Health insurance is good not just for individuals but for democracy

By Emily Nacol

For the past seven months, Americans have watched and weighed in as Congress considered the continued existence of the Affordable Care Act (ACA). Last Thursday, the Trump administration announced that the government would stop subsidizing insurers for making premiums and deductibles more affordable for low-income customers. Most of the discussion to date has been about whether these plans are good for families, and if so, which ones. But what if insurance had another value, beyond protecting individuals from financial and health risks? What if it was good for democracy?

Here’s how we’ve talked about insurance up to now

This year’s debates about health-care reform have produced some memorable sound bites. In March, House Speaker Paul D. Ryan (R-Wis.) said: “The fatal conceit of Obamacare is that ‘we’re just going to make everybody buy our health insurance at the federal government level.’ … The people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.” In September, Trump economic adviser Stephen Moore told CNBC’s John Harwood that “people want insurance for their own families, not other people’s.”

Ryan and Moore’s harshest critics suggested that neither of them understand how health insurance works. But their comments reveal something else: Their baseline assumption is that individuals evaluate the worth of health insurance based on self-interest and personal economic calculus.

It’s true. People do want health insurance to protect themselves and their families, and oftentimes we articulate this in financial terms. Congressional Democrats have appealed to this idea in opposing ACA repeal. Their refrain is that families shouldn’t go bankrupt if someone becomes sick and that no one should die because they cannot afford medical coverage. They argue that keeping the ACA, or making it more inclusive through reforms, will protect individuals and families medically and financially.

These are important considerations, as any person who has ever lived on a budget and needed to go to the hospital knows. But they’re not the only ones.

There’s also an argument for the broad value of insurance for democracy

Daniel Defoe — a 17th- and 18th-century businessman and writer best known for his novel “Robinson Crusoe” — argued that insurance is a public good.

In An Essay Upon Projects (1679), Defoe evaluates (among other ideas) “friendly societies,” mutual aid associations formed by ordinary people. In these voluntary organizations, members paid fees to create a pool of assistance that would be available to any member who needed it. Friendly societies provided, in a word, insurance — fire insurance, livestock insurance, life insurance and health insurance.

Defoe generally approves. He argues that friendly societies have outsized potential to help protect members from the “miseries … and distresses” the future might hold — and to make life better for everyone. He even suggests these insurance pools may even harbor the potential for world peace.

Why such a bold claim?

Defoe’s argument for the positive potential of friendly societies depends on two values they embody: solidarity and equity.

Friendly societies promote solidarity because they encourage interdependence among individuals. Members regularly paid dues and fees into a common pool, with no knowledge of whether they would ever draw on them as individuals, on the off-chance they would need help themselves one day.

Defoe focuses on the larger picture, though. He stresses that these societies were a social project, one that offered security to the group (or to use his word, “mankind”) through solidarity. The political value of friendly societies is that they bonded people together against a risky future.

Defoe also identifies equity as a core principle of the friendly society, although a challenging one to achieve. He worries about whether friendly societies were organized fairly and shares ideas for promoting equity within them. He suggests, for example, that people in high-risk professions form their own insurance pools instead of banding together with people in lower-risk jobs.

But Defoe still praises friendly societies for at least trying to live up to the principle of equity. He says, “To argue against the lawfulness of [friendly societies] would be to cry down common equity as well as charity: for it is kind that my neighbor should relieve me if I fall into distress or decay, so it is but equal he should do so if I agreed to have done the same for him.” When we make such solidaristic commitments to our fellow citizens, we commit to treating them equitably. Defoe saw social insurance as one way to inject more equity into society.

Of course, “friendly societies” are a far cry from vast insurance companies

Defoe’s ideas about friendly societies might seem out of step with the concerns of 21st-century Americans. He was talking about small voluntary groups, and most Americans today buy insurance from large, for-profit corporations. Even those who turn to social welfare programs like Medicare and Medicaid interact with large bureaucracies. Is his defense of insurance as a relationship of solidarity and equity still applicable to us?

In a mass democracy like the United States, solidarity and equity are hard values to realize, but they are ones we still hold. We can see that, for example, in what Tennessean Jessi Bohon said when she stood up in a town hall in February and argued for the ACA’s individual mandate: “As a Christian, my whole philosophy in life is to pull up the unfortunate. So the individual mandate, that’s what it does. The healthy people pull up the sick.” She supported her position using the value of solidarity. (As an aside, Bohon’s link between the mandate and Christian charity would have made sense to Defoe, too.)

We’ve also seen appeals to equity. For example, when Planned Parenthood supported passage of the ACA, they did so based on the principle of fairness, arguing that by subsidizing birth control and mammograms it corrected a gender imbalance in health care costs. Similarly, when Sen. Lindsay O. Graham (R-S.C.) reflected on why the ACA should be replaced, he said that it didn’t recognize that different states have very different needs. He argued it isn’t equitable.

These scattered comments point us toward a conversation about the social value of insurance. Although politicians and policymakers will continue to appeal to individual self-interest as they try to gain support for their reforms, they might also wish to explain how their plans embody democracy’s social goods: solidarity, equity and fairness.


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The problem is the prices

Opaque and sky high bills are breaking Americans — and our health care system.


On September 28, 2016, a 3-year-old girl named Elodie Fowler slid into an MRI machine at Lucile Packard Children’s Hospital in Palo Alto, California. Doctors wanted to better understand a rare genetic condition that was causing swelling along the right side of her body and problems processing regular food.

The scan took about 30 minutes. The hospital’s doctors used the results to start Elodie on an experimental new drug regimen.

Fowler’s parents knew the scan might cost them a few thousand dollars, based on their research into typical pediatric MRI scans. Even though they had one of the most generous Obamacare exchange plans available in California, they decided to go out of network to a clinic that specialized in their daughter’s rare genetic condition. That meant their plan would cover half of a “fair price” MRI.

They were shocked a few months later when a bill arrived with a startling price tag: $25,000. The bill included $4,016 for the anesthesia, $2,703 for a recovery room, and $16,632 for the scan itself plus doctor fees. The insurance picked up only $1,547.23, leaving the family responsible for the difference: $23,795.47.

“I honestly thought it was a mistake,” Elodie’s mother, Annie Nilsson, says of receiving the bill. “There is no possible way anyone could be charged that much for one scan that took 30 minutes.”

Nilsson’s instinct — that these scans should cost a couple thousand dollars — was right. The cost of the same image at other California hospitals is significantly lower. And there was a huge gulf between what the insurance company thought was a “fair price” and what the hospital thought was a “fair price.”

