While Healthcare.gov Struggles, A Different Story Plays Out On The Private Exchanges

All eyes are on the hullaballoo created by the challenges at Healthcare.gov and several of the states’ public insurance exchanges.  Yet all the while, like in a magic show, attention has been diverted from the real action going on elsewhere.  Quietly and in a relatively drama-free way, the private health insurance exchanges are busily taking over the world of insurance and, in my opinion, portend a radical set of changes in how our health insurance system operates.

Several years back, a number of companies began building private health insurance exchanges to initially help companies offload the incredible burden of retiree benefits.  Companies such as Extend Health (now owned by Towers Watson), Senior Educators (now owned by Aon), and several others provided a way for large employers to get themselves out of the business (and balance sheet liability) of providing group benefits for retirees, instead providing them with money to purchase their own individual health policies through then small, now large companies.  The private exchanges went about the business of building websites that work, call centers that buzz and a wide array of insurance product offerings at various prices.  Now, several years later, hundreds of thousands and possibly millions of individuals are out there shopping their little hearts out, choosing their own plans, and dealing with the consequences of high deductibles and the like.

These various private exchanges are now poised and ready to begin serving active employees in 2014 as guaranteed issue (the requirement that all can be insured and no one turned away) goes into effect as a result of the Affordable Care Act.  And lest you think this is a small marketplace, you are wrong.  In 2008 there were about 120 million total employed workers and just over half of these worked for companies of 500 employees and above (39 million worked for companies with 5000 employees or more).  In other words, we are talking about nearly half of American adults and that doesn’t even include the dependents they bring along into their insurance plan.

Interestingly, such large US employers as Walgreens and Petco and DineEquity (parent company of Applebee’s Neighborhood Grill & Bar® and IHOP® restaurants) are all-in on the private exchange program, committing to transfer all of their employees from group plans to the exchange to purchase individual plans come January 2014.  The exchanges of Towers, Aon, Mercer, Buck Consultants and a plethora of others are alive and well and open for business at exactly the time when employers are trying to figure out how fast they can reasonably get out of the middle of health insurance administration and run for the hills.

Yes, there is much discussion (I think it may actually be wishing) about how companies will never do this en masse—that employee group benefits are too important a tool for employee recruitment and retention.  But I don’t really believe this is a lasting consideration for most companies.  A study from consulting firm Oliver Wymansuggested that “20% to 30% of the marketplace would gravitate to a private exchange over the next three to five years without any bias by size of employer.”  They also found that around 50% of all employers would switch to private health insurance exchanges if they could realize 10% savings; more than 20% of employers would move employees to exchanges even if there were zero savings.  If that last statistic doesn’t suggest that HR departments are putting on their track shoes and getting ready to run, I don’t know what does.

I have to believe that while the mass migration to private exchanges may start slowly, it will pick up speed faster than Apolo Ono in winter.  There are a few reasons why I believe this to be the case, including the giant hassle and expense of being the health benefits administrator of record.  Being out of the benefits administration business means less overhead cost, less drama as employees come to you when they want something covered, less lawyers to keep up with HR regulation.  On a positive note, transitioning to an exchange can also be a real positive for employees, opening up far more plan choices to them, enabling plan customization for special populations (e.g., disease-focused plans or regional-focused plans), even creating overall cost-savings in some cases.

But most importantly, transitioning to the private exchange means employers have the ability to fix their annual health benefit costs at a known and predictable amount that they control.  They will give employees an allowance to purchase health plans and each year can choose to raise the contribution by a fixed, amount.  If they are smart they will peg that increase at or near the consumer price index (CPI).  CPI has been rising a few percentage points a year (e.g., it rose 1.7% in 2012) while health insurance costs have been rising 3-5 times faster.

When you transfer your employees to an exchange, this basically becomes not your problem, thus marking the end of sucking up unpredictable rate increases for years and watching it eat into profits.  By fixing healthcare costs at a lower rate of growth than in the past, employers realize real savings to their bottom line, particularly when they have challenging growth years.    WalMart, for instance, as I wrote about HERE, went through 9 quarters of flat sales while healthcare costs rose 9% per year during that period.  As healthcare costs rise faster than sales, margins (profits) get eaten alive.  When a company can predict its healthcare costs and as its margins become better and more predictable, there is an improvement in a company’s bottom line and therefore, likely, it’s stock price.  When one guy’s stock price improves, his competitors have to take notice and act accordingly or suffer the wrath of the market.  In the end, I think this need to “keep up with the Joneses” may be the biggest accelerant under the private exchange flame.

