Health Insurance Exchanges Will Transform Health Care. Magically Increase Transparency. Improve Access. And Maybe Even Lower Costs. But Only if We Get it Right …

NPR ran a story recently about how some retailers are retooling efforts to appeal to consumers in light of increased competition, particularly from online vendors.

Many are striving to be more “customer friendly”; Kohl’s department store was mentioned for adopting a “no questions asked” return policy with the idea that customer loyalty could be enhanced as the retailer made itself easier to do business with.

Comparisons between health care and retail abound, and while we say it is ideal for the consumer experience to be the same in both industries, in fact they are much different. The gap between the two industries was well-illustrated in this video of a shopper in a grocery store. We see them at the counter having their items rung up. But they aren’t told the prices and when they are given the receipt at the end, they’re told the final amount due may actually differ from what they see on the receipt.

Let’s take the analogy a step further: what if the customer expected the same “no questions asked” return policy from Kohl’s? Or a money back guarantee? In health care, only recently has the federal government taken steps to impose financial penalties in instances of poor care (which is the health care system’s equivalent of a “return policy” from providers).

When our team was at Subimo we initially focused on cost and quality (outcomes) information on hospitals. It was clear that – for the same procedures – there were both low cost and high quality providers as well as high cost and poor quality providers. Our efforts with transparency were designed to help people sort through the information so they could make more informed decisions and understand what quality outcomes might mean to them. We knew there was much variation in outcomes with certain procedures (e.g. aortic aneurysm repair) and less variation with others (e.g. normal vaginal delivery). Helping people understand when a poor outcome was more likely to occur helped them with their decisions (and presumably made them better shoppers).

And now our team is providing the latest expression of consumerism in health – private exchanges and online shopping platforms that are designed to help consumers wisely spend their benefit dollars while addressing cost considerations of employers. Private exchanges that provide personalized benefits for consumers and transparency around the price of insurance as well as the employer’s contribution continue to sustain my optimism when it comes to the goal of making health care more oriented towards consumers. I truly believe that transparency and personalization will not just expand but will become touchstones as consumers learn to navigate the health care system, from choosing insurance to finding providers, products and services.

Even with my optimism and with all the market buzz about exchanges, I can’t help but be reminded of disconnects between health care and retail shopping, especially when the differences surface regularly and are so easily remedied. Case in point: Hurricane Sandy caused a longer stay than anticipated on the East Coast, leading to a shortage of prescription medications. I first called our pharmacy benefit manager, asking for a one week supply of meds to be filled at a local Virginia pharmacy. They told me to call the insurance company. Our doctor called the Virginia pharmacy who then called our insurance company for an “override”. The override was approved for five of six prescriptions but declined for the sixth. Why? The patient lives in an area (Chicago) that was not affected by the hurricane. Even though the patient was in Virginia, and not in Chicago. Even though the other five prescriptions were approved. No amount of dialogue could change the insurance company’s decision and the void of logic and common sense (not to mention customer service) was astonishing. I can’t imagine a service person at Nordstrom’s not anticipating this and working proactively on their client’s behalf, especially if they worked at the doctor’s office.

So while I am heartened by how consumer-driven health care has become – retail clinics, quality rankings as examples – I’m reminded that we are only as consumer-centric as our weakest link(s). For every example I have, I know that there are many more. There are plenty of weak links throughout the healthcare system. Like Kohl’s, each of us can look at the top things that make our business difficult for people to deal with. With often only modest effort, we can make changes to significantly improve the consumer experience, lower frustration and minimize confusion.

While technology and financial realities accelerate consumer-oriented innovation like insurance exchanges, I am mindful that the entire industry has to ensure that every facet of the business reflects the same level of consumer orientation. We each need to fix our weakest links if we want to see innovation deliver on its promise.

Ann Mond Johnson is the chairman of board of managers of ConnectedHealth, LLC.

46 replies »

  1. I truly believe that visibility and customization will not just increase but will become touchstones as customers understand to get around the medical care system, from selecting insurance to discovering suppliers, goods and services.