Lucille Packard Children’s Hospital in Palo Alto, CA billed a family $25,000 for an MRI scan
Johnny Harris/Vox

“Elodie has had CT scans, colonoscopies, lots of ultrasounds, so we had assumed the price would be roughly the same,” Nilsson says. “We broadly researched what an MRI should cost, and we thought it would be a couple of thousand dollars. Nowhere in our long back-and-forth with the hospital was there any hint from the people scheduling it that we could possibly see a price like this.”

In a statement, Lucile Packard Children’s Hospital defended the charges.

“Even services that seem routine, like MRIs, can vary dramatically in cost when those services are being provided to sick children,” the statement read. “To make sure we provide the best possible experience and care to our patients, Stanford Children’s employs highly-trained specialists in pediatric imaging.”

It continued: “While we cannot speak to what technology other California children’s hospitals employ or their costs, we know that costs can also vary regionally based on local market demands for labor, supplies, real estate and other essential components of health care delivery. All of these factors impact our pricing, and underlie the amounts we charge for the care we provide.”

Nilsson negotiated the bill down to $16,000, which she now pays in monthly $700 installments. This has made the family budget tight; they already pay $800 each month for a special food formula that Elodie eats, which the insurance plan doesn’t cover at all.

“Every month, I hope they’ll maybe take pity and not send the bill, but of course they do,” Nilsson says. “Sometimes I’m late paying. My biggest issue is, how could the insurance say a fair price is $1,000 and the hospital say $25,000? How could there possibly be such a gap between those?”

Health care prices in America are high — and they are secret

Elodie’s story is common. Americans pay exorbitant prices for all kinds of care. As a health care reporter, I find myself writing about $25,000 MRIs, $629 Band-Aids — even a $39.95fee just to hold one’s own baby after delivery. People send me these types of bills quite regularly via email.

The health care prices in the United States are, in a word, outlandish. On average, an MRI in the United States costs $1,119. That same scan costs $503 in Switzerland and $215 in Australia.

These are uniquely American stories, and they are the key to understanding our dysfunctional health care system. High prices are hurting American families. Most Americans who get insurance at work now have a deductible over $1,000. High prices are why medical debt remains a leading cause of bankruptcy in the United States, and nowhere else.

As Elodie’s case shows, health care prices in the United States are both high and unpredictable. We rarely know what our bill will be when we enter a doctor’s office, or even when we leave. The prices aren’t listed on the wall or a website as they would be in most other places where consumers spend money.

Today, I am launching a project inspired by these reader emails. My colleagues and I at Vox are asking readers to submit hospital bills through our secure system so we can start getting a nationwide picture of one particular hospital fee, called an emergency facility fee. The reason we’ve selected this fee is because nearly all hospitals charge one for seeking emergency room care, but the price varies enormously and is typically kept secret.

We plan to report back on our findings both here at Vox and in my new podcast, The Impact, a reported series that explores the big challenges in American health care through the lives of people who experience it. If you’d like to participate, there are more details for you here.

As that project launches, I wanted to spell out why these prices are such a problem for the American health care system. Obamacare didn’t tackle America’s high health care prices; neither did the Republican plans to repeal the Affordable Care Act.

Our health care prices explain why reform efforts continue to vex each political party. When you’re paying the highest prices in the world for basic services, for scans and drugs, it will undoubtedly be a struggle to provide all citizens with health care.

This is true for a Republican plan to replace the Affordable Care Act — and a plan backed by 17 Democrats to create a single-payer health care system. The problem is the prices — but right now, there is little political will to fix it.

“It’s the prices, stupid”

In 2003, a team of influential economists published a paper pointing out that prices are the key problem in American health care. It came with the title: “It’s the Prices, Stupid.”

The takeaway was absolutely clear. “Higher health spending but lower use of health services adds up to much higher prices in the United States than in any other OECD country,” the paper concluded.

Johns Hopkins’s Gerard Anderson was the lead author of that report. I called him a few weeks ago to ask if he thought the conclusions of his 14-year-old report still stood.

“The Affordable Care Act reduced the price to consumers, but it didn’t reduce the actual, unit price,” says Anderson. “It essentially made everything affordable to people, but the prices actually accelerated in growth post-ACA.”

But this is not always the story told about American health care. Instead, it often goes like this: We are going to the doctor way too much, and that makes our system expensive. Rampant overuse, unnecessary care, and waste are at the heart of our spending problem.

One poll of 627 doctors, published in the Annals of Internal Medicine, found that 42 percent of physicians thought their own patients were receiving too much medical care. “You’re getting too much health care,” a headline in the Atlantic bluntly declared.

In this narrative, American health care is outlandishly expensive because we take advantage of every new scan, drug, or treatment.

Intuitively, this theory makes a lot of sense to me or to anyone who has become a regular consumer of health care. I’ve had a doctor order an MRI to look at an ongoing issue in my foot, only to forget about the scan completely until I reminded him it existed and asked him to review the results.

But when you start to dive into the actual data, there is scant evidence to back up this theory. If anything, it actually turns out that we go to the doctor relatively infrequently.

Data from the nonprofit Commonwealth Fund shows that on average, Americans go to the doctor four times each year.

Dutch people go to the doctor, on average, eight times each year. Germans make 9.9 annual doctor trips. Japanese residents clock in an impressive 12.8 doctor visits each year — more than three times the frequency of their American counterparts.

“This is really counterintuitive,” says Robin Osborn, who directs the Commonwealth Fund’s international health policy program. “With all the specialists and everything, you’d think we use twice as much health care as everyone. But it’s actually just not the case.”

When Americans do go to the doctor, we tend to have less face time or interaction with our providers. The average hospital stay, for example, is 5.4 days in the United States. This puts us roughly in line with New Zealand and Norway (5.2- and 5.8-day averages, respectively) and with much shorter stays than Canadians (7.5 days) or Germans (7.8 days).

The real culprit in the United States is not that we go to the doctor too much. The culprit is that whenever we do go to the doctor, we pay an extraordinary amount.

“It just feels really crazy”

One way you see hospitals flexing this muscle quite clearly is when you look at a common charge: an emergency room facility fee. I recently produced an episode of my new podcast, The Impactdevoted to this specific health care fee — and you can listen to it here.

This is the price that most hospitals charge for using any sort of service in the emergency room, a base fee for seeing a provider. Hospitals argue that these fees are the cost of keeping their lights on and doors open 24 hours each day, seven days a week.

