Case Study: Quantifying Healthcare Industry Adverse

Disruptors

By: Alexander Dewhirst, Chuwen Li, Samual Pfeffer, Cheng Shi

Advisor: Russell Lyons

Indiana University

Department of Mathematics

April 2016

1

Content

I.Executive Summary 2

II.Purpose and Background 3

III.Data 4

1. Lead Exposure

2. Cost of Treatment

3. Financial Report

IV.Methods, Analysis and Models 7

1. Lead Exposure

2. Cost of Treatment

3. Financial Report

V.Conclusion 10

VI.Appendix 11

VII.Reference 18

2

I.Executive Summary

Our goal, as actuary consultants hired to quantify healthcare industry disrupters, is to obtain

reliable projections of expected benefit costs and minimizing losses within a five-year time

horizon. To successfully minimize losses, we consider short and long term procedures resulting

from long term lead exposure. Our disruptors cover three of the major categories, outpatient

services, pharmaceuticals, and physician services: The disruptors include blood tests and post

therapy check-ups, appointments with primary physicians due to observed symptoms of lead

poisoning, and medication prescribed due to lead poisoning. Our paper focuses specifically on

increasing levels of lead exposure among children in Flint, Michigan and our medications target

the use of chelation therapy, a medication which is regarded as unsafe for children. Currently, there

are no treatments for children which have fewer side effects and are less harmful. Our analysis of

increasing observed claim costs resulting from increased lead exposure provide accurate models

and statistical methods, an explicit definition of our disruptors and analyze the effect each has on

their respective medical services.

The Flint Michigan water crisis is a lead contamination crisis that occurred due to a change

in the water source where there was failure to apply corrosion inhibitors. The original water source,

from the Detroit Water and Sewerage Department water, at Lake Huron was changed to the Flint

River water source creating a health emergency. Corrosion of the pipes, caused by corrosive water,

elevated the lead content supplied to the residents of Flint. Our statistical models determine trends

linked with lead exposure among the residents of Flint, controlled by trends of the general

population of the United States. First, there are strong trends of increased lead exposure and the

source of water in Flint. Children are much more susceptible to the negative health effects in

comparison to adults, in part by the development of the central nervous system, which is the where

the strongest impact from lead exposure occurs. Socioeconomic class and residence location were

significantly correlated with increased blood lead levels as well. The data did not, however, show

a significant relationship between kidney transplant percentages and increased lead exposure. Then

we develop several extensions to our basic models to provide more accurate information to

alleviate future error when such an event occurs.

Our analyses provided a few suggestions for a five year outlook of the insurance company.

We suggest to adjust insurance benefits related to the MIChild and Healthy Kids Medicaid plans,

in order to decrease the risk of unpredictable costs associated with chelation therapy. This would

also provide a cost minimizing method after analyzing the impact of the Flint water crisis. The

plan adjustment we find to be the most effective, is to have a ceiling on the number of chelation

therapy medications under universal coverage. Then provide another insurance plan, as a result of

the crisis in Flint, which would allow for further therapy at a higher cost. Long term lead exposure

in children leads to suspended or disrupted development of the central nervous system, thus leading

to increased health risks and higher healthcare costs.

We also suggest that the company determines strategies to better manage their assets in

order to decrease variation in the value of the company and increase their coverage capabilities.

This would provide more incentive to stockholders to invest further into the company.

3

II. Purpose and Background

This topic, the correlation between lead exposure rates among children and an atypical utilization

of medications associated with chelation therapy was chosen due to the increase in younger

patients in the recent crisis in Flint, Michigan. The events that transpired in Flint have adversely

affected our thoughts on health coverage and ways in which benefits should be given to the

residents, introduced new concepts of consideration to health care providers, and raised awareness

to the short and long term effects of lead exposure. The crisis raises many new questions in the

health industry because of increased costs and a high level of variability. Also, the responsibility

of the state government and the efforts put in place to eliminate the source of lead and to fix the

pipes is controversial since the costs are too high to maintain budget. Consequently, there have

been increased hospital and insurance costs caused by the unexpected crisis and we wish to

determine a cost minimizing strategy to care for patients of lead exposure as well as plan for similar

future events. Cost minimizing strategies are strongly dependent on how much the insurance

company or government will manage the costs involved.