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  2. After reading through most of the comments here I realized very quickly that many of you are feeling the pain of high prescription costs and poor prescription drug benefits. While recently helping a family friend navigate through the Prescription Assistance programs offered by the major pharmaceutical companies we developed an easy to use service for other to be able to take advantage of the free medication programs that are offered. In most cases, you can receive your meds for FREE from the pharmaceutical companies. Over 4200 medications are covered under the PAP programs.I strongly encourage you to visit http://www.redemedllc.com so you can read about the prescription drug program assistance that they offer. The folks at Redemed are a family operated organization that truly believes that you should not have chose between buying your medications and feeding your family. This is not SPAM or a scam, it’s a truly innovative approach to helping people and it works! I hope you take the time to explore your options and visit the website to see how you can save hundred if not thousands of dollars on your prescription drug costs.

  3. Yikes! I think I’m going to bow out of this one…I seem to have got way in over my head. I’ll just crawl back to my little Health Conscious Movement at Facebook@TheHealthConsciousMovement and keep trying to squeak about changing the world by changing ourselves first, painfully, one at a time :). In the meantime, we can all have a happy holiday with my upcoming article that’s going to be published on http://www.kevinmd.com called “What advice could I give to the next generation of doctors”…I wonder what that could be??? Blessings, and have a Happy Fantastic Holiday!!

  4. Takes one to know one, jerk!

    You just can’t leave it alone, hope ya choke on it!

  5. People live too long as a whole, we keep people at younger ages alive too long that natural selection would appropriately end with respect,

    That’s pretty fucking cruel and simplistic. Predictable, from you.

  6. My comment was not a shot at you, but to certain commenters. Sorry if I offended. They give the impression those who dissent are alien.

    I liked your comment.

  7. Thanks! I love a frank discussion! Happy Holidays to you, too! And I agree with you about communities. I hope your assessment isn’t true. Maybe it is, but I hope it’s not.

  8. Sigh. You’re right, it is so hard speaking a different language. I’m so sorry, Dr. Determined ;( Can you ever forgive me?? Here’s something interesting. Like all paradigms, shifting our thinking is painful and slow, and met with little comprehension from nay-sayers who still struggle to figure out why we ended up in the place we are today, through their actions from yesterday. I think America is going through this crisis, but it applies to all aspects of our life, not just healthcare. Which is probably why we’re still struggling to understand that health won’t be found through disease-oriented pursuits, but we keep sticking our heads back in the sand, trying to convince ourselves it can. It’s sort of like understanding the Earth revolves around the Sun. I believe it took 300 years for the last of the geocentrists to admit that Copernicus was correct (were you one?). Talking about more incremental fixes….well, haven’t we been there before??? Isn’t it time to turn our eyes and thoughts toward something very different than what’s been done before to ensure change? There’s a tipping point inherent in systems, and America’s about to reach it…like really soon. Time is not on our side. But hey, keep talking and not doing. It sounds like you’re ready to retire anyway, and won’t have to worry about the mess you leave behind…

  9. My last comment for this thread.

    I’ve talked about solutions plenty since first commenting here. The majority of commenters aren’t interested in reality, because most have just pressed for PPACA to stay in place and either hope, or deceive, that things will proceed fine and people will have quality of care at realistic pricing.

    Mandating is always wrong, irregardless of the twisted perspectives others continue to echo. People have the right to say “no”, and then deal with the consequences. But, Democrats and socialists want all to suffer, and believe me when I say with conviction and past history as support, the loudest proponents of policies like PPACA either do not participate, or are joyfully oblivious to what awaits them if they do cooperate with the masses.

    People live too long as a whole, we keep people at younger ages alive too long that natural selection would appropriately end with respect, and create much too much false hope for loved ones watching the ill linger without real quality of life at the end. Furthermore, technology has created false pretenses that people like me as an MD have to endure this press for “cures”, complete symptom resolution, and more and more forced to sign off on patient derived treatment plans that are not grounded in health care limits.

    Let’s face it, sometimes lines in movies or books are so prophetic, and Jack Nicholson’s character in “A Few Good Men” hits it out of the park: “You (the public) can’t handle the truth!”. We are not going to “cure” dementia, people with end stage cancer can’t run up multi hundred thousand dollar costs for less than effective interventions, Nursing Homes will not house tens of millions of elderly by the next decade, and the biggest that is both painful to note, but is also painful to ignore, the plight of our servicemen/women coming home from the Middle East with chronic injuries that technology has prevented death, but, as Bram Stoker wrote, “there are worst things than death”.

    I despise most politicians in office these days, but, find the Democrats the most deplorable of late because they flagrantly sell they “care” more than Republicans, but the Democrat actions are equally putting the public at more risk, just not as overtly as what the Republicans have done prior.

