do with the ability to obtain rate

increases in a timely manner or at all, as well as having the necessary flexibility to

engage in appropriate risk management activities; roughly one-in-three companies

indicated that this had a moderate impact on their decision. The costs of regulatory

compliance and the possibility that such compliance encumbers product innovation

were not seen as factors in the market exit decision.

A number of companies have reinsurance partners that enable them to share or

spread the underlying risks in the product. For some companies, the ability to obtain

reinsurance coverage is a pre-requisite to either entering or staying in the market. For

two of the companies, the difficulty of obtaining such coverage or of meeting the

requirements of the reinsurer proved to be very important to their decision to leave the

market. For roughly one-in-three carriers, the difficulty of obtaining such coverage had

some level of influence on their decision, but it was clearly not a dominant factor. It is

noteworthy that over the last five years the number of reinsurance companies providing

coverage for stand-alone LTC insurance policies has declined and that today, only 1-2

companies provide such coverage. Surveys of executives in these reinsurance

companies suggest that capital requirements and inadequate returns were primary

drivers of their exit from the market as well. The fact that these companies have also

exited the market reinforces findings about the inherent level of risk in the product (as it

is currently configured).

Finally, more than half of companies were concerned that a negative rating on their

LTC insurance business would adversely affect other business lines, and this played

some role in their decision to leave the market. This is because most writers of LTC

insurance are multi-line companies and for the most part this insurance represents a

small component of their overall portfolio. Again, it is worth mentioning that very few

companies felt that an unsupportive public policy played a role in their decision to exit

the market.

In addition to “missing” the interest and voluntary lapse assumptions, another

reason for falling short on profitability assumptions relates to morbidity. Companies

typically focus on two performance measures related to this parameter: the annual and

cumulative loss-ratio and the actual-to-expected loss-ratio. The loss-ratio focuses on

the relationship between claims and premiums and can be viewed on the basis of a

single year (e.g., claims incurred during the year compared to premiums earned during

the year) or on a cumulative basis (e.g., total claims incurred to date compared to total

premiums earned to date). The higher the loss-ratio, the greater are claims in relation

to earned premiums. Over the life of a group of policies, claims payments will ultimately

exceed the amount of annual premium payments; the difference is expected to be paid

for by the reserve that the company sets up. The reserve is funded in large part during

the years where annual premium exceeds the level of annual claims incurred. It is the

excess premium plus the interest earned on that excess premium that funds the future

gap between premiums and claims.

Figure 10 highlights the annual industry-wide loss-ratio as well as the cumulative

loss-ratio.

As expected, claims represent a growing percentage of premium payments over

time. This reflects both the aging of the in-force policyholder base as well as the

wearing off of the underwriting effect on morbidity. The slow-down in sales of new

policies -- with lower initial annual loss-ratios -- also contributes to the rate at which

such ratios are increasing for the industry. The growth in the loss-ratio does not

represent a problem for the industry so long as the premiums collected are sufficient to

fund the expected liabilities priced into the policy. What it does show is how claims are

growing and this is typically compared to what the ratio was expected to be. Thus, the

most important performance measure is whether or not the actual incurred claims by a

company are in line with expected claims paid.

FIGURE 10. Annual and Cumulative Loss-Ratio

SOURCE: NAIC Experience Reports, 2011.

If a company anticipated that during a specific year its incurred claims compared

to its earned premiums would be 50%, and in fact the ratio of incurred claims to

premiums was actually 55%, this would indicate worse than anticipated experience.

The converse is also true: if a company expected to pay out in claims the equivalent of

50% of its earned premium, and instead paid out 45%, this would suggest better than

anticipated experience. An actual-to-expected ratio of 100% suggests experience is

exactly in line with what was anticipated.

The expected claims underlying the pricing in a policy represent the best estimate

for the amount of money that the insurer is going to need to pay out on an annual basis,

given the age, gender, marital status, and health status of policyholders. Typically

companies develop this “morbidity” or “claims cost” curve based on a set of

assumptions related to: (1) the probability of someone becoming disabled in a certain

year (incidence rate); (2) the probability that once disabled, an individual will require

paid care for a certain amount of time (continuance risk); (3) the intensity of care

required while the individual is disabled (intensity risk), and; (4) the level of service cost

in relation to the daily benefit chosen by the individual to pay for care. The claims cost

assumptions are a key input to the overall pricing of the policy -- see Table 4 -- and

once filed with the state, these assumptions become the basis on which reporting and

performance is monitored. If the actual experience does not conform to the initially

priced assumptions, companies can request rate relief from state insurance

departments and they would be required to file a new set of claims assumptions, which

would result in changes to premiums.