Lead exposure has numerous harmful effects, ranging from less critical to more chronic,

threatening emergencies. The use of lead in gasoline between the 1920s and 1980s became

problematic during the later years when researchers discovered connections of health effects due

to lead. Since then, lead exposure across the United States has drastically reduced. During the

1970s and into the 1980s awareness regarding the negative health effects associated with lead

began to spread globally, resulting in an 80% decline in gasoline lead levels and leading to a

reformation of lead limit regulation to just 1.1 grams per leaded gallon (Newell & Rogers, 3-4).

Research on the effects of lead correlating to a range of variables and demographics created

more questions than answers. However, studies found consistent trends in blood lead levels

following the decline in the use of leaded gasoline. Average blood lead levels (BLLs) steadily

decreased from 16 micrograms per deciliter (µg/dL) in 1976 to 10 µg/dL in 1980 (Figure 1).

Studies also concluded that children were adversely affected in comparison to adults and due to

concern, more studies on children were performed. As early as 1979, a conclusive study found that

verbal IQ scores were directly correlated with lead levels. In Figure 2, a study found that verbal

IQ scores among children with high tooth lead levels displayed lower results in comparison to

children with low tooth lead levels. Such studies continued, determining trends among different

variables related to demographics, specifically IQ scores and socioeconomic class among children

(Figure 3, Figure 4). Consistency among lead exposure and health effects gave rise to further

questions, such as the intensity of health effects among different populations and lead treatments

in relation to source of lead exposure and demographics. An informative resource (Figure 5)

displays the lowest observed effects of inorganic lead in children. As low as 10 µg/dL BLL,

children are affected by a decrease in IQ, hearing, and growth. Between 10 - 130 µg/dL there are

numerous consequences to the well-being of children, until finally resulting in death (Figure 5).

More recent findings [7, p. 795] show staggering trends in lead exposure in children. As

early as the third trimester of pregnancy, mothers with increased lead concentrations may present

complications in the central nervous system of the child. Also, the development of the central

nervous system in the third term is also vastly different than that of a fetus with little to no lead

exposure. As noted, brain development is staggered as early as during pregnancy and further lead

exposure creates more complications throughout childhood (Schnaas, Rothenberg, Flores,

Martinez, Hernandez, Osoria, Velasco & Perroni, 795). Also, the demographics in relation to lead

4

exposure display more trends, non-Hispanic blacks consistently showed increased levels of lead

exposure throughout the United States. These increased BLLs are a result of low socioeconomic

status, a significant risk factor for multiple reasons. Primarily, it is the result of living in homes

built before 1946, since such homes contain lead paint and piping. A similar trend was examined

in 1973, when homes built subsequent, again, have reduced BLLs since lead paint stopped being

used.

III. Data

Our methods of analysis are divided into three parts: the distribution of lead exposure among

children including demography and percentage, cost of lead exposure treatment and trend analysis

of the financial report. We select data from different organizations, government to research lab.

All the data will be distributed into the above three parts of our analysis.

1 Lead Exposure

Lead exposure distribution data comes from an academic article of the lead exposure study

reviewed and approved by Hurley Medical Center institutional review board. The study includes

all Children who are under 5 years old and had a BLL test through the Hurley Medical Center’s

laboratory. Hurley Medical center originally collected data from Epic electronic medical record

system after approved by the Hurley Medical Center institutional review board and subject to the

Health Insurance Portability and Accountability Act waiver (Hanna-Attisha, 2016, P284). The

database includes blood lead level, the medical record number, birth date, phlebotomy data, full

address, gender and race per patient (Hanna-Attisha, 2016, P284). The time period from the data

before the Flint water crisis was from January 1, 2013 to September 15, 2013 and after was January

1, 2015 to September 15, 2015. The total number of observations is 3,675, which consists of 1,473

children (pre-time children 736, post-time children 737) living within the city of Flint and 2,202

children (pre-time children 1210, post-time children 992) living outside. Hurley Medical center

performed data analysis relying on the given data set. The analysis and results will be discussed in

the Methods, Analysis and Models section.