“We have to prepare for the sickest of the sick,” says Ryan Stanton, an emergency room doctor in Lexington, Kentucky, and a spokesperson for the American College of Emergency Physicians. “So if you come in with a stubbed toe, I still have to be prepared and staffed for the acute heart attack or the gunshot wound, or whatever is coming in.”

Some level of fee to cover these operating costs seems reasonable. But one thing I’ve learned looking at emergency room facility fees is they seem to be set with little rhyme or reason, reflecting American hospitals’ ability to essentially pick their prices.

Take, for the example, a bill I was sent last year: a $629 fee charged for an emergency room visit where a Band-Aid was placed on a 1-year-old’s finger. The bill included a $7 fee for the Band-Aid — and a $622 facility fee.

“I see both sides,” says Renee Hsia, a professor at University of California San Francisco who studies emergency billing and helped me analyze that bill. “I think there are going to be facility charges regardless of the actual service that will always be part of ER care. But where this father has a reasonable point is that when you look at the cost of the Band-Aid and the proportional overhead, it just feels really crazy.”

A few weeks ago, I asked listeners of my roundtable podcast, The Weeds, to send me facility charges they’ve received. The bills range from a low of $533 to a high of $3,170, the facility fee Erika Siegel was charged after a visit to the emergency room at San Francisco General Hospital.

She estimates she spent less than a half hour there, after she flew over her handlebars in a bad bike accident. Her wedding ring had smashed her finger, leaving it badly bruised.

“I mean, what on earth could possibly have cost them $3,170?” Siegel says. “I was so shocked.”

She tried to call up the billing department to get an explanation.

“The guy on the phone said, ‘Well, you know, that information is designated by people who have degrees in medical billing,’” she recounted. “He asked, ‘Do you have a degree in medical billing?’ I was like, ‘Well, you got me there, I sure don’t.’”

Erika Siegel’s $4,338.20 bill for an emergency room visit, including a $3,170 facility fee charge.
 Courtesy of Erika Seigel

Siegel wasn’t thinking about a facility fee when she went to the emergency room. She had a smashed finger that looked bruised, and a police officer directed her to go to the emergency room.

Two things stand out in Siegel’s story and in many others — the first being that the bills are incredibly high. The cheapest option I’ve seen so far, $533, would still put a strain on many family budgets.

Second, they are all over the place. Emergency rooms don’t make these fees public, so it’s difficult to predict what you might have to pay.

This is why we’re launching our project at Vox to track these fees nationwide. To understand what’s going wrong in the American health care system, we first need to know what’s happening.

What about Obamacare?

The Affordable Care Act did many things. It extended coverage to millions of Americans and created a more equitable health insurance market that treated healthy and sick patients equally.

But that law did not tackle the unit price of health care in the United States.

“The ACA didn’t change the trajectory at all,” Hopkins’ Anderson put it bluntly.

The ACA made health care more affordable in the sense that more Americans have someone else (Medicaid or a private insurance company) paying the majority of those medical bills.

But the medical bills themselves didn’t actually shrink — and that will vex any effort at reducing the cost of American health care going forward.

Building a single-payer system in the United States, for example, would be a massively more expensive endeavor than anywhere else in the world because of our high prices. When you pay exceptionally high prices for each health service, it quite obviously becomes a lot harder to provide those services to all citizens.

Anderson argues there is little constituency for lower prices in the United States.

“We all say we want lower prices, but we’re not willing to give up anything to get them,” he says. “If you are a major corporation, let’s say General Electric, you want price controls except for the MRI machines you build. If you’re a labor union, you want to control health care prices, except for the salaries of your health care workers. And if you’re a patient, you want lower prices except when you’re sick — in which case, you want everything possible done for you.”

Health care prices are unlikely to fall without some level of government intervention. They may be nudged a little with transparency; Elodie’s family says they almost certainly would have had their daughter’s scan elsewhere if they knew it would cost as much as it did at Packard.

But the cheapest price I could find at a children’s hospital for her scans was still $7,758 — and that’s before additional charges for anesthesia, recovery, and lab work. But only 37 percentof Americans say they have enough savings to cover a surprise $500 to $1,000 medical bill.

President Trump initially showed some interest in regulating health care prices, particularly in allowing Medicare to negotiate drug prices, but so far he has not followed through.

Republicans ultimately put together bills that would reduce government spending on health care but not reduce prices. Instead, it would just shift a greater share of those prices onto patients (the opposite of the Affordable Care Act, which shifted the burden for high prices more to the government).

Our health care legislation in the United States focuses on the question of who pays for health care. In order to have real progress, however, we’re going to tackle a new question: How much do we pay? Until we do, we’re likely to continue living in a world of $25,000 MRIs and $629 Band-Aids that families struggle to pay for.


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Critics see Trump sabotage on ObamaCare

By Peter Sullivan and Rachel Roubein

The Trump administration is taking a hatchet to ObamaCare after failing to pass legislation through Congress repealing President Obama’s signature law.

The administration has cut funding for advertising and outreach by 90 percent, raising the odds that fewer people will join the health-care exchanges during the fall enrollment period.

It has slashed funds by 41 percent for outside groups that help reach and enroll likely ObamaCare consumers.

The enrollment period has also been chopped in half, and the administration announced plans to take down the website for maintenance for hours at a time on several days during the sign-up period, two other steps likely to cut into enrollment.

All of these steps could lead fewer people to sign up for the law, which in turn might lead to higher premiums that could force others off the exchanges.

Healthy people are the most likely to drop coverage because of a lack of outreach, leaving a sicker group of enrollees that drives up costs for everyone else.

“One has to assume at this point that enrollment will be lower as a result of the administration’s actions and that will lead to fewer healthier people signing up,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation.

The Trump attacks go beyond enrollment, too.

President Trump has threatened to cut off key ObamaCare payments to insurers in a bid to make the law “implode.”

And on Friday, his administration took a new step to roll back the law, limiting the requirement for employers and insurance plans to cover birth control.

Andy Slavitt, a former top health-care official in the Obama administration, warned on Twitter Thursday that the administration’s “sabotage” of the law added up to what he called “synthetic repeal,” meaning a range of small steps that add up to repealing ObamaCare even if Congress doesn’t act.

The administration counters that ObamaCare is a failing law that should not be propped up.

“Obamacare has never lived up to enrollment expectations despite the previous administration’s best efforts,” a Department of Health and Human Services spokesperson wrote in an emailed statement. “The American people know a bad deal when they see one and many won’t be convinced to sign up for ‘Washington-knows-best’ health coverage that they can’t afford.”