Figure 11 shows industry-wide average cumulative actual-to-expected losses

between 1992 and 2009.

FIGURE 11. Industry-Wide Actual Losses to Expected Losses

SOURCE: LifePlans Analysis of NAIC Experience Reports, 2010.

As shown, there has been variability in cumulative industry performance over the

last decade. If we focus exclusively on the last six years, in four of six of these years the

actual-to-expected loss experience has been over 100%; the average ratio over the

past six years has been 102%; this compares to a ratio of 95% in the preceding eight

years. Moreover, given this represents cumulative experience, for the ratio to increase

by three percentage points between 2008 and 2009 suggests that the annual

performance for that year must have been much worse than this.

As mentioned, in 2009 the NAIC changed its reporting format for companies and

experience tracking for the new format. Data in these reports is not directly comparable

to data from earlier reports because certain methodologies had changed regarding

calculation of the actual-to-expected loss percentages. In the context of the new

reporting, and as shown in Figure 12, based on recent data on the annual actual-to-

expected incurred claims, experience over the last three years has been worse than

what was priced for.

FIGURE 12. Industry Actual to Expected Annual Incurred Claims: 2009-2011

SOURCE: NAIC Experience Reports, 2012.

To obtain a summary view of industry change on key market indicators, we present

data from the beginning and end of the decade, including information on market

concentration. As shown in Table 9, market concentration has increased over the

decade, with the top ten companies now accounting for slightly more than two-thirds of

covered lives and the top five accounting for more than half of all policyholders. Given

the recent exodus of additional companies from the market, such concentration is likely

to grow.

TABLE 9. Summary of Key Industry Parameters: 2000-2010

Industry Parameter

2000

2010

Change

Earned Premium

$5,155,000

$10,614,816

106%

Incurred Claims

$1,870,000

$6,350,413

240%

Loss-Ratio

36%

60%

67%

Actual Losses Incurred to Premiums

Earned (%)

34%

42%

24%

Actual losses Incurred to Expected

Losses Incurred (cumulative)

94%

103%

10%

Number of Covered Lives

4,497,120

7,263,283

62%

Industry Concentration: Number of Covered Lives

Top 5

41%

55%

34%

Top 10

63%

69%

10%

Top 15

74%

78%

Top 20

81%

84%

Carrier with Largest Market Share

10%

15%

50%

SOURCE: LifePlans Analysis of NAIC Experience Reports, 2011.

a. The 103% figure is for 2009.

In addition to identifying the motivations for leaving the market, we also asked if

there were specific actions that were taken in support of staying in the market. Figure

13 shows that most companies changed product design and also changed rates on

existing products. As well, more than two-in-five and one-third respectively changed

their risk management techniques and tried new approaches to marketing and sales.

Not shown in the figure is the fact only three of these companies (12%) have not raised

rates on existing policies. For the remainder of companies, roughly two-thirds raised

rates before they left the market. Only three companies left the market because of a

sense that they needed to raise rates and this would make ongoing sales extremely

difficult.

FIGURE 13. Actions taken Prior to Leaving the Market

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment of

the market.

Clearly, these actions represent most of the “levers” that a company can pull to

influence underlying product profitability. We know for example that companies

changed product designs, tightened up their approaches to underwriting and claims

management, and increased premiums. Some of these actions can only influence

performance on new policies issued (e.g., underwriting approach, marketing

approaches, and policy design changes) whereas others can also affect the

performance of older policies (e.g., rate increases and claims management strategies).

Although not explicitly addressed in this study, we also know that the specific

investment strategy vis-à-vis RBC and premium reserves has a major effect on

profitability. While companies have little control over general interest or inflation rates,

there are hedging strategies that can be undertaken to improve product performance.

Such strategies are important because insurers are paying fixed rates on forward

contracts; that is, premiums are received on an ongoing basis and they have to be

invested in assets that mature around the expected payout dates.

This can cause a

mismatch between future cash inflows and outflows because payouts can be influenced

by macro-economic trends that are outside of the control of the carrier.

Although few companies indicated that the need for rate increase activity is what

drove them to leave the market, there was general concern across companies about the

impact that this would have on sales. We asked respondents how concerned they were

with being able to continue selling the product if rates on the product had to be raised.

Figure 14 shows that roughly two-in-five respondents were somewhat or very

Helwig, D., Bhandula, R. and Barrett, N. (2007). Long-Term Care: Hedging Your Bet. Long-Term Care News,

Long-Term Care Insurance Section, Society of Actuaries. December.

concerned, and this had more to do with reputation risk and the impact on consumer

confidence than it did with losing business to a competitor.