In contemplation of providing visual results, we also select data from Michigan Department

of Health and Human Services. The database contains percentages of Children under 6 with

elevated blood lead levels in state of Michigan, specifically Genesee county and the city of Flint

from 1998 to 2016. Percentages of children under 6 with elevated blood lead levels in Flint are

categorized into above 5 µg/dL and above 10 µg/dL. In the Methods, Analysis and Models section,

we will illustrate the line chart constructed.

The essential focus of the Hurley Medical Center paper is lead exposure of children

associated with drinking tap water in Flint. As we introduced in the background of the Executive

Summary section, our core analysis addresses to Flint Michigan water crisis. According to media

reports, the direct influence of the Flint, Michigan water crisis is poisoned drinking water

consisting of a excessive levels of lead (CNN, April 04, 2016). As opposed to other sources,

5

excessive levels of lead has detrimental effects to children and pregnant mothers (Hanna-Attisha,

2016, P284). Our study is to evaluate the effects of Flint, Michigan water crisis on healthcare and

financial reports of the company for children below 6 years old. Hence, Hurley Medical Center

paper contributes favorable conditions to benefit our analysis. In addition, we also selected data

from Michigan Department of Health and Human Services. The data is collected annually by the

government and presents more reliable data for our analysis.

In favor of gathering appropriate data to determine the distribution of lead exposure of

children below 6 years old in Flint, Michigan, we start to search key word in government database.

Even though government database include abundant data of children lead exposure, all data are

scattered, and some of the data are even uncompleted. As a consulting team, it is paramount for us

to perform analysis and present the efficient solutions to the CEO. Therefore, we adjust our

concentration on mature data rather than row data. We search key word through academia website

and finally select data from Hurley Medical center. The database is cleaned and error-free with

official approval from the academia and government. However, Hurley Medical center database

only contains data of year 2013 and year 2015. The lack of updated data will weaken our prediction

of a 5-year period starting in 2014. Our team additionally select data from Michigan Department

of Health and Human Service. Compared with other government database, our chosen database is

more organized.

Thus, two databases of lead exposure are prepared and ready for modeling and analysis.

We will provide discussion of our methods and analysis of modeling in the section IV.

2 Cost of Treatment

The costs incurred by a health insurance company begins when the insured health care recipient

begins the diagnosis process. In order to properly understand a child’s degree of lead exposure a

blood lead analysis must be conducted by a qualified healthcare professional. According to data

supplied by Fair Health Consumer the baseline cost a blood test specifically looking for blood lead

composition is $29.99. Based on the results of the blood test the doctor will determine if Chelation

Therapy is a necessary treatment. If the doctor sees Chelation Therapy to be a practical form of

treatment than two more expenses will have to be incurred by the health insurance company. The

primary expense associated with Chelation Therapy is the Chelation solution. Fortunately,

Chelation therapy is a relatively inexpensive outpatient procedure. For most cases in Flint, EDTA

will be the only necessary solution administered for any chelation process due to the fact that there

has not been any document cases of a child diagnosed with a blood lead level of 75 micrograms

per deciliter or greater. According to the CDC only cases involving blood level of 75 microgram

per deciliter or greater should receive a combination of EDTA and BAl solution. Therefore, we

will only focus on the cost of Chelation Therapy that includes EDTA. The cost of treatments

consisting of only EDTA based solutions cost anywhere from $75 to $125 dollars per treatment.

However, for the calculations in our financial report we will be using the average of the two

estimates. The number of treatments varies based on the initial blood lead level and the individual’s

response to treatment. The frequency of treatment however must be kept within 5 to 7 days apart.