    Partisan politics has poisoned this society, and really, most Americans either don’t give a smut, or, think it will just go away magically while they continue to bury their heads in front of screens. Here’s a hypothesis to enlighten and intrigue: know why we have not had another serious terrorist attack since 9/11? Because the terrorists aren’t so stupid, they can see we are destroying ourselves with our fairly true decadence and lack of attention to the communities we live in. I’ll bet that if all the usual commenters had a moment of candor, they as a group larger than 60% could not tell you how long their neighbors have lived near them in the block they reside. You know why I propose this sad theory? Because most people who embrace technology as I sense most who comment here do, they don’t interact, they just “friend”, and how “common” that term has become!

    Well, we’ll see what future post will enlighten or annoy. Happy Holidays.

  10. I probably agree with you more than you realize, I just prefer to talk about solutions. I also believe it’s not as easy to lose weight, stop smoking, stop drinking, etc. Look at how difficult it is to get people with eating disorders to start eating again. It’s all too easy to look at life via a rational view, but I’m not sure that gets at all the unconscious and emotional motivations we’re subject to. Bottom line – I think we can serve patients better, and until I’ve explored all those options, I’m not ready to write whole populations off. Yes, we have to be careful with resources. Yes, I’m hoping we have more solutions that come from the private sector as I’m suspicious of government control myself. That’s what excited me about the mHealth Summit – a lot of people figuring out how to deliver non-pharmaceutical, interactive interventions that could deliver real value to people. If you put yourself in an unfamiliar environment and gave yourself the same attention to learning something new and perhaps not in your strength area, you perhaps can relate to patients who come to a physician office for a simple or complex problem; get asked a bunch of questions and perhaps fill out a survey or 2 (“are you depressed?”); have a short time period to address both what they want to discuss PLUS get told to stop smoking and take this anti-depressant; and leave with (at best) a “visit summary” that could have been completed before they even entered the room based on their “reason for the visit” taken at the time the visit was scheduled. Even an “above average” patient may have difficulty managing all that, especially if they’re not feeling well.

  11. What the Left/liberals/progressives are unfortunately somewhat effective in blurring are the boundaries of life and cultural standards that maintain societies. I hate overtolerance as much as intolerance, and that is what was one main element of this past election. These people, who I firmly believe really do not make real sincere efforts to practice what they preach, just pass laws and browbeat people into accepting their failed premises, are just as lame and disruptive as their republican counterparts.

    PPACA is going to fail for numerous reasons, by providers, patients, the health care insurer system, hospitals, and ancillary care parts. Politicians have no business setting the standards of care for at least 2 reasons, in order of importance: one, they really don’t care, they just legislate, which historically does not take into account caring, but convenience and often distraction or displacement, and two, they do not understand the inherent limits and boundaries that exist in health care. And this bunch in office for the past 10 plus years, are the lamest and most frightening group of people ever to be in position to allegedly lead a society of this magnitude.

    Imagine, we have the financial problems at hand that has been going on front and center for over a year, and they are still bickering, posturing, and focused on themselves and special interests first well into this month now, and if you have any background in health care ethics and responsibilities, that is contraindicated to the basic tenets of care. And yet, the Democrats and their ilk act like they not only know better, but have the sheer audacity to be threatening if not the usual ignorant dismissals they shrug at dissenters since the debate started in 2009.

    This law will not make things better, and example A to this was passing the law to not fully implement it for 4 or more years. That is not legislation, that is manipulation and mismanagement. And don’t look to any partisan hack to have a moment of revelation and candor, that is counterproductive to the “cause”.

    People live, people die, and yet if we continue to listen to this bunch, they will try to convince you that the laws of life do not apply in DC.

    The District of Corruption!

  12. See what you think of this. I was sitting in a resort restaurant looking over a lake in Wisconsin when I noticed a man in his 50’s darkly tanned, smoking and drinking a beer. He looked like he had had many cigarettes and beers in his lifetime. I imagined having a “lifestyle” discussion with him and thought he might not be receptive. I was wondering if we should have people decide when they are 25 (30 for men? They mature later? Or is that discriminatory?) if they want to (1) pay more because they want to life a risky life; (2) pay the same and get no care for conditions they caused themselves; or (3) behave (with verification of blood level checks) and get “optimal care” for the standard price because at least they tried. I, personally, would not like to live in that society – Nazi Germany tried a similar scheme that also included a genetic component (euthanizing orphans because they were likely not to be likely to have productive progeny when both their parents died prematurely). A much younger classmate in an ethics class actually wrote a paper saying people should be euthanized when they are no longer productive. Although I think it was meant to be provocative, it made me stop and think about what could happen.