FIGURE 14. Level of Concern about Selling the Product if In-force Rates

had to be Raised

SOURCE: Survey of executives from 26 LTC carriers who exited the market or exited segment

of the market.

D. Current Market Activity

Given the dramatic changes in market participation over the last decade, it is

challenging to obtain an accurate count of the total number of companies selling policies

in the marketplace. Some companies report sales of less than ten policies a year and

others show no policies in one year and then a small number of policy sales in a

subsequent year. In the year 2000, AHIP conducted a survey and found that 125

companies were selling policies in the marketplace; by 2002, however, this number had

fallen to 104 -- a 17% decline in just two years.

This survey has not been replicated

since 2002.

Today, the most reliable source of information on company-specific activity is

provided by the NAIC. Their most recent report, published in 2011, focuses on the top

100 companies reporting premium and claims information on any LTC insurance

policies that they have in-force in 2010. The report showed that fewer than 20

companies were actively selling stand-alone LTC policies in 2010; by 2012, only 11

companies were selling at least 2,500 new stand-alone individual or group policies

annually in the marketplace.

53,54

It is important to note that these figures do not include

companies that are selling various combination-products such as Life-LTC or Annuity-

America’s Health Insurance Plans (2004). Long-Term Care Insurance in 2002. Research Findings, Washington,

DC. June.

LifePlans, Inc. (2012). 2011 Long-Term Care Top Writers Survey Individual and Group Association Final

Report, Waltham, MA. March.

This figure is difficult to determine with precision. Broker World estimates that in 2010 there were 25 companies

selling stand-alone policies, but many of these were selling a very small number on an annual basis.

LTC products. These products still account for a very small -- but growing -- part of the

overall market. Some view such combination-products as the wave of the future for the

industry and the most promising way to increase the number of people covered by

insurance. Moreover, given some of the off-setting risks in these products, they may

also exhibit more premium stability over time, thus enhancing their attractiveness in the

market.

During 2012, companies writing at least 2,500 policies include:

Bankers Life and Casualty

Genworth Financial

John Hancock Financial Services (Individual Market)

Knights of Columbus

MassMutual Financial Group

MedAmerica Insurance Company

Mutual of Omaha

New York Life Insurance

Northwestern Long Term Care Insurance Company

Prudential

State Farm

TransAmerica Life Insurance

As of the end of 2011, policy sales for these companies totaled 223,000 which were

below 1990 levels.

Table 10 shows the top ten companies selling individual LTC policies in 1995 and

their status as of 2012.

Noteworthy is the fact that six of the companies are no longer

actively selling policies in the market and three have been acquired by others in the top

ten. Moreover, in 1995 these companies together sold slightly less than 300,000

policies, and by 2011, had experienced a net decline of 43% in annual policy sales.

Other companies include Auto-Owners Insurance Group, Blue Cross Blue Shield of Michigan (LifeSecure),

Country Life, Humana, United of Omaha, and United Security as reported in Brokers World, 2012.

Prudential announced its exit from the individual market but took applications through March 2012 and in July it

announced its exit from the group market but is taking applications through the middle of 2013.

We focus on the individual market due to data limitations associated with group carrier experience in the 1990s.

TABLE 10. Experience of 1995 Top Writers of Individual LTC Insurance in 2011

Company

# Policies

Sold 1995

# Policies

Sold 2011

Exit/

Acquisition Date

Aegon/Transamerica

22,000

7,095

Exited in 2005 and 2010 re-entry

CNA

24,000

Exited individual in 2000 and Group

in 2003 although continuing to take

enrollments on existing groups.

Bankers Life and

Casualty

38,800

10,948

In Market

American Travellers

(Conseco)

51,700

Exited in 1996

Amex/Genworth

58,100

90,190

In Market

IDS

24,000

Acquired by Genworth in 1995

John Hancock

16,700

20,586

In Market (2010 pause in Group

Market)

Penn Treaty

27,400

Exited in 2008

Fortis LTC

18,600

Acquired by John Hancock 2000

Travelers

18,000

Exited in 2000 and reinsured by

Genworth in 2000

Total

299,300

128,819

Currently, individuals with LTC insurance policies are either being serviced by

companies who continue to sell in the market or by those who have exited and are no

longer selling policies. The latter are considered to be in “closed-blocks”.

In order to

determine the size of the closed-block market, we analyzed and updated information

from the 2010 NAIC Experience Exhibit reports. Table 11 shows the current state of the

market for companies that comprise 95% of total market share, and are selling at least

2,500 policies a year. For the purposes of this analysis, we define a company as having

left the market to be one that ceases selling new policies to any part of the market or to

a particular market segment (e.g., group versus individual).

