Tag Archives: health savings accounts

10 Ways to Fix Obamacare

After a Sunday church service, fellow parishioners approached me with empathy about the prospect of dealing with healthcare after Tuesday’s election. I know this is just the beginning of what state insurance regulators will face as consumers bring us an array of questions regarding the future of the Affordable Care Act (ACA).

  • Will it be repealed?
  • Will it be replaced?
  • Will it be amended?

The answer to each question is the same: No one today knows what will occur with the ACA. However, it’s important for people to understand that it will not be possible to make any changes quickly — and any changes that do occur will happen over time. This means that, because the law is still in effect today, people should take steps to obtain or maintain health coverage that meets their family’s needs.

There are mounting challenges in America’s healthcare system. It’s clear to me that we need a modern-day Manhattan Project to address healthcare — a focused initiative where the brightest minds come together to address the many deficiencies of the ACA and recommend changes to healthcare financing and delivery systems. This type of project would lead to a more affordable and ultimately sustainable healthcare system, something that the ACA was never going to provide.

See also: What Trump Means for Health System  

The ACA did not address what is driving healthcare spending. To “fix” healthcare, we must transform the entire healthcare economy with a focus on what is driving spending. Rising healthcare costs have an impact on all Americans, not just the small percentage that purchase their own coverage through the ACA. Without structural changes to our healthcare system and a focus on costs, healthcare may squeeze out all other government programs and cause employers footing a large percentage of healthcare premiums for employees to drag down wages, which stunts America’s GDP growth. President-elect Trump needs to take a holistic look at healthcare. The ACA should be his starting point as it is currently on life support and needs changes as soon as possible.

If the new Congress passes a bill to repeal all of the ACA, I hope that a replacement for the ACA is stapled to that bill. An immediate repeal would lead to devastating consequences in the disruption of people’s care and would create even more uncertainty for millions of Americans. To ease the uncertainty, a transition time is required for any whole or partial suggested change.

To offer immediate predictability, President-elect Trump could consider keeping transitional (grandmothered) plans in place for another 24 months. At least one state has requested CMS to allow for an extension of the transitional plans because of a severe lack of choice in the market in that state. The request was rejected. Millions of Americans are in grandmothered and grandfathered plans that they like and that are working for them. President Obama allowed the transitional plans to continue, and the new administration should consider keeping the individual and small group transitional plans. In Iowa, we have nearly 117,000 people in these plans today.

To be clear, there are no easy fixes. The existence and reach of the ACA are contentious issues. Issues related to the ACA have been litigated in court and evaluated by public opinion for years now. Some parts of the ACA have merit and should be kept, in my opinion, but, on a whole, with skyrocketing premiums and insurers leaving markets, it is clear the ACA needs a lot of work. To make the individual insurance market work, it is imperative to build sustainable risk pools for individuals.

Rates for 2017 are rising 25%, on average. Affordability is a major issue for Iowans purchasing their own coverage. Premium tax credits may offset and assist with affordability for those who qualify. However, for the nearly 125,000 Iowans who are above 400% of the federal poverty level that did not have access to employer coverage prior to the ACA, affordability is a major issue. The ACA exempts certain people from the requirements of the individual mandate. One of the exemptions is an affordability hardship exemption. If a person cannot secure health insurance for less than 8.16% of their modified adjusted gross income for 2017, they may qualify for the hardship exemption. This would be net of any premium tax credits. Therefore, a significant number of people will be able to “opt out” of the ACA’s insurance mandate today; as the rates continue to rise, however, those individuals will not have health insurance coverage.

Many have stated that the ACA took a sledgehammer to healthcare when it was more appropriate to use a scalpel. Healthcare issues differ by state, but no matter what tool is needed to improve access to healthcare, it is clear that a number of changes should be considered immediately to help ensure that consumers have choices as they seek out coverage.