To determine the quality of the child’s response to Chelation, a urine analysis must be conducted

after each treatment to detect potential lead contained in the urine. The cost of each urine analysis

quoted from hospitals within Flint, Michigan are priced at $15.00. Furthermore, from the urine

6

analysis results the doctor is better able to evaluate the amount of treatments a child will need in

order to decrease their blood lead level to a safe state. Finally, after treatment is complete a child

must undergo a follow up examination that consists of a blood lead test. In sum, an insurance

company is responsible for two fixed costs which consists of blood lead tests and two variable

costs which consist of the varying number of EDTA infusions and urine analysis.

3 Financial Report

Financial report data comes from Aetna, which is an American insurance management company.

Aetna posts their financial report every year containing company’s activities and financial

performance. We extract data including the consolidated balance sheet (Figure 6) and the

consolidated income statement (Figure 7) from 2010 to 2014. The consolidated balance sheet

presents the assets and liabilities of a parent company and all its subsidiaries, with no distinctions

on which items belong to which companies. To provide a larger background picture to benefit our

analysis, a consolidated income statement which combines revenue, expenses, and income of the

parent companies and their respective subsidiaries of the entire corporation is used. We do not

consider money owed between companies that are a part of the consolidated income statement.

Values in the statement are in the thousands.

In 2014, Department of Insurance and Financial Services in the State of Michigan

published an authorized insurance company list. The listed companies are authorized by the

Department of Insurance and Financial Services to write Major Medical Health insurance in

Michigan. Our target company search database to support our analysis and provide a financial

report is from this list. Figure 8 lists top 10 health insurance and managed health care companies

in the United States. Aetna and Humana are the two companies appearing on both the authorized

insurance company list and the top 10 insurance company list. These two lists provide sufficient

support that Aetna and Humana are more adapted and more authorized in Michigan. Aetna is more

familiar to us because Indiana University provides Aetna health insurance to international students.

Hence, we select Aetna to be our exemplar for our financial report. Since the assessment of Aetna

includes numerous transactions, we have large amounts of data to predict the future costs and

decrease overall loss.

Compared with financial reports of non-insurance companies, Aetna provides its finance

report in a different form. For example, non-insurance companies do not have health care costs

payable and reinsurance recoverables in their respective consolidated balance sheet. However,

health care costs payable and reinsurance recoverables are essential entries for Aetna in their

consolidated balance sheet. Therefore, it requires us to understand the difference of financial

reports between non-insurance companies and insurance companies so that we are able to make

more precise analyses and predictions.

The financial report of Aetna has some disadvantages. For example, the trend of net income

is highly unstable and may affect our analysis and prediction as a result. We will explain the effects

of an unstable trend later on. Before making a prediction, we must perform several reasonable

adjustments to the financial reports. For example, the variation of net income through each year is

very unpredictable, so we estimate the variation of net income to better our future analysis.

The database of financial report is prepared and ready for modeling and analysis. We will

provide a discussion of our methods and analyses of modeling in section IV.

7

IV. Methods, Analysis and Models

1 Lead Exposure

Hurley Medical center summarized the percentages of many characteristics for elevated blood lead

level (EBLL) of 5 micrograms per deciliter (µg/dL) in children below 6 years old (Figure 9). In

comparison with the population and data not in Flint, high percentages of EBLL were noticed.

After the Flint water crisis, the percentage of EBLL of Flint increases from 2.4% to 4.9%. The

growth rate per year is 4.9%-2.4%2.4%=1.042. Hence, we are able to predict that the growth rate

of EBLL in flint will be approximately 1.042 if similar circumstances regarding lead exposure

occurs again in Flint. Data from the Michigan Department of Health and Human Services

displaying EBLL can be found in Figure 10. Figure 11 is a line chart for EBLL in Flint above 10

µg/dL and 5 µg/dL shows a two-year hike between 2014 and 2015. The overall trend of percentage

of EBLL is decreasing. However, the percentage of EBLL above 5µg/dL is doubled after the Flint

water crisis. For percentages of EBLL above 10 µg/dL and percentages of EBLL above 5 µg/dL,

each has an increasing rate for two years and then decreasing rate from the initial percentage of