For companies that have

only pulled back from a specific market segment, all reported performance-based data

applies only to that market segment.

In general, company size, product offering, and geographic location do not

differentiate firms that have left the market versus those that have remained. In 2010,

annual premiums for companies still selling policies in the market totaled $5.3 billion

compared to $4.7 billion for those who exited the market and were administering

“closed-blocks” of business -- 53% compared to 47% of the total. On a cumulative

premium basis, however, closed-blocks represented 55% of all earned premiums.

Regarding claims, in 2010, closed-block companies represented 53% and 57% of

annual and cumulative total claims costs. As demonstrated below, just one year earlier,

the picture looked very different.

A “closed-block” means that while policyholders who hold policies continue to receive services from the

company, no new sales are occurring and hence, no additional individuals are being added to the risk pool.

A company may decide to exit one market segment but stay in another if it perceives greater risk or unique

challenges in a particular market segment. For example, the administrative burden of implementing rate increases in

the group market may be perceived as far greater than in the individual market, and therefore exiting this market

may be more attractive to some carriers.

TABLE 11. Distribution of LTC Insurance Companies by Current Market Status

Companies Still Selling in the Market

Companies Out of the Market

Bankers Life & Casualty Company

Genworth Life Insurance Company/

Genworth Life Insurance Company of New

York

John Hancock (individual policies)

Knights of Columbus

Massachusetts Mutual Life Insurance

Company

Medamerica Insurance Company/

Medamerica Insurance Company of New

York

Mutual of Omaha Insurance Company

New York Life Insurance Company

Northwestern Long Term Care Insurance

Company

State Farm Mutual Auto Insurance

Company

Thrivent Financial For Lutherans

Transamerica Life Insurance Company

Ability Insurance Company (Medico)

Aetna Life Insurance Company

Allianz Life Insurance Company of North

America

American Family

American Family Life Assurance Company

of Colorado

Continental Casualty Company

CUNA Mutual Insurance Society

First Unum Life Insurance Company

Guardian Life

Guarantee Trust Life Insurance Company

John Hancock Group

Kanawha Insurance Company

Lincoln Benefit Life Company

Metlife Insurance Company of Connecticut

Metropolitan Life Insurance Company

Monumental Life Insurance Company

Penn Treaty

Physicians Mutual Insurance Company

Provident Life & Accident Insurance

Company

Prudential Insurance Company of America

RiverSource Life Insurance Company

Senior Health Insurance Company of

Pennsylvania

Southern Farm Bureau Life Insurance

Company

Time Insurance Company

Union Security Insurance Company

United Teacher Assoc Insurance Company

Unum Life Insurance Company of America

WEA Insurance Corp

SOURCE: Analysis of NAIC Experience Exhibit Reports, 2011 and LifePlans Sales Survey

2012.

The 2009 NAIC Experience Exhibit Report is the last that contains detailed

information on actual-to-expected loss experience by company. In that year, 192

companies reported their individual claims experience. We extracted and analyzed

information from that study in order to determine whether or not the experience of

companies that left the market differed from those that remained in the market. At that

time, there were about 27 companies (among those reporting that year) that were

actively selling policies. The remainder administered closed-blocks or had negligible

sales. Figure 15 summarizes key market size and performance indicators for each of

these distinct segments in 2009. As indicated, quite a few companies left the market

between 2010-2012, so the picture would likely look different today than it did just a few

short years ago.

FIGURE 15. Market Indicators by Company Sales Status 2009

SOURCE: LifePlans Analysis of NAIC Experience Reports, 2010.

There are a number of important issues of note. First, in 2009, a majority of

individuals with LTC insurance policies were being serviced by companies selling

policies (75%). However, not shown in Figure 15 is the fact that by 2010 -- when

additional companies exited the market -- the percentage of policies serviced by

companies’ still selling policies in the market had fallen to 45%. Second, on a premium-

weighted basis, the actual-to-expected incurred claims experience in closed-blocks was

115% compared to 93% for companies still selling policies at that time. Thus,

experience was markedly worse for the companies that had already left the market, and

the impact on profitability was clearly negative. Finally, there was also somewhat

greater volatility in the cumulative actual-to-expected claims experience among

companies that exited the market. Volatility is an important performance indicator,

because the greater the level of volatility, the greater is the range of possible negative

(and positive) outcomes. Typically, when there is more variability in expected

outcomes, to attract capital, the return needs to be greater than for products or

industries with less volatile results. Taken together, these data suggest that unless

there are significant new entrants to the market, over time overall financial performance

will be increasingly dominated by the experience of closed-block companies, and such

experience to date, has been less positive than for companies still selling policies in the

market. To some degree, the relative difference in performance is not unsurprising

given that closed-blocks tend to derive from companies whose policies were sold many

years ago when there was less certainty around key pricing parameters affecting

premiums and claims.