Ten Points to help improve the ACA:

  1. Create a mechanism for covering catastrophic claims, separate from individual insurance pools. As a parent of a child with Type 1 diabetes, I am grateful that the ACA eliminates pre-existing conditions. I know that if I ever need to buy my own insurance, I can find coverage that will still be meaningful for my family. However, it is clear that the most chronic and catastrophic conditions are the drivers for an extraordinary amount of the rate increases. In testimony I provided before Congress, I stated that looking at high-risk pools for catastrophic claims (defined as claims that cost over a certain amount) has merit. These high-risk pools could be state-funded pools like many states had before the ACA, or it could be a large federal pool. If we can keep the most expensive claims out of the individual risk pool — while still providing coverage to those families — it will lead to predictability in pricing. In Iowa, one claimant is driving nearly 10% of the 2017 rate increase for one of the companies offering coverage to Iowans. That family needs coverage but, if the coverage was provided through a mechanism where the costs are spread to society in general and not to the small pool of individuals using a single insurance company, costs for individual health insurance could be kept more manageable and predictable.
  2. Eliminate the mandate. Instead, allow people to enroll in health insurance only once every two or three years, unless they have a proven special enrollment event. Let companies validate the special enrollment with an appeal available to a third party or the state department of insurance.
  3. Shorten the grace periods to 30 days. There are stories all over the country with people gaming the lengthy grace periods.
  4. Abandon metal tiers. There are no platinum plans in Iowa and few gold plans. Look at better ways to judge and compare plans.
  5. Review the need for prescriptive essential health benefits. Require carriers to have two or three standard plans, similar to how Medicare Supplement plans are standardized. Then carriers could also design and offer non-standard plans.
  6. Move the age band back to 5:1. At 3:1, the younger, healthy people feel penalized and are priced out of the market. Getting younger people into the pool will stabilize the rates for everyone.
  7. Encourage innovation in the market. Encouraging innovation with limited underwriting rewards healthy people, similarly to how lower-income folks are given incentives through tax credits. Allow consumers to be rewarded with healthy behaviors, and allow companies to innovate on product design.
  8. Look at health savings accounts as a means to increase consumers’ pricing awareness. If this is adopted widely, look at ways to fund health savings accounts for certain lower-income Americans.
  9. Publish healthcare prices and create objective quality benchmarks and metrics for consumers to review. This will help inform consumers about price and quality. In the current market, individuals have no clue what healthcare-related procedures and items will cost us. We are more price-aware buying a refrigerator than we are when having a heart procedure. That needs to change.
  10. Fix the 3 Rs. Abandon risk adjustment and risk corridor and continue a public reinsurance option.

Much has been written about selling insurance across state lines. I do not see that as a major factor to help drive down costs. Those insurers that would sell across state lines would have to comply with applicable state mandates and would still have to build a network of doctors for competitive pricing. New companies can enter states today with ease, and many companies sell in multiple states. The issue is the cost to contract with doctors in those states. More competition in insurance sounds good, but if those carriers cannot get enough scale to get competitive pricing arrangements with providers, they will be priced out of the market.

See also: What Trump Means for Best Practices  

This is hardly an exhaustive list, but we need to start somewhere. Many more things must be reviewed in the healthcare economy, such as the cost of prescription drugs, emerging technologies and end-of-life care. However, looking at the financing of healthcare and insurance is the logical place to start — money always is front and center. My hope is that reasonable people come together to address this challenge.

What Trump Means for Healthcare Reform

With the (surprising) election of Donald Trump as America’s next president, I’ve been asked by quite a few folks what this might mean for the Patient Protection and Affordable Care Act, especially as it relates to individual health insurance. It’s been more than seven months since I posted anything in this blog (been busy launching a couple of companies), but I thought I’d use this space to provide my perspective.

For the impatient among you, that answer is: either a complete disaster or some modest fixes that actually improve the ACA. Dramatic, but non-lethal, changes are unlikely.

As for the details: Trump’s call to repeal and replace the ACA was core to his campaign. His official health care reform platform promised to:

  1. Repeal Obamacare in its entirety.
  2. Permit the sale of health insurance across state lines.
  3. Allow individuals to fully deduct their health insurance premiums.
  4. Promote health savings accounts (HSAs).
  5. Require all healthcare providers to publish their pricing.
  6. Provide block grants to states for Medicaid expenses.
  7. Remove barriers that delay the introduction of new drugs.

Some of these ideas, such as promoting HSAs and increasing pricing transparency, have merit. Some, like enabling carriers to sell across state lines, are nonsensical for several reasons I have described previously. None offer much solace to the 20 million-plus consumers in danger of losing their individual coverage if the ACA is repealed. Trump and his Republican allies in Congress will need to do more.

See also: What Trump Means for Workplace Wellness

I hesitate to predict how Trump will lead as president, but he seems to be  a “big picture guy” who leaves details to others. So let’s assume he lets Congress take the lead on repeal and replace. In December 2015, Republicans in Congress passed legislation aimed at gutting the ACA. President Obama vetoed the bill, but its major provisions are instructive:

  1. Repeal the federal government’s authority to run healthcare exchanges.
  2. Eliminate premium subsidies available to individuals purchasing through the exchange.
  3. Eliminate penalties on individuals for not buying coverage and employers who failed to offer their workers health insurance.