The cuts are having real world consequences already.

Reducing the outreach budget has forced local organizations known as navigators to dramatically scale back their operations.

Shelli Quenga, director of programs at the Palmetto Project, a navigator group in South Carolina, said her organization has had to cut staff from 62 people to 30 after its funding was reduced by around 50 percent.

“You want to talk about designed to fail?” she said. “This is the playbook for how to build something to make sure it fails.”

Quenga said that she only found out about the cut to her organization’s funding after the administration publicly made an announcement about the navigator cuts and she was called by a reporter for reaction.

She said the career officials she works with at the Centers for Medicare and Medicaid Services (CMS) were not aware of or involved in the decision to cut the funding, saying the decision was made at higher levels of the administration.

Navigators across the country had to scramble to craft new plans ahead of the open enrollment period beginning on Nov. 1.

“I’m just feeling very anxious about the fact that we have a whole lot less time to gear up then we should have had,” said Jodi Ray, director of Florida Covering Kids and Families, which is affiliated with the University of South Florida.

“We had a very well thought out plan, and we definitely had to go back and revise that plan, except we didn’t plan on having 3.5 weeks to put it together,” said Ray, whose group will receive $900,000 less, a 15 percent reduction.

A group of former Obama administration officials this week announced plans to launch their own enrollment effort, called Get America Covered, to try to fill the gap left by the cuts.

Insurers and ObamaCare supporters are also on edge about an executive order from Trump that could come as soon as next week loosening rules to allow businesses and other groups to band together to purchase health insurance. The problem is that these special insurance plans are not subject to the same ObamaCare rules and pre-existing condition protections, which could suck the healthy enrollees out of ObamaCare plans and damage the market.

The administration has also resisted efforts by some states, even conservative ones, to make changes aimed at stabilizing ObamaCare.

Iowa submitted an innovation waiver, which lets states alter ObamaCare as long as the law’s basic protections are retained. Part of the proposal included conservative reforms to the Affordable Care Act, yet President Trump reportedly wasn’t on board.

Trump saw a story about the waiver in The Wall Street Journal, and asked CMS to deny it, according to The Washington Post.

The application has not been formally rejected, at least not yet. It is in the midst of a 30-day public comment period, and is still pending, an Iowa Insurance Division spokesman confirmed to The Hill.

But without it, Iowa’s Insurance Commissioner Doug Ommen has warned the impact “on many Iowa families would be catastrophic.”

The deep-red state of Oklahoma had sought a waiver to help stabilize its markets, but withdrew it at the end of September because it hadn’t received approval from the administration in time.

The withdrawal came even after “months of development, negotiation and near daily communication over the past six weeks” between the state and the administration, Oklahoma wrote in a letter complaining to the administration about the lack of action.

“While we appreciate the work of your staff, the lack of timely waiver approval will prevent thousands of Oklahomans from realizing the benefits of significantly lower insurance premiums in 2018,” wrote Terry Cline, Oklahoma’s Commissioner of Health.


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Are You Sure You Want Single Payer?

By Olga Khazan

“Medicare for all” is a popular idea, but for Americans, transitioning to such a system would be difficult, to say the least.

French women supposedly don’t get fat, and in the minds of many Americans, they also don’t get stuck with très gros medical bills. There’s long been a dream among some American progressives to truly live as the “Europeans1” do and have single-payer health care.Republicans’ failure—so far—to repeal and replace Obamacare has breathed new life into the single-payer dream. In June, the majority of Americans told Pew that the government has the responsibility to ensure health coverage for everyone, and 33 percent say this should take the form of a single government program. The majority of Democrats, in that poll, supported single payer. A June poll from the Kaiser Family Foundation even found that a slim majority of all Americansfavor single payer.

Liberal politicians are hearing them loud and clear. Vermont Senator Bernie Sanders reportedly plans to introduce a single-payer bill once Congress comes back from recess—even though no Senate Democrats voted for a single-payer amendment last month. Massachusetts Senator Elizabeth Warren has also said“the next step is single payer” when it comes to the Democrats’ health-care ambitions.

But should it be? It’s true that the current American health-care system suffers from serious problems. It’s too expensive, millions are still uninsured, and even insured people sometimes can’t afford to go to the doctor.Single payer might be one way to fix that. But it could also bring with it some downsides—especially in the early years—that Americans who support the idea might not be fully aware of. And they are potentially big downsides.

First, it’s important to define what we mean by “single payer.” It could mean total socialized medicine, in that medical care is financed by—and doctors work for—the federal government. But there are also shades of gray, like a “Medicaid for all” system, where a single, national insurance program is available to all Americans, but care is rationed somewhat—not every drug and device is covered, and you have to jump through hoops to get experimental or pricier treatments. Or it could be “Medicare for all,” in which there’s still a single, national plan, but it’s more like an all-you-can-eat buffet. Like Medicare, this type of single-payer system would strain the federal budget, but it wouldn’t restrict the treatments people can get. Because it’s the term most often used in single-payer discussions, I’ll use that here.

The biggest problem with Medicare for all, according to Bob Laszewski, an insurance-industry analyst, is that Medicare pays doctors and hospitals substantially less than employer-based plans do.

“Now, call a hospital administrator and tell him that his reimbursement for all the employer-based insurance he gets now is going to be cut by 50 percent, and ask him what’s going to happen,” he said. “I think you can imagine—he’d go broke.” (As it happens, the American Hospital Association did not return a request for comment.)

The reason other countries have functional single-payer systems and we don’t, he says, is that they created them decades ago. Strict government controls have kept their health-care costs low since then, while we’ve allowed generous private insurance plans to drive up our health-care costs. The United Kingdom can insure everyone for relatively cheap because British providers just don’t charge as much for drugs and procedures.

Laszewski compares trying to rein in health-care costs by dramatically cutting payment rates to seeing a truck going 75 miles an hour suddenly slam on the brakes. The first 10 to 20 years after single payer, he predicts, “would be ugly as hell.” Hospitals would shut down, and waits for major procedures would extend from a few weeks to several months.

Craig Garthwaite, a professor at the Kellogg School of Management at Northwestern University, says “we would see a degradation in the customer-service side of health care.” People might have to wait longer to see a specialist, for example. He describes the luxurious-sounding hospital where his kids were born, a beautiful place with art in the lobby and private rooms. “That’s not what a single-payer hospital is going to look like,” he said. “But I think my kid could have been just as healthily born without wood paneling, probably.”