So who absorbs that increase in healthcare costs if the employers cap theirs?  Yes, indeed, the employee, who is now experiencing pretty dramatic increases in out of pocket costs.  The hope is, of course, that some of the major changes underway in the healthcare system (ACOs, pay for performance, preventive services, yadda yadda) will help alleviate the build up of that pressure.  But as they say, hope is not a strategy.  Thus, employees, aka healthcare consumers, must take a serious look at how they consume healthcare and start to play a role in managing their own costs and the behaviors that drive them.  No doubt this will take a while, but it may well be just the kindling needed to drive more consumer accountability.  Ironic, isn’t it, that Applebees might lower their healthcare costs by using exchanges and, accidentally, cause a reduction in sales of their Riblets Platter (calories: 1720-2100; sodium: 3130-4850 mg). We can already see consumer engagement rising, even though in microscopic amounts, where consumers have access to price transparency information:  who wouldn’t choose a $1000 ultrasound when the alternative down the road is twice as expensive and where information on quality is largely absent?

It is interesting to note that early indicators show that people joining exchanges definitely price shop. Aon found that 42% percent of employee populations from three companies participating in Aon Hewitt’s Corporate Health Exchange chose less expensive coverage than they had previously, 26% selected richer coverage and 32% went with a plan that was comparable to what they had, according to this article in HIX.   It will be interesting to see how much this price shopping translates to more accountable or at least more cost-aware consumer behavior.

One of the most significant changes in the healthcare system, one which I have written about before but which is becoming of greater and greater urgency as exchanges proliferate, is the imperative for insurers selling products on the exchanges to learn how to market to and serve consumers.  Until the exchanges, virtually all insurance was sold to employers in business-to-business mode.  Now carriers have to figure out how to differentiate themselves on websites and via marketing where the guy listening is you and me.  With insurance carriers loved just about as much as cable companies (aka, not), this is no mean feat.

There was a NY Times article last week about how culturally dour Russian service workers, such as waiters and flight attendants, have had to go through a pretty significant amount of “charm school” to get good at serving consumers in their newer capitalist system.  I can imagine that the next class to enroll will be the US insurance carriers.   Health insurers are going to have to get good at consumer acquisition and, more importantly, retention, if Aon’s data is any indication:  they found that nearly 80% of the more than 100,000 U.S. employees enrolled in plans through their exchange chose a different plan for 2013 than they had in 2012 – with more opting for cheaper coverage than better benefits.

One discussion I haven’t seen anywhere yet is the impact that all of this exchange upheaval will have on the health/wellness/prevention market, particularly as it pertains to small companies selling products to payers and employers.  It has long been true that health insurers want to see a return on investment of no more than 1-2 years when they invest in programs that profess to reduce costs.  Why? Because they don’t have those enrollees for very long, usually a couple of years, and they want to realize the return from spending money on weight loss and smoking cessation and disease management and all the rest.   If health plan members are switching every year, and if insurers are required to spend 80% of all premiums on care, not administration (as they are as a result of the ACA), will they keep investing in these programs?

And furthermore, if employers are going to be getting out of the health benefits business, will they also turn away from these purchases?  I see a billion little companies trying to sell a variety of niche wellness, prevention and care management programs directly to employers and I am wondering if they have a future if employers want to forget about this topic entirely.  I imagine that some employers will see the provision of these programs as key to employee recruitment and retention, but not because it lowers cost.  Rather they will look for meaningful perks–and they may be unrelated to health–that make employees happy to come to work.  Instead of smoking cessation it might be ping-pong tables in the lunch room or time off to do charity work or free ice cream on Fridays; after all, they don’t have to care that much about whether the ice cream leads to worsening health if they have capped their costs.

Yes, I know, employers are worried about absenteeism and productivity and all that jazz, but those things are incredibly hard to measure and even harder to correlate with specific initiatives on the health front.  Thus, should all those health and wellness entrepreneurs be worried?  Maybe so.  I would love to hear from employers on this or see the Pacific Business Group on Health study this potential phenomenon.  I think this could become a real objection for investors looking at all of these little companies; one has to wonder whether their market will still be there 5-10 years from now when it is time to exit or whether the marketplace of purchasers will have declined precipitously.