EBLL. The growth rate of EBLL above 5 µg/dL is 6.4%-3.6%3.6%=0.778, and the growth rate of

EBLL above 10 µg/dL is 1.1%-0.3%0.3%=2.667. The overall growth rate 1.042 is averaged by

these two categories of EBLL growth rate. Hence, the lead exposure effect is a two-year horizon

with an incremental positive growth rate of EBLL approximately 1.042. According to the book,

Kids Count Data [4], published by Michigan League of Public Policy, there are 692,723 children

below 6 years of age in Michigan as of 2013. The number of kids below 6 years of age rose to

770,378 in 2006. Suppose the growth rate of kids below 6 years old is constant. Therefore, the

annual growth rate of kids below 6 years old is -0.015. The summary of lead exposure will be the

following:

Suppose the percentage of EBLL of children below 6 years old having EBLL a year prior

to lead exposure due to the Flint water crisis is α %, and the lead exposure happens 𝛽 year after

2013. Hence, the total number of children below 6 years old with an EBLL after lead exposure

over a two-year period will be

692,723 × (1 − 0.015)𝛽−1 − α% × (1 + 1.042)

This is the approximate number of children who need to get a blood test.

Suppose the percentage of EBBL of children below 6 years old, having EBLL above 10

µg/dL a year before lead exposure, is τ%. Hence, the total number of children below 6 years old

with an EBLL above 10 µg/dL and after lead exposure over a two-year period will be

692,723 × (1 − 0.015)𝛽−1 − α% × (1 + 2.667)

The resulting number is the approximate amount of children who will most likely receive chelation

therapy.

8

2 Cost of Treatment

Demographically, the portion of Flint’s population that is below the poverty line is 42.8%.

According to a study conducted by Dr. Mona Hannah-Attisha, areas with high poverty ratings also

experienced the greatest increase in documented lead poisoning cases. Displayed within two

charts, Dr. Mona Hannah-Attisha shows a connection between poverty and areas of varying water

lead levels as well as a connection between rate of increase in reported lead poisoning cases and

water lead levels. Based on the transitivity of these two connections it is clear that the areas that

experienced the most document lead poisoning cases were also areas where socioeconomic classes

were at Flint’s lowest levels. Dr. Mona Hannah-Attisha’s method was executed by giving areas

with low water lead levels, high water lead levels, and areas outside of Flint a socioeconomic

disadvantage score. From there she was able to document a connection between poverty and

reported lead poisoning cases. Our assumption based on these charts is grounds, we believe, for

the total cost to be incurred to the insurance company per lead poisoning case. This is due to two

major government sponsored health insurance programs in Michigan. MICHILD and Healthy kids

are health insurance programs for children 19 years and younger that grant full coverage without

co-pays for qualifying families. Qualification depends primarily on income. Therefore, many of

the kids who are documented having lead poisoning are subject to low income families and are

likely covered by either of these government sponsored plans. So, within our financial report are

figures are implications of low income children having complete coverage.

3 Financial Report

Our financial report analyses are to predict the costs of chelation therapy to the insurance company

over the next five years. First, we assume the costs of blood test for lead poisoning in inpatient

services and chelation therapy in 2018 and 2019 are insignificant. Second, we also assume the net

income growth rate fluctuates within a 95 percent confidence interval. Third, to calculate our

projections, we used averages from the previous five years for prediction in our analyses. The cash

and equivalents and the short term debt rows in our data to balance the total asset to equal the total

liabilities and stockholders’ equity. Lastly, we assume that the population of patients due to lead

poisoning remain in Flint. Our assumptions allow us to analyze the costs of the next five years and

how the disrupter effects the financial report by narrowing the insignificant, or irrelevant, factors.

These factors are whether people move to and from Flint, the obscurity in data involving the

success rate of chelation therapy, and the insurance company strategies involved with the Flint

water crisis.