    As a Christian, I’m sorry that our religious institutions have left the care of the vulnerable to government programs and pulled back from their traditional roles of caring for those who can’t afford to care for themselves. I can understand your frustrations trying to care for people unprepared for death, but I hope not to live in a society where people are left to die in the streets because they don’t personally have the resources for their own care.

    By the way – I truly appreciated the mHealth Summit for at least trying to bring useful tools for those people who need more effective and efficient ways to obtain the care they need. Maybe we have a whole new generation of people who do want to take care of themselves! At a health reform roundtable session I sat next to a young woman who came because she wanted to voice her opinion that she shouldn’t need a prescription to get her insulin. She said, “I take care of myself; why should I have to pay $200 4 times a year just because a doctor has to write a prescription? I’ve been taking care of myself for 20 years – I know more than any physician how to do it!” Hard to argue with that! Maybe DIY medicine is right around the corner!

  13. What is it with many of you? Have you met the average patient circa 2012? They think that health care interventions come in these little round or oval products called tablets or capsules, that MRIs and PET scans will draw circles around the culprit lesions and then robot devices will make 2.5cm incisions and neatly remove them, so the patient can recuperate in less than a week. And then go back to their Krispy creams and Frozen lattes while sitting in their cars, puffing away on Marlboro Lights and typing furiously away on little devices, usually in 140 character lame short hand abbreviations saying cute, dumbass things like “U R so Rt!”.

    This, is America folks. The blind leading the deaf, the ignorant berating the clueless, and all wrapped up on screens, some so small you need 1 inch thick conclave glasses to read ’em. And these partisan, hidden agenda guided blind loyalists want this majority fraction, er, faction to buy the lies, literally. Oh, and all these simpletons think they’ll live to 90 or beyond, while the young will toil in gleeful appreciation to keep this dependent, useless population of contribution-less elderly alive to just use up more finite resources.

    Does that spell it out more clearly now!?

  14. Thanks legacyflyer. I was thinking that was it, but I’m wondering about the specifics. What advice is given to stop smoking? Lose weight? Exercise? Drink less? These aren’t easy, and I’m not sure the problem is all one sided. Most people are aware of their issues and probably do try to the best of their abilities, and I wonder sometimes if we don’t understand the problems well enough and are not even necessarily giving the best recommendations. I wonder if all our recommendations for low fat in the 1990’s (including for children) actually affected people’s ability to maintain a reasonable weight (including children). I wish I thought that all that advice was actually helpful. Difficult issues – I wish I had the answers.

  15. Determined,

    Wow – lots of anger in that comment.


    I believe Determined is referring to all the standard bits of advice that doctors give their patients; stop smoking, lose weight, exercise more, drink less, etc.

  16. Do you have specific examples of “act[ing] on what the doctor tells him or her to do to live responsibly”? Just curious what advice you’re referring to.

  17. Nice post. The average reader here reads it as this, in general:

    Kyteig sht tvrctctt nn d rfgkjjf sdrr hen hdhdhehee ok btctxt aosoivyb.

    Tried to throw in some vowels for some coherency.

  18. Today’s outrageous comment: people as patients are more and more cheap, entitled, and narrow minded. And you all pontificate and bloviate about utopian health care environments and cost containment. Truly disingenuous, dishonest, and deceitful. The average American citizen voted for basically one of 2 things at least in the presidential part of the election: what’s in it for me, or, care for yourself or just get out of the way.

    The usual commenters here either are in pathological denial of this obvious polarization, or, their naïveté is pathologically clueless. People expect to live to what really amounts to biologically inappropriate lengths of time. And, possible example A of “hear the lie enough and it becomes the truth”

    Oh no, I’m sorry, the PPACA sales pitch is example A. Ain’t it just politics as usual? Really, honest and invested representation lets the fiscal cliff issue just continue to the end of the time line? Like a patient acts on what the doctor tells him or her to do to live responsibly. The electorate and politicians are mirror images. Yeah, but who’s lookin’?!

  19. Providers are prohibited from quoting how much insurance pays them. Want price then ask for cash pay, however that number will be significantly higher than what the provider will get from insurance.