Many of those entrepreneurs will say that the solution is building direct-to-consumer products.  I have to say that answer makes me wince.  Perhaps I am too much the cynic after all these years watching healthcare costs fiddle while consumers burn.  It is definitely possible that the rise in exchange purchasing, alongside its companion effect, the rise in high deductible health plans, will drive better consumer purchasing behavior and increased health accountability; as I noted above, I genuinely believe it will have some impact.  But will consumers ever really invest large quantities of their own cold hard cash in preventive health products on a big enough basis to sustain all those aspiring wellness entrepreneurs?  Perhaps if they have money left after that yummy platter of Riblets.

Lisa Suennen is a founding partner of Psilos Group Managers. She blogs at Venture Valkryie, where this post originally appeared.

29 replies »

  1. Memang itu yang aku tunggu selama ini.Lia juga tidak dapat menahan sebaknya dan terus memeluk aku. Lalu dia menarik tangan Sofia keluar dari biliknya. Mak ada nak pesan apa-apa tak? Dengan kaum Hawa bukan main lagi, bakal isterinya, Semakin lama semakin sayu. Dirabanya ke kanan dan ke kiri. Nanti tak la terkial-kial abang bila doktor amir tanyakan pada abang, Siapa abang.

  2. aku akan selamat. sekarang atuk tinggal di Mekah sekejap. Perasaanku terhadap Aznan, Ibu mencari gadis yang mengikut citarasanya. Zahim. kami dipisahkan kerana kami dibawa ke rumah keluarga angkat masing-masing.” tambah Anis lagi kami hanya memandangnya dengan senyuman hambar. Kesian pun ada. “Alaa?? Manalah tahu dia bakal bertemu dengan jodohnya.

  3. Lisa:

    Excellent article on a number of issues. I especially like and agree with your observations about the likely future for wellness and other similar vendors-the graveyard for providers of these services is growing fast. There are a number of better ways to retain ee’s, build your employer brand and what-not. These more or less useless wellness programs aren’t one of them, at least not for most. Give me a free (healthy) lunch every day and I will be thrilled:) And engaged, likely to recruit my healthy friends and so forth.

  4. Barry, the number of beds and bed-days are indeed going down, but hospital spending keeps going up in the aggregate.

    This is because hospitals have learned to take advantage of insurer fee schedules in many cases. There is an entire industry showing hospitals how to maximize the ‘intensity’ and reimbursement from the fewer and fewer patients.

    Hospitals by and large remain a ‘money pit.’ Most non-elderly patients fear them economically even while they appreciate the care that is received.

    My fear is that hospitals will get even meaner about collections and debt, all at the same time that they are trying to reduce their own spending.

  5. Bob –

    Over the last 30 years or so, the number of acute care hospital beds in the U.S. declined by almost one-third despite significant population growth and is now less than 1 million. There is a long term secular trend away from inpatient hospital care thanks to less invasive surgical techniques and better drugs that help keep people out of the hospital or shorten stays when they’re there among other things. The large insurers reported fairly impressive declines in the number of inpatient bed days per thousand members in the last few years including among Medicare Advantage members.

    Regarding the expensive cases, I think they are now subject to more intensive case management to ensure better care coordination than in the past. Personally, I don’t have a problem with very expensive care episodes when the patient is a premature baby or a person in the prime of life with a young family and a lot to live for. I do have a problem when the patient is an elderly person who has already lived a normal lifespan and then some, the outlook is grim to hopeless and the family expects taxpayers to finance a full court press yet they most likely wouldn’t spend their own money for such care even if they could afford to.

    Michael –

    In the most recently completed fiscal year, federal spending for Medicare net of beneficiary premiums and adjusted for differences in the timing of payments vs. the prior year rose only 2.3% which I think is even slightly less than the growth in the number of beneficiaries which means, of course, that per capita spending actually declined slightly. HDHP’s are a non-issue for the Medicare population and so is job loss due to the sluggish economy. In the prior three years, Medicare spending grew 5% or less per year which was also materially lower than in prior years. To quote the first two lines of the song by the late 1960’s rock band, Buffalo Springfield, “There’s something happening here. What it is ain’t exactly clear.”

  6. Your observations are appreciated. I have written on the tendency of a tiny number of heroic medicine cases to ‘break the bank’ and cause a rise in health insurance premiums.

    I wish there was more effort spent in attacking the details of the most expensive care. On a $2 million claim, how much is spent on grotesquely expensive drugs? How much is spent on ICU charges and hospital bill padding?

    I would like to see all large claims posted on the internet, of course leaving out the patient’s names but including the provider’s names. Let our pesky journalists at it.