He cautions people to think about both the costs and benefits of single payer; it’s not a panacea. “There aren’t going to be free $100 bills on the sidewalk if we move to single payer,” he said.He also predicts that, if single payer did bring drug costs down, there might be less venture-capital money chasing drug development, which might mean fewer blockbuster cures down the line. And yes, he added, “you would lose some hospitals for sure.”

Amitabh Chandra, the director of health-policy research at Harvard University, doesn’t think it would be so bad if hospitals shut down—as long as they’re little-used, underperforming hospitals. Things like telemedicine or ambulatory surgical centers might replace hospital stays, he suspects. And longer waits might not, from an economist’s perspective, be the worst thing, either. That would be a way of rationing care, and we’re going to desperately need some sort of rationing. Otherwise “Medicare for all” would be very expensive and would probably necessitate a large tax increase. (A few years ago, Vermont’s plan for single payerfell apart because it was too costly.)

If the United States decided not to go that route, Chandra says, we would be looking at something more like “Medicaid for all.” Medicaid, the health-insurance program for the poor, is a much leaner program than Medicare. Not all doctors take it, and it limits the drugs and treatments its beneficiaries can get. This could work, in Chandra’s view, but many Americans would find it stingy compared to their employers’ ultra-luxe PPO plans. “Americans would say, ‘I like my super-generous, employer-provided insurance. Why did you take it away from me?’” he said.

Indeed, that’s the real hurdle to setting up single payer, says Tim Jost, emeritus professor at the Washington and Lee University School of Law. Between “80 to 85 percent of Americans are already covered by health insurance, and most of them are happy with what they’ve got.” It’s true that single payer would help extend coverage to those who are currently uninsured. But policy makers could already do that by simply expanding Medicaid or providing larger subsidies to low-income Americans.

Under single payer, employers would stop covering part of their employees’ insurance premiums, as they do now, and people would likely see their taxes rise. “As people started to see it, they would get scared,” Jost said. And that’s before you factor in how negatively Republican groups would likely paint single payer in TV ads and Congressional hearings. (Remember death panels?) It would just be a very hard sell to the American public.

“As someone who is very supportive of the Democratic party,” Jost said, “I hope the Democrats don’t decide to jump off the cliff of embracing single payer.”

  1. Common misconception: Not all European countries have single payer.


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Employer Plans Join Obamacare In Narrowing Doctor Networks For 2018

By Bruce Japsen

Health plans beyond just Obamacare are paring lists of doctor and hospital choices for 2018 as they struggle to contain rising medical care costs by guiding patients to quality choices, insurers and health benefits consultancies say.

Up to half of the nation’s large employers are looking at or already implementing narrow network strategies, benefits’ analysts say, even as insurers like Centene, Molina Healthcare, Oscar Health and Blue Cross and Blue Shield plans introduce more narrow network plans to maintain individual coverage offered on public exchanges under the Affordable Care Act for 2018.

Protesters join together in front of the office of Rep. Carlos Curbelo (R-FL) on August 3, 2017 in Miami, Florida. The protesters are asking for Rep. Curbelo to explain his vote on the Affordable Care Act and to take a stand against what they say is ‘President Donald Trump’s budget that slashes Medicaid by more than $800 billion and weakens the social safety net for more than 113,000 residents in Rep. Curbelo’s district who rely on Medicaid. ‘ (Photo by Joe Raedle/Getty Images)

“We are remediating high-cost provider contracts and building around high-quality, cost-effective networks,” Molina CEO Joseph White told analysts earlier this month on the company’s second-quarter earnings call. “This initiative will take time and will likely not show meaningful benefits until 2018.”

But health insurers say these moves to rein in costs don’t mean their customers will be forced to see doctors and hospitals that lack quality. Instead, Molina executives say they are focused on “driving” more health plan enrollees to providers with “strong quality records.”

Take Oscar Health, which has partnered with the Cleveland Clinic to offer individual coverage in Ohio on the ACA’s public exchange.

“This is a rare opportunity to work with Cleveland Clinic to deliver the simpler, better and affordable health care experience that consumers want,” Mario Schlosser, Oscar Health’s CEO said when the partnership was announced.  “By linking Oscar’s member engagement platform to a world-renowned, physician-led health system like the Cleveland Clinic, we can align incentives and focus on the things that matter most: keeping members healthy.”

Insurers and employers would prefer to the words “high performance” be subbed in for “narrow” when talking about their networking strategies. Health benefits analysts say it’s not necessarily a bad thing if health plans and employers cull from their lists of doctors and hospitals those that aren’t achieving whatever quality metrics have been established.

Half of U.S. employers are considering “condition-specific high performance networks over the next three-to-five years ,” the human resources and benefits consulting giant Aon said last week.

“As employers continue to look for ways to improve health and manage cost within their health benefits program, one area of focus is consistently considered – provider network optimization,” Jim Winkler, senior vice president of Health & Benefits at Aon. “Beyond cost and quality considerations, employers have increasingly turned to narrower provider panels to provide simplicity of choice and consistency of care for plan members.”

Winkler said the trend is akin to a move by employers to suggest choices for their retirement plans.

“The increased interest in narrow networks is similar to the trends we see in 401K plans,” Winkler said. “Employers are increasingly offering smart “default choices” and not relying on wide-ranging menus that are often difficult for people to navigate.”

National Business Group on Health said 19% of employers in its survey will use “high-performance networks” next year though that is down from 26% this year, according to its 2018 health benefits report. 

But the dip in narrow networks is likely only a temporary phenomenon, NBGH’s CEO Brian Marcotte says.

“There is is significant interest in both performance networks and ACOs for 2019 and 2020,” NBGH ‘s Marcotte said. “I think employers are trying to make sure that these networks are truly quality and efficiency networks and not just a deeper discount with a limited group of providers.  Employers have been down that road in the past and want to make sure that these networks are moving towards value-based arrangements.”

There are no more counties without any Obamacare plans


Paulding County, Ohio, come on down!

The last empty Obamacare county, where 380 customers on the individual marketplaces were at risk of having no insurance options at all next year, has been filled. CareSource, which had filled other bare counties in Ohio and Indiana this summer, agreed to sell coverage there in 2018.

With that, every county in the country will have at least one insurer for its Obamacare market in 2018.

It’s a sharp reversal for the law. In June, when Republicans were still working to repeal and replace Obamacare while President Trump threatened to deal it a devastating blow, there were 47 counties, with 38,000 customers, without insurers. At one time or another this year, 82 counties were at risk, according to the Kaiser Family Foundation.