We must first calculate the net income growth rates based on the data of past five years

from 2010-2014. To calculate the net income growth rate we use the formula, Next Year Net Income−Previous Year Net Income

Previous Year Net Income × 100% and the previous net income growth rates are

as follows:

9

Each net income growth rates is positive, with the exception of 2012, and this indicates

that the insurance company net income is increasing overall. The mean of the growth rate is 4.53%,

and the standard deviation of growth rate is 14.38%. The 95% confidence interval is (-23.640%,

32.709%). Thus, we are able to estimate the next five year net income growth rate by using the

confidence interval:

The confidence interval is really wide, therefore our prediction of new income growth rate is less

accurate.

The historical operating ratios are calculated by each entry divided by the net income in

each year and provide the percentage of each entry with respect to net income. The average

historical operating ratio for each entry and use the average historical operating ratio are used to

predict the operating ratios for next five years. In order to predict the net income for the next five

years using the actual 2014 date and the predicted net income growth rate, the data suggests that:

All other entries are predicted by the predicted net income and forecasting operating ratios.

The predicted liquidity measurement ratios (i.e. current ratios) and leverage ratios (i.e. debt to

equity ratios):

The formula of the current ratio is Current Assets

Current Liabilities. The formula of debt to equity ratio is

Total Liabilities

Shareholders′ Equity. The predicted current ratio increases every year, so we are able to conclude the

company has strong ability to pay off its short-term debt. The predicted debt to equity ratio

decreases every year, so we can conclude that the company is less risky to file for bankruptcy.

The total Flint population is 99,000. Based on the population demographic of 2012, the

population of children below 6 years old is approximately 7740, the number of children who need

to take blood test of lead poisoning. The population of children who need to receive chelation

therapy is approximately 200, found using the increment of the percentage of children with an

EBLL (3, P4). The cost of a blood test from lead poisoning is $29.99, and the cost for chelation

therapy is $2000 per month. The total cost of a blood test in Flint is $29.99×7740=$232122.6, and

the annual total cost of chelation therapy is $2000×12200=$4800000. Hence, the total cost is

$4800000+$232122.6=5032123 for 2015 and 2016. The success rate of chelation therapy is 0.89.

10

We assume only 200× (1-0.89) = 22 children will receive chelation therapy in 2017, and no child

needs to get a blood test. The overall costs of lead exposure for the insurance company in the next

5 years are:

The net income increases each year and the costs incurred from lead exposure decreases over time.

V. Conclusion

In our research, we are able to come to a few conclusions. The data we analyzed provided

significant insight into the financial impact this insurance agency would incur following the lead

exposure and water crisis in Flint, Michigan. From our lead exposure analysis, we conclude that

an increasingly large portion of people move from Flint, however the percentage of children with

EBLL increases. This suggests that there more cases of lead poisoning that may be undiagnosed,

which causes long-term health care impacts that would require further investigation. The insurance

agency may consider an increased budget associated with more long-term health care implications

caused by lead exposure. Such implications may be further use of chelation therapy and the costs

of chelation therapy would likely be higher due to a lack of intellectual development in children.

The insurance company would likely be required to maintain a larger amount of consistent costs.

We suggest adjusting benefits associated with chelation therapy from their MIChild and Healthy

Kids Medicaid insurance plans, as it is an inconsistent, unreliable treatment compared to other

therapies. The variable cost of the number of treatments a child receives should either have a

ceiling with an explicit number treatments a child can receive while also being covered by

insurance. We consider the possibility of pairing the previous insurance plan with a ceiling on the

number of treatments paired with another plan if higher risk patients require further medical

attention. These higher risk patients are more likely to have long term health effects, in which the

paired insurance plan would help to pay off. These costs are from the medical services associated

with long term health effects due to lead exposure, since this plan would cost more.