E. Factors that Might Lead Companies to Re-Enter the Market

Many of the same reasons that compelled companies to enter the LTC insurance

marketplace 20-30 years ago remain relevant today. Foremost among them is the fact

that LTC represents the single largest unfunded or uncovered liability during retirement

and demographic trends suggest a growing need for the product. Yet it is clear from the

data presented thus far, that a variety of factors have made the product in its current

form a difficult business proposition for companies. The underlying risk in the product,

which results in significant capital requirements and the need for a meaningful rate of

return on that capital make it difficult to generate an attractive level of profit at an

affordable price to support robust sales. We asked all respondents whether they

believed that their own company had left the door open to coming back into the market

at some point in the future. About 42% of respondents affirmed their belief that the

“door remained open”. When queried further, only one-quarter indicated that the

chance was greater than 25% and the other 75% said that the chance was very low or

that it simply was not going to happen. Not shown is that roughly one-third estimated

that if they returned to the market, it would be within the next five years.

FIGURE 16. Chance that the Company would begin Selling LTC Insurance Again

SOURCE: Survey of executives from 25 LTC carriers who exited the market or exited segment

of the market.

We also queried respondents on what might be needed to have them reconsider

their decision. We asked about regulatory, public or other policy design changes that

might make it more attractive for them to again develop and sell policies in this market.

More specifically, for a series of policy design and regulatory changes, we asked

whether the recommended change would “Definitely”, “Maybe”, “Probably Not”, or

“Definitely Not” influence their decision to reconsider entering the market. In the survey

instrument, background information was provided for each recommended change so

that the respondent knew precisely what was being asked. In Table 12, we paraphrase

the changes that were offered.

It is important to note that many of the changes that we asked about have been put

forward by industry advocates as positive and supportive of the private market. The

focus of our inquiry, however, was not on their desirability, but rather, whether they

would make a difference in the decision to re-enter the market. Thus, if a respondent

indicated that a particular change would “Definitely Not” make a difference regarding

market re-entry, this does not mean that the change would not be viewed positively or

important to efforts to support the private market.

TABLE 12. Factors Potentially Influence the Decision to Re-Enter the Market

Change

Would the Recommended Change Influence Company to

Reconsider Entering the Market?

Definitely

Maybe

Probably

Not

Definitely

Not

Undecided/

Other

Having premium rates vary by

interest rate. That is, having the

ability to file multiple sets of new

business premium rates the use of

which is automatically determined

by an external interest rate index for

new business premium rates and

in-force premium rates.

36%

20%

36%

Having premium rates vary by

interest rate. That is, having the

ability to file multiple sets of new

business premium rates the use of

which is automatically determined

by an external interest rate index.

32%

24%

36%

Allowing stand-alone LTC and/or

combination-products to be funded

with pre-tax dollars.

25%

33%

29%

Being able to offer other

combination-products for example,

disability income with LTC, or

critical illness with LTC rather than

just life and annuity combination-

products.

28%

40%

---

Being able to offer a Universal LTC

policy design which would allow for

premium flexibility, interest

crediting, cash values, age and/or

duration adjusted insurance

charges (current and guaranteed)

for LTC, and surrender charges.

20%

24%

40%

Allowing stand-alone LTC and

combination-products to be offered

in cafeteria plans.

---

21%

42%

38%

---

Changing the mandatory offer of 5%

compound inflation protection to a

mandatory offer of 2% inflation

protection.

---

20%

32%

40%

Removing the requirement of

offering 5% compound inflation

protection on a combination-annuity

product.

---

16%

52%

16%

Removing the requirement for a

minimum benefit period.

38%

42%

Requiring all agents to get LTC

education to obtain their life/health

license and continuing education.

---

36%

52%

Changing the application to remove

questions about other health

coverage, financial questions, or

reconfirming benefit choices.

16%

72%

Allowing longer Elimination Periods

like 180 day period.

---

44%

48%

TABLE 12 (continued)

Change

Would the Recommended Change Influence Company to

Reconsider Entering the Market?

Definitely

Maybe

Probably

Not

Definitely

Not

Undecided/

Other

Allowing Waiting Periods for those

who are insurable today, but want

benefits in later years or using a

Waiting Period as an underwriting

tool.

---

36%

52%

Allowing multiple policyholders to

share one pool of benefits so that

benefits are not "saved" but are

exhausted when used up,

regardless of who uses them.