So Obamacare didn’t implode. Why? I walked through some of the reasons earlier today. More briefly, I’d break it down like this:

  1. Insurers see a solid business opportunity in bare counties. They can set prices to recoup their costs, knowing that most customers who receive subsidies through Obamacare will be insulated from premium increases. The feds will pick up the tab.
  2. State officials worked hard behind the scenes — and had ample leverage, as the still-predominant regulators of insurance — to bring carriers on board. We saw this play out in Nevada and Ohio, where governors flew in insurance executives for meetings and insurance officials got into nitty-gritty negotiations matching different insurers to different counties.
  3. Republicans failed to repeal and replace Obamacare, and Trump hasn’t followed through on his threat to cut off the law’s payments to insurers. I wouldn’t say things are stable or certain, but they are more so than they looked over the summer — and now Congress is turning explicitly to shoring up the markets, not overhauling them.
  4. A few companies — namely Centene, which filled 45 of these empty counties — specifically invested in helping the law. Sarah profiled the former Obama administration executive now in a leadership role at that company.

This isn’t a perfect solution, especially for people who don’t receive subsidies and therefore aren’t protected from premium increases in a monopolized market. It’s also possible that Trump does something in the next few weeks to disrupt the market again — insurers have until the end of September before they are truly locked into selling plans in 2018.

We’re still likely to hear a lot about counties with only one insurer. There are 1,340 of them, with 2.7 million Obamacare customers, according to our estimates.

That’s a real issue. But I thought I’d share a couple of observations from Craig Garthwaite, a health economist at Northwestern University.

First, he pointed out that the problem is not that insurers will charge exorbitantly high premiums in a monopoly — there is little evidence of that happening, he said, and we know from aggregate data that insurers aren’t exactly making a killing in the Obamacare markets.

“We should be careful about why exactly we care about the monopoly,” he said. “As long as there are meaningful opportunities for entry, I don’t think we should worry that much.”

The real problem is for consumers, who were promised under Obamacare the opportunity to choose from a variety of health insurance options. That opportunity is either narrowed or completely lost in a monopolized market.

“When there’s a monopoly provider in the exchanges, we lose that ability to match with the plan that’s best for you,” Garthwaite said.

He made one last point, something that’s easy to forget as we grow accustomed to blaming any and every problem in the insurance market on Obamacare:

“We’ve had trouble offering insurance in rural counties for a long time. This was neither created by nor will it be solved by the ACA.”

Map of the Day


A full Obamacare market. The empty counties were shown in yellow, but they’re all gone now. We’ll probably be talking about the gray counties a lot more in the coming weeks and months. Those are the areas that have only one insurer selling plans right now. They don’t comprise the majority of the marketplace (about 2.6 million customers out of 9.6 million, by our internal estimates), but that’s still a lot of people with limited options.

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Senate to begin bipartisan health care push

By MJ Lee

(CNN)When Congress returns to Washington after Labor Day, it will immediately confront a tough question: Can there be bipartisan agreement on fixing the country’s health care system?

The Senate health committee announced Tuesday that it will hold two back-to-back hearings on health care September 6 and 7. That will be the first time that Republican and Democratic senators officially gather together to examine potential ways to stabilize the Obamacare marketplace. Witnesses are expected to include governors and state insurance commissioners.
“While there are a number of issues with the American health care system, if your house is on fire, you want to put out the fire, and the fire in this case is in the individual health insurance market,” Tennessee Sen. Lamar Alexander, the Republican chairman of the health committee, said in a statement.
Washington Sen. Patty Murray, the top Democrat on the panel, said: “It is clearer than ever that the path to continue making health care work better for patients and families isn’t through partisanship or backroom deals. It is through working across the aisle, transparency, and coming together to find common ground where we can.”
One of the panel’s main concerns — that many Americans may have no options on the Obamacare exchange in their area in 2018 — has largely abated. While several large insurers have pulled out of the individual market, others have stepped up to take their place. Only one county in rural Ohio, with fewer than 350 Obamacare enrollees, remains at risk of having no insurer on its exchange next year.
Another key problem, however, remains unresolved. One reason why many insurers are hiking premiums for 2018 and others are fleeing is because the Trump administration won’t commit to continue paying a key Obamacare subsidy. Insurers, along with governors and insurance commissioners, have been pressing the administration to guarantee these cost-sharing reduction payments will be made through 2018. It’s vital to the stability of the market, they say.
President Donald Trump agreed last week to make the August payment, despite earlier threats to end what he calls a bailout for insurers. He has not made a decision on future payments.
The Congressional Budget Office last week said that insurers would hike premiums on Obamacare silver plans by 20% next year if Trump stops the funding.
The hearings follow the GOP’s failed attempt last month to repeal major portions of the Affordable Care Act, widely known as Obamacare.
House Republicans had passed a bill earlier this year to gut the law, but Senate Republicans were unable to do the same. Despite months-long efforts by Senate Majority Leader Mitch McConnell to rally rank and file members, Sens. Susan Collins of Maine, Lisa Murkowski of Alaska and John McCain of Arizona ultimately voted “no” in a dramatic late-night scene on the Senate floor.
The spectacular political defeat helped cement a reality that Republicans have openly begun to acknowledge. Despite having railed against Obamacare for years, there is now growing acceptance within the GOP that wholesale repeal of the health care law is not viable.
Since the failed Senate vote, there have been growing calls on both sides of the political aisle to start fresh discussions to fix Obamacare on a bipartisan basis — a clear sign that even Democrats admit that the law is far from perfect.

20-plus health care stats that will blow you away

By Selena Maranjian

You’ll never guess how often patients are misdiagnosed, how much America spends per capita on healthcare, or how many Americans go without dental insurance.

“The whole issue of health care is very complicated. There have been seven presidents who’ve tried to get healthcare reform passed.” — Valerie Jarrett

“Now, I have to tell you, it’s an unbelievably complex subject … Nobody knew healthcare could be so complicated.” — Donald Trump

No matter who you are, the more you learn about health care, the more impressed you’ll be with how complicated — and interesting — it is. Here are some healthcare stats that should surprise and impress you.

$3.2 trillion: The United States spends a whopping sum on health care. The total U.S. healthcare expenditure in 2015 was $3.2 trillion, per the Centers for Medicare and Medicaid Services. At that level, it accounted for 17.8% of our gross domestic product (GDP).