Combined with Trump’s campaign promises, these elements of the Republicans’ repeal-and-replace legislation give a glimpse to the starting point of GOP-style healthcare reform. Add House Speaker Paul Ryan’s call earlier this year for high-risk pools, and the hazy outlines of a possible reform package begin to emerge.

Given Trump’s commitment to start the repeal-and-replace process on the first day of his administration and Senate Majority Leader Mitch McConnell’s statement after the election that getting rid of the ACA was “pretty high on our agenda,” healthcare reform is coming — and soon.

Whether the result will be an outright, actual repeal of President Obama’s signature legislative accomplishment is no sure thing. Supporters of the ACA are already vowing to defend the law. And while Republicans will hold majorities in both chambers of the new Congress, they are a long way from having 60 votes in the Senate. And that’s problematic.

Senate filibuster rules require 60 votes to cut off debate and allow legislation to come to a vote. This means the most powerful person in Washington on healthcare reform may not be President Trump, Speaker Ryan or Senator McConnell, but the senator needed for that all-important 60th vote. Yes, the first through 59th supporters are important, but their support means little if a 60th vote is not found. As a result, the 60th senator can have a tremendous impact on the final language in the bill simply by offering (implicitly or explicitly) a favorable vote in exchange for whatever is important to that senator.

In 2017, the 60th senator for repeal and replace will be a Democrat. A Republican is expected to win Louisiana’s run-off election, giving the GOP 52 seats in the upper chamber. Assuming Republicans vote as a block — something they’ve become quite adept at in the past eight years — eight Democratic votes will be needed to end a filibuster. The requests of each of the first seven will need to be considered and addressed, but it’s the demands of the eighth senator, that 60th vote, that ultimately matters. Unless …

The Senate can temporarily eliminate the possibility of a filibuster against a bill under the rules of budget reconciliation. However, reconciliation bills must address the federal budget, a vague definition that Congress has interpreted with varying strictness throughout the years. Clearly, eliminating funding for exchanges, taxes and monetary penalties affect the budget. Much of the ACA, however, doesn’t. For example, requiring carriers to issue individual policies to all applicants regardless of their health conditions (what’s called “guarantee issue”) has no impact on the budget.

The situation in the Senate creates dangerous possibilities. Just one example: Republicans use the reconciliation process to eliminate penalties paid by consumers who fail to purchase health insurance but not the guarantee issue requirement. Under this situation, few consumers — especially young, healthy consumers — will likely obtain coverage until they get sick or injured. This adverse selection would be cataclysmic, and few, if any carriers, would want to participate in such a market. After all, insurers are in the business of spreading risk across a broad population. Guarantee issue without an obligation to buy coverage guarantees a concentration of risk across a narrow population.

See also: Why Can’t U.S. Health Care Costs Be Cut in Half?  

President Trump can significantly affect the Affordable Care Act through executive orders, but the risk is the same as a partial repeal through legislation. The ACA is a multi-faceted construct with interlocking pieces. The wrong changes can cause devastating unintended consequences.

Republicans in Congress and President Trump may not care. The ACA has taken on nearly mythic proportions as the symbol of all that is evil with the liberal, big-government side of politics. However, making careless changes would not only be irresponsible, it would risk the wrath of millions of voters tossed out of the individual market. Those votes matter. Keep in mind, Trump’s election was close. He lost the popular vote. His leads in Wisconsin and Michigan add up to a combined total of less than 40,000 (as of today).

Yet failing to repeal Obamacare after making it so central to their 2016 campaigns could be a political disaster, as well. Republicans jumped on replace and repeal in 2010, and over the past six years this position helped deliver durable GOP majorities in both houses of Congress. Many in their ranks may not care about the consequences of dismantling the law.

Assuming a desire to address healthcare reform in a responsible way will require the help of at least eight Senate Democrats. Fortunately for Republicans, 10 Democrats have an incentive to responsibly neutralize the ACA issue in 2017. All are up for election in 2018 and hail from red or nearly red states.

