It’s Time to Turn Health Insurance Around

When employer paid health insurance became a tax-deductible expense in the 1940’s employers jumped in with the idea of providing employees a different type of compensation to attract and retain talent. I would bet they could not have imagined the health insurance world of today where the cost of health insurance significantly impacts profitability and employers are forced to deal with managing the health of their employees. The reaction of the industry insiders over the past 20 or so years, but even more so since the passage of Obamacare, has been to push employers even more into the path of this health care cyclone by having them take on even more risk and responsibility. Many have joined coalitions to perpetuate this misguided trend. I would contend that the reason for skyrocketing costs is the perpetuation of employer-based health insurance promoted by interested industry insiders. I say it is time to turn this trend around. It is time to move the risk and responsibility away from employers and onto where it belongs, which is the health care system and the patients.

I have written in previous articles that the two major financial frauds in the U.S. that are causing financial harm to millions of people are the costs health care and college education. In both cases, third-party payors fund the costs (often temporarily and indirectly) and the insiders have no incentive to stop the cost escalation. In both cases it is the system that drives costs up because there are few built-in incentives to control costs. And even those that try to control costs may be doing so with good intentions, but most continue to support the “system” that is designed to protect the status quo and drive costs up.

In the health insurance business, for the past 25 years we have seen many efforts to control health care cost. From HMO’s to PPO’s, claims management and prescription drug programs, wellness programs, and other incentives to modify employee behavior, have all failed. Over the past few years we have seen the proliferation of efforts to try to control costs by shifting more risk and responsibility to the employers who have often then pushed more risk onto the employee. Smaller and smaller firms have turned to self-funded plans. Deductibles have risen significantly for the employee. Many consultants have been promoting referenced-based pricing policies, that I think are “desperation” only policies. All these programs shift the risk and responsibility towards the employer and employee.

The insurance companies have also been shifting risk. They are using claims experience on smaller groups to adjust pricing when there is no statistically valid reason to do so. They “laser” underwrite, which means if a group comes up with a big claim and can’t move their insurance, they get a big rate increase and are told, “well, you have a large claim”. For self-funded employers they may change the insurance limits for that one claimant. This is not insurance.
Employer-based insurance policies are one-year term policies, meaning rates are adjusted annually for a period of one-year. Most small businesses can’t afford to assume the risk of a large claim and the increased premiums related to that claim, which is why they buy insurance in the first place. A one-year term policy for a group health insurance program is simply a flawed concept. Health insurance needs to be priced over a longer term like other high-risk types of insurance.

There are many benefits consultants pushing employers more into the health risk and responsibility business. They say, “you are in the health insurance business, get over it”. I contend that employers want out. Business owners don’t start businesses to be in the health insurance business. They don’t come to work wanting to control their health care costs. I say it is impossible anyway. There may be some stories of short-term success here and there but for the most part, they don’t want to be doing this and they shouldn’t be. The health of one’s employees should not be the risk or responsibility of an employer. They can care about an employee but not assume the risk. And then they hire an employee whose spouse is pregnant with triplets. As Mark Bertolini, ex-CEO of Aetna, said when asked at Stanford, “how do you create a more educated consumer…so they utilize the system appropriately”. He responded as follows, “trying to educate everybody on how the health care system works and the level of detail isn’t going to work”. The idea that employers and employees can manage health care and health care costs is a far-fetched idea. Ask anyone being rushed to a hospital in the back of an ambulance what they are thinking at that time.

The good news is that there is a whole new health insurance and health care system that is evolving that will turn things in the right direction. One of the catalysts to this change is the recent Executive Order by President Trump that will allow an individual insurance purchase through an employer-sponsored Health Reimbursement Account. This one change will remove the handcuffs from a system that needs to move the risk and responsibility into the right hands from the employer and insurance companies to the consumer and providers of health care. Health care will become more personal and less expensive. Health care will be more about keeping people healthy rather than fixing them after they are ill.

When imagining a new health insurance and health care system one needs to remove today’s version from one’s mind. The new system will be much different from today. Who employees buy their insurance from will be different. No more one-size fits all from employers. The types of plans will be different. No more PPO’s. Imagine no deductibles or copays and no paperwork. No more annual 10% increases in health care costs for employers or employees. Imagine knowing about an emerging health condition before it happens.

The time to change is now. Employers need to rethink the way they view health insurance in their organizations. They need to engage consultants who don’t support the status quo, which is the current system. It is time to turn health care around, so let’s be part of the solution.