---

20%

72%

Last-survivor policies which would

pay benefits only after one spouse

had died.

---

28%

64%

SOURCE: Survey of executives from 25 LTC carriers who exited the market or exited segment of the market.

NOTE: It is not always clear that a number of the policy designs are not currently allowed; however, there is enough

uncertainty about regulatory and tax treatment, that it might be the case that this represents a barrier.

a. This would enable the premiums that are paid by consumers to fluctuate based on a pre-determined schedule

which would be a function of a pegged interest rate. Multiple sets of rates would have to be approved by state

insurance departments.

b. The purpose is to simplify the application process, which is sometimes viewed as a barrier for consumers and also

can make it difficult for agents to sell the product.

As shown in Table 12, there are very few specific policy design changes or

regulatory modifications presented to respondents that would lead companies to

definitely reconsider their decision to exit the market. On the other hand, the ability to

file multiple business rates -- which in part helps to mitigate the investment (interest

rate) risk -- was cited most frequently as a change that would potentially lead to a

reconsideration of the decision. Filing multiple business rates would allow companies to

charge alternative premiums depending on the level of the interest rates and these

premiums would be pre-approved by state insurance departments. As well, expansion

of combination-products to include LTC-disability, LTC-critical illness, LTC-annuity

products, or others was viewed as something that might cause companies to think

about getting back into the market.

Noteworthy is the fact that one-in-three respondents suggested that allowing

policies to be funded with pre-tax dollars also would lead them to potentially reconsider

their decision. This is a lower percentage than those citing the ability to file multiple

rates which suggests that issues related to consumer demand are less important drivers

of the decision than are risk management issues; more specifically, risk management

on the investment side.

Respondents were given an additional opportunity to express what it might take for

them to consider returning to the market. They were asked to indicate the

circumstances under which they would consider doing so. They were provided with

broad categories and then requested to provide specific suggestions within each

category. The categories included changes to regulatory policy, distribution

approaches, policy design features, tax status, and consumer attitudes.

Figure 17 shows that product structure changes were cited most often as likely to

have a meaningful influence; many of these had to do with the level-funded nature of

the product, the “long-tail risk”, and the fact that the product is complicated. Those

citing regulatory requirements pointed to high capital requirements, as well as a general

sense that carriers needed to have more flexibility in product design. Finally, consumer

attitude changes that insurers felt might influence a decision to re-enter the market were

focused primarily on the need for additional education so that consumers would be

aware of the risks that they faced and how the product is designed to address this risk.

FIGURE 17. Circumstances under which the Company would Consider

Re-Entering the Market

SOURCE: Survey of executives from 25 LTC carriers who exited the market or exited segment of

the market.

V. IMPLICATIONS

By almost all measures, the private market for LTC insurance is not meeting the

initial expectations of companies that entered the market as well as current expectations

of those that continue to sell policies. Yet no one disputes the need for a product that

insures against the financial risk associated with LTC services nor is there an argument

about the fact that this need will increase over time. Even so, as companies have

entered the market to fill this need, most have fallen short on meeting sales and

profitability objectives and it is this latter failure that has driven most of them from the

market.

Clearly companies can do little to influence macro-economic trends affecting

interest rates and in fact, many companies have exited the market over the past seven

years because of the extremely low interest rate environment. Simply put, they could

not generate sufficient income on reserves and RBC to fund future liabilities. Yet there

are a number of actions that carriers can take to improve the overall profitability of

products. The results presented in this study suggest that the ability to generate a

reasonable level of profit is critical to assuring that companies remain in the market and

that new companies will find the market attractive.

First, change to the underlying funding structure of products should be considered.

Currently, products are level-funded, but they could be priced on a “term-basis”, much

like life insurance. This may be particularly relevant for individuals purchasing policies

at younger ages. For example, the premium could be set to cover the risk (expected

claim costs) over the term (e.g., one year) and there would be an understanding that

every year the premium would increase to cover the increase in expected claims. At a

certain point the premium would be fixed and level-funded, say at age 70 or 75. The

schedule may also include a small amount of pre-funding.

Because the annual

increase in premiums could approach 10%, in addition to limiting the age at which

premiums can be increased, it may also make sense to limit annual increases to smaller

amounts.

Such an approach minimizes the importance of interest earnings, makes the

product more affordable and attractive at younger ages and makes awareness of future

LTC risk more pervasive. This in turn, should help to reduce selling costs and

“mainstream” the product as part and parcel of a standard retirement plan. Results

presented here suggest that it may also draw companies back into the market.