  • Sen. Tammy Baldwin of Wisconsin
  • Sen. Bob Casey Jr. of  Pennsylvania
  • Sen. Joe Donnelly of Indiana
  • Sen. Heidi Heitkamp of North Dakota
  • Sen. Tim Kaine of Virginia
  • Sen. Angus King of Maine (officially an independent, but he caucuses with Democrats)
  • Sen. Joe Manchin of West Virginia (and arguably the most conservative Democrat in the Senate)
  • Sen. Claire McCaskill of Missouri.
  • Sen. Debbie Stabenow of Michigan
  • Sen. Jon Tester of Montana

The important question, then, is not what Republicans want to replace the ACA with, but what will it take to get enough of these senators to come along? The task could be extremely difficult if new Senate Minority Leader Charles Schumer doesn’t make it politically impossible for many of these senators to break ranks.

Republican then have two choices:1) Go nuclear and gut the ACA through the reconciliation process, but keep in place market reforms like guarantee issue; or 2) pass something palatable to eight Democrats, but which they sell as “repeal” to their base. Clearly the first option is irresponsible, but these are not necessarily responsible times. Nuking the ACA will appeal to many in the party, both in Congress and in their districts.

The more responsible choice, repealing the ACA in name only, makes the law more palatable and workable. This last point is critical: once they repeal and replace the ACA, the GOP will own health care reform. It darn well better be clear by say, October 2018, that the new system is working.

Which result — destruction or refinement — is most likely? We’re in a new and wacky world. We’ll find out soon enough.

How a GOP Congress Could Fix Obamacare

Republicans are primed to take over Congress. A new FiveThirtyEight.com projection gives the GOP a 60% chance of winning the Senate this fall. And, according to RealClearPolitics, there’s virtually no chance Democrats will take the House.

If the GOP succeeds, public displeasure with Obamacare may be why. A recent poll from Bankrate.com found that more than two-thirds of voters say that Obamacare will play a role in how they vote in the coming election. Nearly half said it would influence them “in a major way.”

Of course, the next Congress has little hope of repealing Obamacare outright. The president would just issue a veto. Overriding it — though technically possible — would be difficult with an intransigent Democrat minority.

A GOP majority should instead focus on incremental reforms with bipartisan support — like tax cuts, regulatory reforms and repeal of some of Obamacare’s most unpopular mandates. That’s the most effective way for lawmakers to move our health care system toward one that puts markets and patients at its center.

Step one? Repeal Obamacare’s medical-device tax. This 2.3% excise charge on all device sales is expected to collect $29 billion over the next decade, according to government data.

Device firms are compensating by cutting jobs. Stryker, for instance, has cut 5% of its workforce — about 1,000 people. Zimmer Holdings has chopped 450 jobs. In total, Obamacare’s device tax could kill 43,000 jobs, according to Diana Furchtgott-Roth, an economist at the Hudson Institute.

Getting rid of the tax is a no-brainer. In March 2013, 79 senators — including 34 Democrats — approved a non-binding resolution calling for its repeal. It’s time to make that vote binding.

Second, a GOP-controlled Congress should strengthen health savings accounts. These financial vehicles allow patients to stow away money tax-free for medical expenses. HSAs are typically coupled with high-deductible health insurance. Patients bear the cost of routine care, and coverage kicks in when needed, like in the event of a medical emergency.

HSAs give patients a financial incentive to avoid unnecessary medical expenses. Converting someone to HSA-based insurance drops her annual health expenses by an average of 17%.

This year, 17.4 million people are enrolled in HSA-eligible plans — a nearly 14% increase over 2013. Among large employers, 36% now offer HSA/high-deductible plans, up from 14% five years ago.

Annual HSA contributions are currently capped at $3,350 for an individual and $6,550 for a family. Congress should raise them to $6,250 and $12,500, respectively. And patients with HSA coverage through the exchanges should be eligible for a one-time, $1,000 refundable tax credit to be deposited directly into their account.

Third, the new Congress should reform medical malpractice. Frivolous lawsuits and the threat of baseless litigation are increasing health costs and degrading quality of care.

Excessive malpractice suits drive “defensive” medicine, in which doctors order unnecessary procedures and tests simply to shield against accusations of negligence. This practice costs the country an estimated $210 billion every year, according to PricewaterhouseCoopers. Injecting common sense into the medical tort system would bring down that bill.

Earlier this year, the House Energy and Commerce Committee passed a bill that restricted lawsuits against doctors by, among other things, limiting non-economic damage judgments to $250,000. It was effectively ignored once it moved out of committee. Republicans should dust it off and pass it.

Finally, the GOP should repeal Obamacare’s employer mandate, which slaps midsize and large companies with a fine if they don’t provide sufficiently “robust” health coverage to full-time employees.