  20. No one can adequately purchase healthcare as an informed consumer as the system stands now. There’s a great story in today’s Kaiser Health Newsletter about a reporter who tried to shop for an MRI and couldn’t be quoted a price because every provider had a different negotiated rate for every healthcare plan.

    You don’t know what costs are until after you’re billed.

    Exchanges may help consumers make better choices about healthcare plans, but they won;t make them better consumers of healthcare.

  21. A significant problem is that Medicare is not that great. Almost everyone with Medicare has a supplement insurance policy or they have another program, such as Medicaid, if they qualify. “Medicare Advantage” may provide better coverage, depending on what you selected and how much you’re paying yourself, but that’s just insurance.

  22. No, there are many things that may serve the public good, but Medicare is a public good. Obviously Medicare should operate in a lawful manner, which I believe it already does. However, it should not be artificially forced to compete with private for-profit (or revenue) businesses. Just like public schools are not forced to compete with private ones and Police departments are not forced to compete with private security outfits.
    Medicare should be allowed to control prices and use its heft (and mission) to negotiate the best possible terms for its members.

    The private “options” are there to make money for a few individuals. Medicare is there to service the citizens of this country. There is a slight difference, I believe.

  23. You seem to be implying that only Medicare/public options serve the public good, which would imply an ideological bias that makes dialogue impossible.

    If the rules for private options don’t serve the public good, why are they there? If they do serve the public good, why wouldn’t they apply to the public option?

  24. Kim,

    I am a Radiologist so some of what I am about to say is not typical for other docs.

    The reason that the PATIENT is not a customer is:

    1) They don’t chose to come to us – they are typically referred by another doc or we provide service in the hospital they have come to.

    2) They don’t pay us. Other than a small copay, we are typically paid by Insurance Companies or the Government

    3) They typically have no idea of how to judge the quality of our service.

    4) They can’t upgrade their services or order more of them if they really like us. They can go somewhere else (sometimes) if they don’t.

    I am an advocate of treating PATIENTS well – as if they were a member of my family or a friend. I think they should be treated courteously, their wait kept to a minimum, etc.

    But confusing the patient with our customer (Insurance Company, Referring Doctor and Government Agency) doesn’t help anything.

  25. I find it interesting that some people can view the concept of treating patients as customers as a bad idea. Hmm, treating the patient experience as important, giving people choices, having consequences for entities who do not treat the patient well and/or do not provide value — these are things someone opposes? Honestly?

    As for Margalit’s long-standing support of a public option, I think that’s fine — IF Medicare has to play by the same rules. Same oversight and rules, honest accounting of costs, no subsidies on marketing & such from SSA and other public agencies, no artificial price controls, etc.. If there is a more complicated benefit design or more provider-unfriendly set of regulations, I’d like to know what it is. Why do we think virtually every senior not in Medicare Advantage or on Medicaid buys Medicare supplements?

  26. Wow! It’s quite magical hanging out on THCB today! It’s amazing to see exactly how correct Elizabeth Kubler-Ross was on the 5 stages of grief. But she probably thought she was talking about the individual. No, this is the “collective” mind-set of a medical community watching American healthcare breathe its last. Some of us are still in denial. Some have moved on to anger, arguing back and forth. Some are looping to a vain attempt at bargaining their way out, while some are getting really depressed. It’s been quite easy to predict who will actually survive this mess, and who’s going to stand like a deer in the headlights when the tsunami hits. Anyone at the ‘acceptance’ stage yet? I suppose the longer we keep trying to do the same things over and over expecting a different result, we’re going to keep suffering. Me? I operate from a whole different paradigm these days. I’ve stopped fragmenting our bodies under Newtonian physics, trying to piecemeal it together with pills, fixes and cures, ending up worse than when we started. When we push aside this obsession with disease – – well OMG! Disease corrects itself by our clear focus on the big picture – – health! Repeat this phrase a thousand times, “I’m sick, I’m sick, I’m sick…” What are you? What do you believe you are? So, anyone going to stop wasting the precious moments of their lives by pandering to the dogma of an archaic institution and corrupt system, and come along to actually make a difference??? The PARADIGM we currently operate from will KEEP us spinning through cycles of disease after disease, epidemic after epidemic, growing ICD-10, 11, 12 codes like weeds in a garden until we keel over and die! Last I heard, the very definition of insanity was doing the same things over and over and over and over….each time expecting a different result. Have we not learned anything yet, or will we be the last to figure it out? http://www.youtube.com/watch?feature=player_detailpage&v=6-IOsBOLG0I

  27. Bit of projection on your part, sir? Probably post your comments on Facebook for your choir friends. Empty laughs!

  28. Trouble is Margalit Medicare doesn’t fund election campaigns or give jobs to politicians family.

    This is the hurdle that’s always a bit too high for us to clear.