This is similar to designing LTC insurance like Universal Life. An account value is credited with premiums and

interest earnings and charged with current insurance charges, withdrawals, and expenses. As the account value

increases, the net amount-at-risk decreases. The early pre-funding is available to the policyholder in the event of

lapse or early death.

Mohoric, E. (2013). Long-Term Care Product Design: Two Common-Sense Recommendations. Long-Term Care

News, Long-Term Care Insurance Section, Society of Actuaries. January.

A second approach involves indexing both premiums and benefits to account for

increases in the cost of services. Such an approach should be tied to actual changes in

the cost of LTC services which many companies track on an annual basis.

This

method has the virtue of reducing the uncertainty around the inflation risk, as well as

lowering initial premiums, since a fixed inflation adjustment (e.g., 5%) is not built into the

initial premium. It makes the product more affordable for consumers but even more

importantly, reduces the level of initial reserves that must be set up by the company,

which in turn eases the amount of capital required to support the product.

Clearly, a focus on restructuring the product is an important direction to consider

for the industry as well as for regulators, who have a great deal to say about what is and

is not acceptable in terms of product design. The industry will need to work with the

NAIC as well as consumer groups to assure acceptance of such designs. Even though

current regulations do not prohibit such approaches, insurers have not offered them in

part because of a concern about introducing additional complexity into the product.

Moreover, there is a legitimate concern that increasing premiums for people who are on

fixed incomes will cause them to drop their policies. Designs that begin with term or

indexed pricing, and then adjust the indexing rate downward at a certain point can

reduce these concerns. As well, new combination-product approaches are also

designed (in part) to lower the inherent risk in the product or even provide for off-setting

risks (mortality and morbidity) within a single product (e.g., annuity-LTC products).

Another strategy involves deploying more sophisticated investment strategies.

Even with major changes in product design, there will always be some need for an

investment strategy that maximizes returns on invested premiums and capital. While

companies have little control over general interest rates, there are mechanisms that can

minimize some of the risk associated with the mismatch between future cash inflows

and outflows. Helwig et al. (2007), identify a number of financial market innovations that

can mitigate interest and inflation risk in products. For example, a carrier can use what

is called a “Forward Interest Rate Swap” to lock in future interest rates; it then replaces

these contracts with assets funded by future premiums which can help to match the

asset/liability of their profile.

The same principle holds for Inflation Swaps; the carrier

pays a fixed inflation rate in exchange for the realized inflation rate for a period of time,

thus eliminating any uncertainty about future inflation. These strategies are designed to

hedge against the inflation and interest rate risks and they do require a level of

sophistication in managing investment portfolios.

Providing companies with more certainty regarding the anticipated actions of state

insurance departments vis-à-vis requested rate adjustments is also very important.

Many companies were uncertain how they would be treated by regulators when making

rate increase requests. While it is true that the vast majority of companies have

Both Genworth Financial and MetLife conduct annual cost of care surveys that track changes in the cost of key

LTC services including nursing home care, assisted living, and home health care.

Helwig, D., Bhandula, R. and Barrett, N. (2007). Long-Term Care: Hedging Your Bet. Long-Term Care News,

Long-Term Care Insurance Section, Society of Actuaries. December.

increased rates on exiting policyholders, in many cases the approved rate change is

less than what carriers demonstrated they required to cover anticipated losses, let alone

earn a minimum return on their investment. Insurance regulators must of course

balance insurer solvency and consumer protection, and it is not the role of insurance

regulators to guarantee a certain level of profit to companies. Nevertheless, the

concern about being able to obtain rate changes, when state-approved actuarial

assumptions have not been met, is real: the product is priced to be guaranteed

renewable but not non-cancellable.

This means that companies have approached this

market with the knowledge that if experience is not consistent with underlying pricing

assumptions -- all of which are reviewed and approved by state insurance departments

-- they have the ability to make adjustments prospectively. One approach to dealing

with this issue and viewed positively by many companies is the ability to file multiple

business rates that could be pre-approved and triggered when events occur outside of

the control of the individual company such as precipitous declines in interest rates. This

has the virtue of reducing the inherent risk in the product and thus may attract more

capital and firms into the marketplace.

By taking some of the most risky elements out of the product, one could argue that

relatively high capital requirements would no longer be justified. High capital

requirement have been both a major barrier to entry as well as a major reason why

companies have not been able to justify staying in the market. New arrangements with

reinsurers may also reduce some of the need for capital, but this would also require

changes in product to make the business opportunity attractive to reinsurers.