The mandate is destroying jobs. Employers are holding off on hiring and ratcheting back workers’ hours to avoid additional insurance costs. A Gallup poll found that 85% of businesses are not looking to hire. Nearly half cited rising healthcare costs.

There’s ample political support for repealing the employer mandate. The administration has already unilaterally — and maybe illegally — delayed its implementation. Several prominent backers have openly called for repeal.

All of these reform ideas are imminently actionable. They could find broad bipartisan backing and avoid a veto. Most importantly, they would move U.S. healthcare closer to a consumer-driven system, with patients empowered to control their own spending and market forces pushing costs down.

When Leaders Don’t Lead on Medicaid

The big debate across the states over the expansion of Medicaid only deals with half of the equation.

The first half of the equation is political: who gets added to the entitlement rolls and who doesn’t. Wisconsin’s Gov. Walker, for example, decided to: turn down federal funds for expanding coverage; add 80,000 adults who are below the poverty line; and move some 70,000 residents who are above the line to the new federal exchange and subsidies.

But Wisconsin, like other states and the federal government, has ducked the rest of the issue: the staggering cost increases. Medicaid expenses, for which the states pay about 40% and the feds 60%, are crowding out funding for just about every other priority: K-12 education, the university system, environmental advances and economic development.

It’s the same story on health costs at the federal level. Medicaid, Medicare and the health bill for federal employees are the biggest driver of the crushing federal deficit. One recent secretary of defense said the department spends more on health costs than on weapons.

The void in the debate is the deafening silence on how to get the costs under control, with the exception of cutting people off the rolls.

It’s especially sad because there are solutions. Leading-edge employers in the private sector have put together a new business model for the delivery of health care that drastically lowers costs while improving health. Their best practices are applicable in the public sector, as some units of local government have discovered to great advantage.

Here are some proven, audited, beyond-debate cost-cutting moves that could be made with Medicaid plans:

  • Consumer-Driven Health Plans (CDHP) — Indiana has received a waiver from the Obama Administration to install Health Savings Accounts and to set higher deductibles for Medicaid recipients. Such CDHP plans cut costs by 20-30%. School districts and counties have deployed HSAs, as has Indiana for state employees and Purdue. Medicaid is rife with utilization abuse, because of an absence of such incentives and disincentives.
  • Reference Based Pricing (RBP) — CALPERS, the giant California pension fund that buys health care for 1.3 million members, has installed caps on procedures, such as $1,500 for colonoscopies and $30,000 for joint replacements. It’s easy to pay twice those maximums or more. But why do it? Why not RBPs for Medicaid? Note: A good number of providers have accepted the maximum prices.
  • Medical Homes — Another 20-30% can be cut from medical costs by offering proactive primary care. Many companies have set up on-site clinics to provide holistic care and keep people out of expensive hospitals. Why not set up medical homes where there are concentrations of Medicaid patients? Primary care is a lot less expensive than specialty care, the main offering of large hospital corporations. It’s also less expensive by far than care from emergency rooms, to which Medicaid entitlees often default. Obamacare provides some funds for community health centers, so there is a start for such medical homes.

The biggest problem for introducing aggressive and innovative management into Medicaid dynamics is the joint ownership of the program by federal and state governments. Differing agendas produce stalemate in most states. And, in the void, the costs scream upward.

Gov. Walker turned down the new federal dollars for a larger Medicaid program because of skepticism about the long-term availability of federal dollars. The soaring, unsustainable cost increases give substance to his position.

But his worry should be redirected to the costs. His concerns could be mitigated if the overall charges were sharply reduced.

He would look presidential if he followed the lead of private sector payers. That, again sadly, is in the political arena, so he probably wouldn’t get a federal waiver from the Obama administration for innovations, even if Indiana did.

Who loses in the managerial paralysis, when leaders don’t lead? In the case of Medicaid, it’s the taxpayers and poor people.

Three Ways to Fix Health Insurance (No Matter What Happens With Obamacare)

Whether Obamacare is fully implemented or collapses under the weight of its 906 pages of law, its 15,000 pages of regulations, and the well-publicized glitches in its rollout, the underlying, ineluctable problems with health insurance remain largely unresolved. How we respond will determine whether we hit the iceberg and sink or veer away in time to save our private health care system.