  29. ” Do any other readers read this stuff”

    You mean your stuff? Maybe the sane ones don’t.

  30. Precisely. The only thing I don’t understand is why liberals feel compelled to support this junk. What are these exchanges supposed to achieve? A more effective way to funnel tax dollars to private insurance? Better tools for “consumers” to pick their poison?

    There should have been a public option, i.e. anybody can buy into Medicare, and only people buying into Medicare could receive tax dollars to subsidize their premium. It would have helped Medicare and the people. And if everybody opted to get the subsidy, and “insurance” would have gradually migrated to Medicare for all, so be it.
    And if members of the Ayn Rand book club choose to purchase their overpriced insurance from private parties, even better.

  31. “Is that the health care system we want?”

    That appears to be the system Republicans want.

    Why is it Republicans want the free market to fix health care but they don’t want the free market to fix storm relief? I didn’t hear Governor Christie saying people should buy insurance if they want their homes and neighborhoods rebuilt after Sandy.

  32. How about being treated like “citizens”?

    “One Dollar, One Vote” didn’t seem to work out so well in 2012, ‘eh?

  33. If you want people to be treated like customers, then make them customers. Get rid of Medicare, Medicaid and most insurance regulations and EMTALA and HIPAA and everything else.
    Then if you have money, you will be treated like a customer because you are a customer. If you don’t have money, you will be treated like all retail establishments, including the best and the nicest ones, treat people who have no money. Kohl will not let you take home that nice pair of jeans if cannot pay for it in full. Maybe wait for a sale, or put it on layaway….

    Is that the health care system we want? If not, perhaps we should quit all this “customer” talk…. before we get exactly what we asked for.

  34. “Until patients really start acting like it is really their own money, it’s going to be tough to change the existing mind-sets.”

    You like getting three written quotes?

  35. Great post, Ann. Right now it seems like everyone else — e.g., doctors, insurance companies, the feds, — is in line ahead of patients in terms of being treated as customers . Until patients really start acting like it is really their own money, it’s going to be tough to change the existing mind-sets.

  36. “I truly believe that transparency and personalization will not just expand but will become touchstones as consumers learn to navigate the health care system, from choosing insurance to finding providers, products and services.”

    And I truly believe that Elvis will come down with Jesus at the end days of man and serenade us while we travel to heaven. Do any other readers read this stuff and just stare at the screen waiting for a spam window to open and just laugh out loud and tell you “Gotcha”?

  37. “You should look to the model of the Cap and Trade Green Energy ‘exchanges’ out of Chicago….. and just how have they improved the environment ?”

    You like this one?

    “The Acid Rain Program (cap & trade) has produced remarkable and demonstrable results. It has reduced SO2 emissions faster and at far lower costs than anticipated, yielding wide-ranging health and environmental improvements. In fact, a 2003 Office of Management and Budget (OMB) study found that the Acid Rain Program accounted for the largest quantified human health benefits – over $70 billion annually – of any major federal regulatory program implemented in the last 10 years, with benefits exceeding costs by more than 40:1.”

    I don’t think the two exchanges have anything in common. I don’t however hold out hope that the insurance exchanges will bring down the cost of insurance unless of course you get that government subsidy.

    Insuring health is insuring risk and the risk is a constant unless benefits are taken away. As long as we continue to pay the highest prices in the world for medical services we won’t solve the cost problem.

  38. As the plans that are mandated to be carried in the exchange are federally imposed for deductibles, coinsurance, coverage lines, without any front line brokers or agents to support them with any commission or production incentive; your optimism about the miracle of the ‘exchanges’ should be more couched in what are ACTUALLY existing ‘exchanges’. You should look to the model of the Cap and Trade Green Energy ‘exchanges’ out of Chicago….. and just how have they improved the environment ?
    Expect the exact same trajectory from the “Health Care Insurance Exchanges” and their affect on improving ‘health’