Based on our calculations within our financial report, we discovered an issue with the insurance

company's liquidity ratio. The liquidity ratio is between 1.5 and 2.0 and indicates the company has

short-term financial strength. However, from a long-term perspective, the insurance company is

unfortunately not using its current assets sufficiently and managing its capital very well. If the

company does not account for the increase in lead poisoning related treatments, then the insurance

company will face financial struggles down the road. Currently, very little capital is reserved for

claims related to lead poisoning treatments. In order to reduce company volatility, capital must be

allocate money more properly to account for the expected increase in lead poisoning treatments.

According to our distributions mentioned earlier, the insurance company can find justification

when determining how much money should be moved to cover lead tests, Chelation Therapy, and

urine analysis. Without an increase in such areas, the company will continue to leverage long term

costs with short term capital thereby exacerbating its already fragile financial state.

11

VI. Appendix

Figure 1

Change in blood levels in relation to a decline in use of leaded gasoline, 1976-1980

Note: Retrieved March 31, 2016.

Source: Annest JL, 1998

Figure 2

Cumulative frequency distribution of verbal IQ scores in children with high and low tooth lead

levels

Note: Retrieved March 31, 2016.

Source: Needleman et al., 1979

12

Figure 3

Blood lead levels and IQ scores of children, from cross-sectional and retrospective cohort studies

Note: Data from prospective studies are not included. Retrieved March 31, 2016.

Figure 4

Relationship between children’s blood lead levels and housing age and condition, Cincinnati

Note: Number of children at 18 months of age indicated in parentheses. Retrieved March 31, 2016.

Source: Clark et al., 1985.

13

Figure 5

Lowest observed effect levels of inorganic lead in children

Note: Retrieved March 31, 2016. The levels in this diagram do not necessarily indicate the lowest

levels at which lead exerts an effect. These are the levels at which studies have adequately

demonstrated an effect. Source: ATSDR, 1990

14

Figure 6

15

Figure 7

Figure 8

16

Figure 9

Figure 10

17

Figure 11

18

VII. Reference

[1] Annual Financial Reports. (n.d.). Retrieved

from http://investor.aetna.com/phoenix.zhtml?c=110617&p=irol-reportsannual

[2] Flint lead poisoning: Living with uncertainty long-term. (n.d.). Retrieved April 04, 2016, from

http://www.cnn.com/2016/03/04/health/flint-lead-exposure-long-term-pain/

[3]Hanna-Attisha, M., Lachance, J., Sadler, R. C., & Schnepp, A. C. (2016). Elevated Blood Lead

Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk

and Public Health Response. Am J Public Health American Journal of Public Health, 106(2), 283-

290.

[4] KIDS COUNT IN MICHIGAN DATA PROFILE 2016 (Rep.). (2016). MI: Michigan League of

Public Policy.

[5]Newell, R. G., & Rogers, K. (2003). The U.S. Experience with the Phasedown of Lead in

Gasoline (Rep.). Resources for the Future.

[6] Preventing Lead Poisoning in Young Children: Figures. (1991). [Figure 1, Figure 2, Figure 3,

Figure 4, Figure 5]. Retrieved March 31, 2016, from

http://www.cdc.gov/nceh/lead/publications/books/plpyc/figures.htm#Fig

[7] Raw data: Lead poisoning of kids in Flint. (n.d.). Retrieved April 04, 2016, from

http://www.motherjones.com/kevin-drum/2016/01/raw-data-lead-poisoning-kids-flint

[8] Schnaas, L., Rothenberg, S. J., Flores, M., Martinez, S., Hernandez, C., Osorio, E., . . . Perroni,

E. (2005). Reduced Intellectual Development in Children with Prenatal Lead Exposure. Environ

Health Perspect Environmental Health Perspectives, 114(5), 791-797.

[9] Snyder, R., & McPharlin, P. M. (2014). Authorized Major Medical Companies (Rep.). Lansing,

MI: Department of Insurance and Financial Services.

doi:https://www.michigan.gov/documents/lara/Major_Medical_359547_7.pdf

[10] Top 10 Insurance Companies By The Metrics | Investopedia. (2014). Retrieved April 08,

2016, from http://www.investopedia.com/articles/active-trading/111314/top-10-insurance-

companies-metrics.asp