Finally, actions designed to reduce the costs of producing the product will enhance

profitability. The most important non-claims related cost is sales commissions. Many

view them as high today, in large part because of challenges in selling the product and

the need to attract more agents to sell LTC insurance. As noted, however, given the

challenges involved in selling the product, commissions are not out of line with what is

paid for other voluntary insurance products in the individual market. There are a variety

of reasons why it is difficult to sell the product and these have been outlined -- along

with potential solutions -- in Frank et al. (2013).

Some of the reasons relate to

household behaviors associated with savings, purchase of insurance, and health-

related behaviors (i.e., demand) and others with the efficiency of the private insurance

market (i.e., supply). Solutions include strategies linking LTC insurance to health

insurance, simplifying the product, providing more support for employer-sponsorship of

insurance, educating the public about the risk and costs of LTC, forcing active choice,

providing state-based organized reinsurance pools to provide a “back-stop” for industry

experience, implementing targeted subsidies, and others. All of these strategies are

A guaranteed renewable product in this context means that the insurer cannot cancel a policy if the individual

continues to pay premiums but the company does have the right to change premiums based on credible experience

for a class of individuals. A non-cancellable policy implies that the company cannot change premiums once they are

set, regardless of whether or not pricing assumptions are met.

See Frank, R., Cohen, M. and Mahoney, N. (2013). Making Progress: Expanding Risk Protection for Long-Term

Services and Supports through Private Long-Terms Care Insurance. Unpublished policy brief submitted to the

SCAN Foundation. January.

designed to increase demand -- both through lowering selling costs and through

changing peoples’ attitudes about the value of LTC insurance -- and help address risk

challenges facing the industry.

While not directly related to the central issue of product profitability, it is worth

noting again that a majority of policyholders are in closed-blocks of business. These

tend to perform less favorably than open blocks and in fact, a small number of large

companies are responsible for this experience among both closed and open blocks.

Thus, negative performance is to some degree skewed by a few companies and may

not represent the overall experience of the industry as a whole. Unless there is a

dramatic increase in new sales, the experience of these blocks will increasingly

characterize overall industry performance. Because such blocks may not represent

significant profit or growth opportunities for companies, it may become increasingly

difficult to attract necessary levels of investment to service the policyholders in these

blocks. As well, it may become increasingly difficult to attract and retain top risk

management talent to work with a segment of the business that has been deemed

unprofitable.

This poses potential risks to policyholders and challenges to regulators who may

face unique issues associated with closed-blocks of business. A certain level of

regulatory flexibility may be required to work through new and unknown issues. There

may be circumstances where carriers desire to take actions that will benefit consumers

as well as reduce costs or mitigate risks to the carrier, and it may not be clear whether

such actions are allowable under existing regulations. For example, adding no-cost

riders to policies that enable a more proactive approach to managing care, offering

policyholders the ability to change the underlying structure of benefits to keep premiums

more stable, supporting flexible approaches to applying alternate benefit provisions that

take account of changes in the service delivery environment and so on.

VI. CONCLUSION

Although the market has experienced a very major contraction in the number of

companies actively selling policies, it is worth noting that the LTC insurance market

covers more than seven million Americans and is larger than the individual disability

market. Significant reserves have been established to pay for future LTC costs and the

increasing flow of private insurance dollars to LTC providers is growing in importance.

As essential, there is a core of major insurers highly committed to this market and under

the right circumstances more carriers could be drawn back into the market.

While many early market entrants learned the “hard way” about what is required to

price and manage the risks in this product, there have been many valuable lessons

learned. Such lessons can help set the industry on a more solid financial foundation and

make entry for new carriers a more attractive proposition. Identifying strategies that

produce a level of profitability attractive enough to draw capital into the market is a key

to assuring that the growing demand for the product can be met by a robust and

competitive market of insurers. Public policy and regulatory approaches designed to

lower the cost of policies, allow greater product funding-flexibility, support new forms of

combination-products, and encourage strategies that help to minimize risks outside of

the control of companies, could provide needed support for a market “re-set”.

To obtain a printed copy of this report, send the full report title and your mailing

information to:

U.S. Department of Health and Human Services

Office of Disability, Aging and Long-Term Care Policy

Room 424E, H.H. Humphrey Building

200 Independence Avenue, S.W.

Washington, D.C. 20201

FAX: 202-401-7733

Email: [email protected]

NOTE: All requests must be in writing.

RETURN TO:

Office of Disability, Aging and Long-Term Care Policy (DALTCP) Home

http://aspe.hhs.gov/office_specific/daltcp.cfm

Assistant Secretary for Planning and Evaluation (ASPE) Home

http://aspe.hhs.gov

U.S. Department of Health and Human Services (HHS) Home

http://www.hhs.gov