$9,990: Putting the figure above into context, the U.S. spent about $9,990 per person on health care, as of 2015, per the Centers for Disease Control. A National Public Radio report put that in perspective, noting that as of 2014, Somalia spent $33 per person on health care, and Japan, with a longer life expectancy for its citizens than the U.S. (83.1 years vs. 79.1 years), spent just $3,816 per person.

20%: In 2015, Medicare spending totaled $646 billion, making up about a fifth of our total national health care spending. (Medicaid, at $545 billion, made up another 17%.)

19.8%: You might think that most of our health care spending goes toward physician services, but you’re wrong — they get about 20%. Hospitals get the biggest chunk. Here’s how 2015’s national health care spending breaks out:



Hospital care


Physician and clinical services


Retail outlet sales of medical products


Prescription drugs


Nursing care facilities and continuing care retirement communities


Dental services


Source: Centers for Disease Control. 

9%: Between 2014 and 2015, spending on prescription drugs grew by 9% to $325 billion. That’s an alarmingly fast growth rate, but it’s slower than the 12% growth rate from the year before.

28.9%: Of our national health care spending, the federal government shouldered 28.9% of the total amount, while households forked over 27.7% and private businesses 19.9%.

5,564: There were recently 5,564 registered hospitals in the U.S., per the American Hospital Association. Some 2,845 of them were non-profit community hospitals, while 1,034 were for-profit (i.e. investor-owned) community hospitals.

897,961: There were recently nearly 900,000 staffed beds in U.S. registered hospitals, 87% of which were in community hospitals.

923,308: There were recently 923,308 professionally active physicians in America, per the Kaiser Family Foundation. About half of them, 48%, were primary care physicians, and the others specialists. About a third of American physicians are women.

7,300 to 43,100: The Association of American Medical Colleges estimates that by 2030 there will be a shortage of primary care physicians — with the shortfall between 7,300 and 43,100. The estimated shortfall for specialists is more severe, between 33,500 and 61,800. What’s going on? Well, some factors are that many current physicians are expected to retire in the coming years, and our aging population will be driving demand for doctors.

$107,460: The median salary for nurse practitioners in 2016 was $68,450, according to the Bureau of Labor Statistics. Nurse practitioners have been growing in number and are especially good to have around in areas with physician shortages. They are advanced registered nurses, and can examine patients, diagnose illnesses, prescribe medication, and provide treatment. Here are some more median salaries in the health care field:







Dental Hygienists




Dieticians and Nutritionists


EMTs and Paramedics


Home Health Aides


Licensed Practical and Licensed Vocational Nurses


Medical and Clinical Lab Technicians


Nurse Anesthetists, Nurse Midwives, and Nurse Practitioners








Physical Therapists


Physician Assistants


Physicians and Surgeons

More than $207,000



Registered Nurses


Speech-language Pathologists




Source: Bureau of Labor Statistics. 

$260,000: Per Fidelity Investments, the average 65-year-old couple can expect to pay about $260,000, on average, out of pocket for healthcare services over the course of their retirement — and that doesn’t include any long-term care expenses.

11th: According to the Commonwealth Fund, the U.S. ranked last in a study of 11 developed nations when it comes to the performance of our healthcare system.

30%: The Centers for Disease Control has estimated that at least 30% of prescriptions for antibiotics are unnecessary. It notes that, “…most of these unnecessary antibiotics are prescribed for respiratory conditions caused by viruses — including common colds, viral sore throats, bronchitis, and sinus and ear infections — which do not respond to antibiotics. These 47 million excess prescriptions each year put patients at needless risk for allergic reactions or the sometimes deadly diarrhea, Clostridium difficile.” Those prescriptions cost money, too, driving up the cost of healthcare.

5% to 44%: Various studies estimating how often a patient is misdiagnosed have come up with figures ranging from 5% of the time to 44% of the time. The bottom line is that it’s not an insignificant frequency, even at 5%.

35%: According to a recent survey by Morning Consult, 35% of people questioned either didn’t realize that the Affordable Care Act (ACA) and Obamacare are the same thing, or weren’t sure about it. The same survey found that 45% of respondents didn’t realize that if Obamacare were repealed, the ACA would be repealed, too.

26 million: There were about 57 million Americans without health insurance before the ACA took effect. As of early 2017, there were just 26 million uninsured Americans — reflecting 33 million more people now covered.

114 million: The increase in covered Americans is great, but many remain uninsured for dental care. Recently, more than 114 million Americans had no dental coverage, and with many dental procedures being costly, that puts poorer Americans at great risk of doing without and enduring pain — not to mention greater risk of further health decline.

738,000: About 738,000 people end up in the emergency room each year due to dental problems, according to the National Association of Dental Plans.

87,000 lives: According to the Department of Health and Human Services, patient-safety initiatives have saved more than 87,000 lives and $20 billion between 2010 and 2014.


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Healthcare incentives are necessary if we want to spur innovation

By David S. D’Amato

The healthcare sector suffers from an unfortunate lack of real competition, encumbered by a seemingly ever-expanding pack of new rules and regulations. Many of these, in theory at least, are designed to make healthcare more affordable for consumers.

The Affordable Care Act (ACA) was supposed to solve the problem of ever-rising healthcare costs while bringing health insurance coverage to every American. Instead, the law has yielded higher premiums and fewer choices for consumers, results that ObamaCare’s critics predicted again and again when it was still a bill.

There is at least one thing that the drafters and proponents of the law could not do. They could not abolish incentives, and the law as it stands creates a healthcare system that simply cannot work given the incentives at play.

When policymakers do not allow rational self-interest to operate within normal, socially-beneficial parameters, that self-interest asserts itself in ugly and perverse ways.

For example, because ObamaCare regulations have outlawed insurance as we know it, forbidding insurers from accounting for health differences and thus risk, the law and its rules effectively punish insurers that offer coverage for certain very expensive conditions.

Sure, the insurance companies cannot deny one with such an expensive pre-existing condition a policy, but, compelled by cost considerations, they can “either leave the market, as many have, or slash their coverage.” This is just one of many examples of incentive problems created by a shortsighted law that, however well-intentioned, will end up hurting those segments of the population it is intended to help.

History hints at a world of potential. The decades enveloping the turn of the century were the golden age of fraternal lodge practice, an innovative ground-up answer to a problem facing working people, a voluntary solution produced by civil society on its own.

As historian David Beito teaches, by 1920, “at least three out of every ten adult males” were dues-paying members of fraternal orders and thus entitled to certain benefits in times of sickness and need. Such societies anteceded the modern welfare state; they were a way to spread — indeed socialize — risk without compulsion or coercion.

