By Michael Turpin

Alice: Cheshire-Puss, would you tell me, please, which way I ought to go from here?

Cheshire Cat: That depends a good deal on where you want to get to.

Alice: I don’t much care where.

Cheshire Cat: Then it doesn’t matter which way you go.

Alice: —So long as I get somewhere.

Cheshire Cat: Oh you’re sure to do that if you only walk long enough.

Lewis Carroll, The Adventures of Alice in Wonderland

2013 has arrived and employers now find themselves on the other side of a looking glass facing the surreal world of healthcare reform and a confusion of regulations promulgated by The Accountable Care Act (ACA) and its Queen of Hearts, HHS Secretary Sebelius. Many HR professionals delayed strategic planning for reform until there was absolute certainty arising out of the SCOTUS constitutionality ruling and the subsequent 2012 Presidential election. They are now waking up in ACA Wonderland with little time remaining to digest and react to the changes being imposed. A handful of proactive employers have begun, in earnest, to conduct reform risk assessments and financial modeling to understand the impacts and opportunities presented by reform. Others remain confused on which direction to take – uncertain how coverage and affordability guidelines might impact their costs.

If reform is indeed a thousand mile journey, many remain at the bottom of the rabbit hole – wondering whether 2013 will mark the beginning of the end for employer sponsored healthcare or the dawning of an era of meaningful market based reform in the US. HR and benefit professionals face a confusion of questions from their companions — CFO’s, CEOs, shareholders and analysts.

How will reform impact our business? Will we take a hit to earnings as a result of penalties or the cost of having to expand coverage? Have we reviewed our strategies for modifying our employment practices to mitigate coverage risks? How will we offer benefits in 2014 and beyond? What financial and coverage considerations should guide our ultimate decisions? Do we think we can manage our healthcare costs to low single digit levels of annual medical inflation? Do we have the right funding strategy? What are our competitors likely to do?

It seems that questions only lead to more questions. For many, the future is less certain and for a few doomsayers, ACA is the final chapter in a narrative about a world of entitlements gone mad. Like Alice, benefits decision makers are asking, “Which way should we go?” — to which the historical response for employers has been: “follow the path of least disruption.” Yet, ACA has set a new normal in motion and with it, the historical axioms of “do no harm” will no longer work in benefits management. There is no path to achieve the holy grail of affordability that does not carry some risk of delay, disruption, confusion and/or increased administrative complexity. The decisions one makes for 2013 will have an impact on costs and plan participation in 2014. It’s time to get moving but you’ll need some advice to safely cross Wonderland:

1. Think like a risk manager – Any risk management professional has been trained to first review risks, evaluate risk drivers, eliminate or mitigate the identified risks and find the most advantageous way to finance the risks. The roadmap to ACA compliance requires similar planning. Equipped with payroll, coverage and actuarial plan value estimates, any employer can quickly determine what, if any, penalties they may face associated with offering unaffordable or inadequate benefits to eligible employees. Once the risk is assessed, you can explore safe harbor and limited penalty scenarios as well as financing solutions designed to direct participants toward “win-win” scenarios that achieve savings for the employer while helping lower paid workers become eligible for more generous federal subsidies.

2. Strategy first, structure second – Planning for reform means understanding where you want to go. Do you believe providing healthcare is an essential part of the social contract between you and your employees? Are your business conditions changing – causing you to rethink what you offer to employees and how you pay for their benefits? Are higher per capita healthcare costs requiring you to think differently about providing compensation, benefits and retirement? Your total compensation strategy may require you to think differently about the road ahead. You may want to tie annual medical premiums to profits through a defined contribution approach. Strategy is essential. It dictates your direction and enables speed. Without it, you are merely running through the forest, hoping to find a path.

3. The reform roadmap requires you to either “play” or “pay” – While certain industries such as retail, manufacturers, hospitality and agriculture are already calculating the additional costs associated with reform, other employers are finding that they satisfy many of the requirements dictated under reform.

Most firms over 100 employees generally offer medical coverage that meets or exceeds ACA coverage and affordability requirements for the majority of their employees. They have little exposure to penalties. However, these same firms are plotting the coordinates of how reform may change the way they think about financing and offering medical benefits. If the Y axis of reform is “Play” (some version of employer sponsored healthcare) and the X axis is “Pay” (electing to pay a penalty either as a result of failing to meet affordability or coverage requirements), employers have a continuum of choices that range from Maximum Play (Cover All Eligible Employees) to Minimum Pay (Drop Coverage, Pay Penalties, Don’t Gross Up People For Lost Coverage). Each direction requires careful planning and an eye toward discrimination and coverage regulations dictated prior and post reform. One thing is clear: there is more than one way to navigate the Affordable Care Act.

4. Don’t feel guilty about reviewing pay or play scenarios – Reform gives any employer a rare opportunity to reexamine their employee benefits strategy. Management has a fiduciary responsibility to explore all the alternatives presented when business or public policy changes. There are obvious risks to course corrections that may steer you away from traditional employer sponsored insurance. They include the inability to attract and retain talent, effects on employee morale and one’s public image in the community. While over 85% of employers surveyed by the International Foundation of Employee Benefits confirmed their intent to continue to offer coverage, many are privately considering a different future. In the last two decades, employers have simply failed to rein in healthcare costs and have been stuck in a perpetual rut of health plan renewals that start with double digit increases and end with the shifting of costs to employees in the form of higher contribution requirements, reduced benefits or lower wages that arise out of lower profit margins eroded by health spending. The question remains: have you really tried to change? Reform will either happen for you or to you. It is essential that you openly discuss every alternative and that you have a robust multi-year dashboard that holds all stakeholders accountable to achieving low single digit medical trends.