    I realize that many hospitals depend on these ‘home run’ cases
    to balance their budgets. However, as you say, hospitals have been expanding in staff and salaries and buildings and equipment for over 30 years, and now their bubble may be ending.

  7. Hospitals are deeply concerned about the bad debt arising out of HDHPs. It is a real concern. Anytime you introduce self insurance, there is a risk of bad debt. However, the bad debt is limited to the maximum out of pocket cost mandated by the new law. After taking a deduction for bad debt and whatvshould be increasing reimbursement from formerly uninsured , now insured patients, my suspicion is the risk is limited for those losing sleep over HDHP proliferation.

    HDHPs offered alongside richer plans tend to drive better trends because the rich plans retain the high utilizers who are often driven emotionally to think of their lowcdeductible, low co-insurance plan as prepaid coverage e.g. Lower out of pocket, higher reimbursement etc. If an employer goes to a full replacement HDHPs as their only option, the cost of rising care ( medical inflation, demographics, technology, cost shifting from under reimbursement from government programs ) will eventually require more out of pocket from everyone. The pool of risk will have both high risk and low risk patients. Over time, normal consumption and rising unit costs will continue to corrode one’s purchasing power.

    Consumerism works for ambulatory services but does not work for catastrophic care which still drives a very large percentage of plan costs. I see unit cost and intensity of services increasing. In recent years, costs are lower due to decreased consumption and reduced admissions. We are nit sure if he orevalence of HDHPs is driving this or a sluggish recovery.

    In the future, we will see more $2m+ claims. End of life/palliative care will be an issue and an ethical hot potato. End stage renal failure is as much as $200k a year. Given our huge diabetes problem and the wildly poor rates of compliance among active diabetics with multiple co-morbidities ( conditions hat can kill them ), costs will keep rising. Private care will only prevail if hospitals form ACOs and can reengineer treatment to be rewarded on outcomes and not units delivered. The incentives must change. If not, hospitals and higher cost providers will cost shift to those who do not have the critical mass to get the best discounts. Once they run out of people to cost shift to, they either convert to risk sharing arrangements, sell, go out of business or form alliances. Met hospitals realize they need to cut operating cost by as much as 25% in the next few years or they will perish.

    The best plan of the future might offer 100% reimbursement up to some predetermined number ( Medicare + 25%) for all ambulatory and elective procedures where consumers can make point of service decisions. We can provide provider concierge location services to navigate accesss issues which will arise. For all else, the best option is a Primary Care Based medical home/ACO model where all care is rendered in the narrow network. No out of network! Kaiser trends routinely runs 400-600bps better than traditional open access PPOs. The most controllable aspect of trend is variable unit cost and effective care management. Align the incentives and you can achieve the equilibrium we seek.

  8. Thanks Michael for a very good analysis.

    I was fascinated by your sentence that long term medical costs will go up if a majority have high deductible plans, due to unit costs and hospital intensity.

    This is actually a blockbuster statement as opposed to the conventional wisdom of virtually all conservatives. Can you expand on your position?

    Also, the spreading of high deductible plans creates another set of problems.
    Hospitals and doctors will have more and more problems with collecting money from patients………….especially those patients who chose an HSA style plan just because it was cheaper, not because they actually had $10,000 in the bank.

    bob hertz, the health care crusade

  9. A properly designed exchange must offer plan designs capable of achieving lower single digit year over year medical costs. An exchange, by itself, is merely a financng mechanism — it is hardly a panacea for rising costs as Lisa points out. Cafeteria plans were around in the 80’s. As a consultant who is ancient enough to remember them, we watched as younger healthy people ( generally 50% of the population ) bought higher deductible, cheaper medical plans and pocketed the difference. The premiums they no longer spent in the health plan were no longer available to offset the claims of those employees who consumed a high level of benefits and often chose the richest benefit plan – as they wanted lower thresholds of co-pays before they got into 100% co-insurance. With fewer dollars to peanut butter spread to offset the same amount of claims, plan loss ratios spiraled and eventually employers started pricing the richest plans at such egregious levels that everyone was forced into the higher deductible plans. Affordable choice disappeared.