So were these lodge practices examples of free market healthcare? Much, of course, turns on how one defines the free market. Fraternal societies generally were not run for profit. Far more important than the term “free market,” though, is the fact that lodge practice was a spontaneous and cooperative response to a perceived problem, a response organized and administered not by politicians and bureaucrats, but independently, by the people with the problem for themselves.

Though far from perfect, lodge practice suggests the possibility of a less centralized and more flexible healthcare ecosystem. The defective American healthcare system calls desperately for heterogeneity, for a variety of delivery models of shapes and sizes that correspond to patients’ wants and needs. Rigid uniformity, created and nurtured by and for government bureaucrats and private pressure groups, is limiting the prospects for genuine affordable care.

An economic architecture with so few outlets for energy, resources, and innovation — a relatively static system with few nodes and connective avenues — offers insufficient opportunities for change and course correction. With new, cost-competitive delivery models and medical products actively proscribed, the American healthcare system is constantly tending toward collapse, unable to function successfully even with billions of dollars in subsidy handouts to insurance companies.

Politicians and industry groups profess their commitment to addressing the crisis of ever-rising healthcare costs even as they continue to erect entry barriers and consolidate the market. So onerous are existing healthcare regulations that many companies are simply unable to remain in business, forced to leave the business altogether or be swallowed by larger conglomerates in the search for economies of scale.

Rather than trying desperately to preserve America’s entropic status quo, policymakers ought to allow free market competition to disrupt and destroy that status quo.

That they consistently decline to consider the most basic economic principles bespeaks either a profound ignorance of those principles or (perhaps more accurately, if more cynically) an acute awareness of what might be gained from their violation. Their criticism against the potential of free markets ring hollow and are laden with old fallacies that reek of special interest influence.

Good public policy seeks to understand and accommodate ordinary economic incentives, not pretend they don’t exist or attempt to override them. Properly directed, self-interest and incentives are a powerful force for good. They economize and preserving scarce resources, which spur innovation, driving us to search for the best, most efficient ways to provide goods and services.

If we must have massive subsidies and special tax benefits, these ought to attach to individual Americans, not giant corporations. Healthcare dynamism requires real market reforms that center on the consumer, not stale D.C. platitudes and the concerns of powerful pressure groups.

David S. D’Amato is an attorney, a policy adviser at both the Future of Freedom Foundation and the Heartland Institute. D’Amato is also columnist at the Cato Institute’s


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Don’t understand health care? You’re not alone. It’s the industry’s fault — not yours

By: Holly Fletcher

Clear Health Analytics designs its tools to help people navigate choosing health insurance by writing to a fourth grade level.

The company uses “12 monthly payments” instead of “premium” because of early feedback from an advisor that insurance lingo didn’t register with insurance users.

It would design tools without words at all if it could, said Jennifer Sclar, CEO of the Clear Health Analytics out of Stamford, Conn., that’s getting funding from Jumpstart Foundry. The start-up builds tools to help people shopping on the insurance exchange as well as for employees choosing between job-based plans.

“If we could figure out a way to do that, we would do that because with decision support tools you’re dealing with two kinds of literacy — both the ability to read and comprehend as well as numeracy literacy,” said Sclar.

Translating healthcare jargon

It’s a fool’s errand, she said, to try to teach people the difference between copay and coinsurance. They’re not going to remember it — and Sclar doesn’t think people should have to understand the complex jargon to understand how to effectively use the plan.

There’s a growing but small subset of companies geared toward translating and opening up the health care system to people who come from all walks of life and income and education.

The proliferation of high deducible health plans, or consumer directed health plans, combined with the necessity of capping the rise of health care spending means the industry will have to change how it thinks about its processes, overhead and interactions with people.

“Everyone likes to talk about the ‘consumerization of health care’ but without offering people good information you can’t really ask them to be a partner,” said Sclar. “I think it’s integral to the ability of consumers and employees to participate and be engaged that they must have — they must have — access to really quality information about what they are buying and how much it’s going to cost them.”

People need care but health care providers haven’t gotten much better at showcasing value 

Health care is an unusual industry because people don’t (often) wake-up and decide they need to be a patient.

Disease and injury can creep or spring up due to lifestyle, an accident or genetics.

People enter the system when they need care, and they find an expensive, complex system that seemingly requires training just to navigate a local system.

For many people transitioning from a copay insurance plan to a high deducible plan is a challenge because the necessary information to inform decisions is not readily available.

Healthcare Bluebook is piloting a search in Middle Tennessee that allows people to compare and shop for health care services.

People have been shielded from price for so long that “you tend to think all care costs $25,” said Bill Kampine, co-founder of Healthcare Bluebook.

“That can be a shock,” said Kampine.

In some ways, the companies’ digital platforms — or decision support tools — are a bridge connecting people to the existing payment and service system, which is waiting to morph into its next phase.

The companies are carving out a niche by throwing back the veil on small pockets of health care, and educating people about how to be smart shoppers when information is available.

The existing model is, slowly, being flipped on its head. As more costs shift to consumers, providers are left to convince patients — not insurance companies — their services are worth the money.

Issues arise when companies are trying to solve the problems of a consumer, and have to explain value. For years value had to be explained to the insurance company — not the person receiving the service.

“That’s what going to have to happen in health care,” said Larry Van Horn, executive director of health affairs at Vanderbilt University’s Owen Graduate School of Management. “It’s going to be incumbent on providers. The onus is on the provider, not the consumer.”

‘None of this will move quickly’

The catalyst for broader changes to the way people make decisions to buy services or products is likely to come from companies outside of health care that have experience filling gaps in people’s lives that they didn’t know existed.

Google, Apple and, increasingly Amazon, are taking on health care projects, said Phil Gibbs, principle of the Disruption Lab. Each is more attuned to the desires and expectations of shoppers, in part because they created the platforms that people have come to see as benchmarks.

The Disruption Lab, created to help companies evolve rather than go extinct, is taking a group of Nashvillians to New York and Barcelona — the Silicon Valley of Europe — this fall to talk to companies that are re-shaping a variety of industries.

“It’s going to happen in health care delivery here in Nashville,” said Gibbs.

But for people who are balancing every day costs of living with increasing share of their responsibility for health care payment, getting access to the information they need — in a format they understand — is rare and often relegated to pockets of the industry.

“This will be a much slower evolution than what I would like to see as an economist. None of this will move quickly, in part, because we have such strong vested interest in the ways things are,” said Van Horn.