5. Wellness is vital for any employer who desires to continue to offer sponsored plans: ACA offers expanded wellness incentives to employers who aggressively embrace health management improvement. If an employee chooses not to participate in an incentive based wellness plan, it remains unclear whether the act of having to pay a higher premium would make the employee eligible for a public exchange subsidy. Assuming that those who choose not to participate in wellness incentive plans are more likely to be less engaged employees, it stands to reason any employee that opts into a public exchange to avoid the accountabilities of a wellness based incentive plan could help an employer sponsored plan improve its own risk profile.

6. Understand public exchange benefits: Private insurers participating in heavily regulated public exchanges will be under intense political pressure to keep costs down. States and HHS have publically noted that double digit annual premium increases will be viewed as “egregious.” Most open access PPO plans continue to be plagued by double digit medical trends. It is likely that while community rated public exchange plans may actuarially mirror private plans, they will attempt to incorporate more stringent medical management controls such as mandatory primary care gatekeepers, narrower PPO networks and aggressive preauthorization oversight to limit overconsumption, fraud and abuse. Additionally, community rating will shift more premium cost to younger employees as age/sex rate bands limits exchange insurers ability to spread premium burdens to older participants. To the degree an employer is actively pushing employees toward a public exchange, the employer must understand that cost and coverage will not mirror private plans. The rules governing healthcare in the public exchanges may comes as a shock to previously coddled private insured patients while it will be a relief to the uninsured.

7. Defined contribution (DC) plans are a way to redistribute costs, not a path to improved affordability: If you do entertain the notion of migrating to a more defined contribution approach for employees, be certain to understand your options can range from a cafeteria style plan using a single insurer supported by on-line decision and enrollment support tools to a third party private exchange where employees are offered an annual stipend and a range of insurer choices. Cafeteria plans have been available since the early 1980s. Many of these plans failed because of their inability to simplify complicated administration and the natural adverse selection that arose when younger, healthier employees chose lower priced coverage options and redirected premium that might have helped offset claims into the purchase of alternative benefits. Choice will always help reduce employee heartburn when confronted with rising costs. People tend to value those benefits that they can choose for themselves. In the case of a single carrier defined contribution plan, the employer remains active as plan sponsor but has the ability to fix annual contributions while offering employees a greater range of medical and ancillary benefits choices. In the case of multiple carrier private exchange, the employer allows the group to fragment as insurers compete for participants. In these instances, it is more likely that an employer becomes an even more passive financial sponsor, defining annual subsidies but over time becoming less concerned over issues arising from excessive utilization, lack of engagement or rising costs. In a future dominated by DC plans, affordability becomes the employee’s problem.

DC is a cost shifting strategy. If plan costs grow at historical trends, employees will become increasingly disgruntled at the eroding value of the benefit dollars they receive to purchase benefits in the private exchange. Without active efforts to control costs, private exchanges will experience a similar limited life expectancy to the myriad unsuccessful state and private group purchasing based arrangements that have preceded them. Despite the risks, some industry experts view the move toward defined contribution medical plans as inevitable and a logical migration similar to the path taken by defined benefit pension plans toward the 401k savings plan.

Some firms will be intrigued with the notion of private exchanges as they allow management to refocus their energies on other strategic human capital priorities. There is increased recognition that national insurers are engaged in synchronized swimming with similar networks, unit cost contracts, and administrative services pricing. Some analysts believe that offering the choice of multiple insurers in a private exchange reduces employer leverage, undermines the ability to self insure and leads to the inevitable deconstruction of employer sponsored healthcare.The path through ACA Wonderland will invariably require crossing the bridge separating defined benefit and defined contribution plans.

8. Self-insurance is 20/20 vision– Health reform includes assessments that stakeholders will pass on to commercially insured and self funded plans. The preservation of group fully insured policies are essential to insurers profit models. The opaque practice of pooling fully insured risk often lead to the overcharging of employers. Many fully insured plans already contain inflated margin, administration and reserve charges as well as hide inflated broker remuneration. For employers under 300 lives, many insurers do not divulge paid claim data that might help an employer better direct their health management strategies. Despite ACA capping an insurer’s overall allowed loss ratio at 85% for their entire block of 50+ life insured accounts, any individual client can still run well below an 85% loss ratio and they may never know it. Self-insurance remains the most efficient method of financing healthcare – provided an employer understands its risk tolerance. Self-insurance, if structured correctly, can limit financial risk while maximizing transparency. Transparency leads to increased competition leading to lower costs. We estimate that post reform, an employer that chooses to self fund may avoid as much as 4% to 8% of additional expenses arising out of ACA insured plan fees, state premium taxes, margin loads for increased risk arising from compliance, the cost of complying with state mandated benefits and the lost opportunity cost arising out of one’s inability to understand what one’s true loss ratio is when negotiating a renewal.

Which way? The road through Wonderland will be serpentine and fraught with blind corners, misinformation, and strange characters. The future of employer sponsored healthcare and market based reform hinges on which direction employers choose to move. Those that understand where they are today and move with a blend of caution and resolve have a higher probability for making it through the looking glass. For those who remain behind, irritated by the hassles imposed by reform, the future will be considerably more complex. Will we eventually navigate this upside down world of regulation and change? Oh yes! But you have to first decide if you are looking for a way forward or a way out. How long will it take to arrive?

That will depend on whether you know where you are going…

Michael Turpin is frequent speaker, writer and practicing benefits consultant across a 27 year career that spanned assignments in the US and in Europe. He served as the northeast regional CEO for United Healthcare and Oxford Health from 2005-2008 and is currently Executive Vice President for Benefits for the New York based broker, USI insurance Services. He writes at Usturpin’s Blog.