    Fast forward, most employers have been poor fiduciaries of their medical spend and in a low GDP growth economy, CFOs and CEOs want the rate of growth of healthcare equal to or less than the organic growth rateof the company. That means fixing the cost of healthcare to the rate of growth of any firm — perhaps like a profit sharing plan. An exchange that does not incorporate the critical elements that we know drive healthcare affordability – self insurance, high deductibles, consumer decision support tools, heavy emphasis on PCP engagement and annual physicals, smoker/non smoker rates, disease management/case management provided by a reliable third party ( not an insurer), narrower networks, utilization review and concierge advocacy for patients to help manage access and a carved out pass through Pharmacy programs that returns 100% of rebates back to the plan sponsor — won’t control costs. Just so you understand, self insurance is essential as insurers bundle services in insured financing arrangements often allowing their own subsidiaries to manage things like Pharmacy and behavioral health. we have found that by unbundling these services to third party vendors or even threatening to unbundle ( which can only be done when one is self funded ) forces the insurer to become more competitive with the open market. Selling your own services to your own sister company through inflated transfer pricing had been a way they have enhanced margins over the year and avoided competition. Self insurance is vital to transparency.

    The Aon/Hewitt exchange assumes that multiple carriers quoting on the same plan design on a fully insured basis ( not self insured) can be pushed into a Costco type of purchasing construct that will force carriers to cannibalize one another for precious market share to drive premiums well below the traditional markets. Don’t count on it. The notion of defined contribution and multiple choices has been around for a long time. The change is technology now makes enrollment and decision support easier. These exchanges are essentially on-line enrollment and benefits admin platforms. An employer can do all this today — use the technology and offer ten plan options through one insurer – maintaining the integrity of their risk pool and if self funded, avoiding as much as 6% in taxes and fees that will be levied on insured plans. The first year or two of private exchanges will offer false positive savings as people buy high deductible plans. he employer wins as they have fixed their contribution. 60% of employees win because they get to buy a plan that reflect the fact that they don’t consume much healthcare. he other forty percent get screwed with much higher premiums. Long term, costs go up as medical inflation increases unit cost and as intensity of services rise in hospitals.

    Let’s face it. If I am an employer spending more than $4k per capita on healthcare per employee, I purposely fail the affordability test so any employee making less than 400% of the FPL has the option to go to the federal or state exchange and get some kind of subsidy. Subsidies wont be meaningful above 250% of the FPL but if my per capita cost is let’s say, $5500 per person, I pay only $3k per person on an aftertax basis ( assume $4k equivalent) for everyone that goes to the exchange. Whoever is left, I give them a salary bump and let them pick health options from my single insurer exchange. After 2018, I start paying a 40% tax on amounts above $10,200 for employees and $27,500 for families. I know I will lose my deduction for healthcare so defined contribution is the way I will go.

    I predict most end up in high deductible plans in single carrier defined contribution plans supported by a range of “exchange” options that range from consultant, broker, carrier owned and third party aggregators. People will no longer pre-pay for healthcare by buying low deductible, low out of pocket plans but fund care as they go using an HSA and high deductible. As costs inevitably go up, they will go to HR to complain about their eroding healthcare dollar — only to find HR has been outsourced and a letter is pinned to their door. ” If you don’t like your healthcare, write your Congressman,” Thus begins the final shift to single payer.

  10. Nice article, Lisa. I’ve been watching the industry from a senior employee point of view for a while. In this area, the private exchanges offer a pretty good service helping to transition Medicare eligible employees off of company health benefits and into the Medicare system.

    It’s curious to me that people react so strongly to this transition. After all, the “privatization” of retirement benefits started decades ago, and for most of us it works. It works because none of us want to be handcuffed to a company based purely on benefits. Most of us prefer to be upwardly mobile, and that frequently means moving to a new company.

    If it works for retirement benefits, why shouldn’t it work for health benefits? Frankly, I’d prefer that an employer give me pre-tax “benefit” dollars to use the way I want. Maybe I need more money in my 401k than I do in my health plan, or perhaps I want an HSA because I’m super healthy and can risk paying more out of pocket from my own account.

    Good bye, corporate benefits manager… you won’t be missed. Hello marketplace… who wants my business?

  11. Lisa,
    Did you actually try purchasing a policy on those exchanges as an individual? I looked into it and couldn’t find anything worth buying. I actually found an “insurance” where the yearly maximum it would pay was a little less than the premiums! Such a deal. Even with its current warts, the options on the ACA state exchange are better than what I could find before the ACA.