To understand some of the real cost drivers for health insurance, let’s look at the “Doe” family. John and Jane Doe pay $600 per month for health insurance for their family of four. Most states have a list of benefits, or “mandates,” that, by law, insurers must cover – from gastric electrical stimulation to breast implant removal. While some states have fewer mandates, others have piled them on. (Utah has 26, while Rhode Island, Maryland, and Minnesota all have at least 65.) The Doe family could see savings up to 50% or more on their insurance rates if they could just buy a basic health plan without the mandates. That could drop their monthly premium to as low as $300.

Premiums would come down even further if tort reform ended “jury lotto,” where patients get large, unjustifiable settlements or jury awards for medical treatment gone awry. While doctors are human and are certainly capable of errors, the legal system allows for these big settlements even when doctors are not at fault.

Here’s the scenario: Imagine that Doctor Smith treats a woman who complains of an ear infection and gives her a prescription, telling her to call if the condition doesn’t improve. The woman dies a few days later from a brain tumor. The family sues, alleging the doctor should have been able to diagnose the tumor. The jury sympathizes with the grieving family, believes that doctors should be omniscient, and reasons that rich doctors and their insurers can easily afford a large payment, so the family receives a $10 million award. The pestilential result is that everyone’s health insurance rates go up to cover such settlements, the doctor’s malpractice rates increase, and he now orders extra tests for the next patient to protect himself from the next lawsuit.

Tort reform could provide significant savings to the health care system, resulting in insurance premiums dropping as much as 10%. The Doe family might now see its insurance rate go down to as low as $240 – a whopping 60% drop in their monthly premium.

(Some have talked about allowing consumers to buy across state lines to reduce premiums even further by increasing competition and making it easier to buy policies in states that mandate fewer benefits, though this has not yet been shown to be true.)

A third way to drive insurance rates down is consumer engagement – changing the dynamic so that people actually know and care about what their health care costs. As long as it is Other People’s Money (OPM), there is little incentive to lower the cost of care, which continues to rise and, in turn, drives up insurance rates. (Contrary to public opinion, a recent analysis by the accounting firm PriceWaterhouseCoopers found that health insurers pay an average of 87 cents to providers of medical and pharmaceutical services out of each premium dollar and, after expenses, earn just three cents in profit. The problem, then, with health insurance isn’t that insurers are gouging people; it’s that costs are high, and consumers are generally unaware and unconcerned.)

So how can we get engaged? Even while we wait for the regulatory and legal changes that will need to occur to reduce mandates and rein in unjustified malpractice awards, here are two things for consideration in lowering health care costs.

First, we need to change our mindset as consumers when it comes to health insurance. What if we treated health insurance more like homeowner’s insurance? In other words, what if we bought coverage for the unexpected (illness or injury), while paying for our day-to-day medical needs out of pocket, as we do for home repair and maintenance? Great insurance options to consider include high-deductible health plans with linked Health Savings Accounts (HSAs). In general, we need to shift our thinking on health care from OPM (Other People’s Money) to MM (My Money).

Second, how about a radical “Groupon” type of approach? Let’s say John Doe is diagnosed with a hernia and needs an operation. There are three hospitals in town. All three are fully credentialed and meet quality standards. John’s surgeon can admit to them all. Hospital 1 is an older, traditional facility in a more frugal setting, with an estimated cost for the surgery at $10,000. Hospital 3 is a new, state-of-the art “Hyatt” hospital with high end amenities and a fancier environment – estimated cost: $50,000. Hospital 2 is in the middle, with an estimated $25,000 price tag. Here’s what John’s health insurance company tells him:

“You are covered at all three hospitals. But if you go to hospital 3, you have an additional $2,000 copay. If you go to hospital 2, we’ll cover the cost at 100%. If you go to hospital 1, we’ll pay you $2,000. Your choice.”

John is comfortable at hospital 1 and likes the idea of getting rewarded for choosing a lower cost setting. He has his surgery done there. He gets the $2,000, while the insurance company saves $38,000 off the cost of hospital 3.

This kind of savings will eventually be reflected in lower premiums for everyone. Decisions like John’s will also encourage hospitals to lower costs, as market forces come into play, leading to even more reductions in insurance costs.


We are not going to reform the health care system and resolve our health insurance problems overnight. And even if Obamacare is fully implemented, we still need to make fundamental changes, including how we see and use health insurance as consumers. If we are going to steer the Titanic away from the iceberg, we as consumers need to change our mindset and get engaged – and have financial incentives to do so, leading to powerful market forces. Once the sleeping giant of the American consumer awakens, watch out.