  12. Lisa: I think IRS Notice 2013-54 says the employer funded arrangement must satisfy health care reform’s prohibition on annual dollar limits–and it will fail to do so because it’s deemed to impose an annual dollar limit equal to the amount of the premiums used to purchase the individual policy and it cannot be integrated with the individual policy to demonstrate compliance with health care reform. This should not be an issue for group policies purchased on a private exchange.

  13. Jeff, it is the health insurance product purchased by the employee (or employer) that needs to meet that test of no annual limit, not. The employer contribution.

  14. Very nice, thought-provoking article. But I’m wondering if the model you are positing here (employer defined contribution plan used to purchase individual insurance on a private exchange) can survive IRS Notice 2013-54. Doesn’t the IRS notice prohibit this arrangement, because the employer defined contribution plan will, by its very nature, violate health care reform’s prohibition on annual dollar limits?

  15. Hi Lisa, Thank you and a few follow ups if I can?

    1. The facilitating through a defined contribution means that the employer contributes enough to satisfy the shared resposibility aspect of an employee not paying more than 9.5% of their w2 towards premium?

    2. The plans available via the private exchange are individual policies or group policies?

    Thank you again,

  16. Barry, sorry to hear that Extend wasn’t helpful to you. I have heard lots of positive stories too, but I suppose these things can happen. it is a brave new world to be sure and I agree that the employee being treated as a customer will be an essential factor in the exchanges’/carriers’ ongoing success. Lisa

  17. If the employer facilitates coverage through defined contribution, they have satisfied their obligation and would not be fined, provided the insurance plans provided in the exchanges meet the mandated federal minimum benefits.

  18. Bubba, I have also heard these rumors and it makes sense. Why open a mall and sell only one thing? But I think it will be a while or at least more of a way to differentiate the exchanges from each other (offer voluntary benefits for instance, or financial support services). Lisa

  19. Hi Bob, the exchanges did have guaranteed issue because they were all targeted at over 65 retirees, thus guaranteed Medicare. As for the subsidies, it is possible that some employers will decide to move lower income employees to public exchanges for the subsidies, but if they want to keep a semblance of employee benefit good will they will choose the private option. This is a complicated set of decisions, actually, and will likely play out quite differently between large and very small employers. Lisa

  20. Shortly before I retired at the end of 2011, my employer stopped allowing its new retirees to buy into the employer’s plan with our own money. The company engaged Extend Health to help employees find a new insurance plan though the employee had to pay the premium out-of-pocket. For those of us like me who were Medicare eligible, Extend Health was to help sort through options for choosing a Medicare Advantage, Part D and supplemental plan. In my particular county, I found them to be all but worthless.

    The concept of the private exchanges for employed workers is, in effect, a premium support or voucher approach. The employer caps its cost and gains predictability by moving to a defined contribution which, presumably when added to the employee’s prior contribution toward the premium, will be enough to buy an acceptable plan in the first year at least. Going forward, any increase in the defined contribution amount may or may not be sufficient to keep pace with the growth in health insurance premiums. So, the financial risk gets shifted from the employer to the employee.

    On the plus side, I agree with Lisa that the new approach should make employees and family members more cost conscious with respect to the premium itself and the cost of healthcare as well. Perhaps this new paradigm could also increase the pressure on providers to offer cost information that reflects actual contract reimbursement rates before services are rendered. That would be a great thing. Also, in the past, when the member called the insurer about a claim or other question, insurers often had the attitude that the member was not the customer. The employer was. Hopefully this will change as well which is also a positive development.

    Finally, the private exchanges do not have to deal with the highly complex issue of verifying income and calculating subsidies. Without that requirement, it’s a heck of a lot easier to get the exchange and the website to work properly.

  21. When employers move / allow their employees to go a private exchange, does that mean that the employer then pays the fine for not offering coverage?

    If they also provide a defined contribution, does that somehow satisfy the play or pay issue?


  22. Is there any truth to the reports I keep hearing about healthcare services other than insurance plans eventually going on the exchanges? My guess is that these things will really only work in the way they’re supposed to on paper when you can buy things other than just health plans on them ..

  23. Good article, Lisa, thanks.

    Couple of questions:

    – Won’t the subsidies on the ACA exchanges be more attractive than the private exchanges for some employees?

    – how did any of these exchanges work in recent years without guaranteed issue?

  24. Next employers will want out of the retirement funding for employees. After that they will simply have no employees….just use temps and 1099 contractors.

    Wages and therefore taxes will go down as people compete for any income they can find.

    Legalizing marijuana will stem the political tide.

    Bankrupt.gov will be a website that actually works.