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Thursday, 2 September 2010

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Mandate

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Initiative
According to an article in the New England Journal of Medicine, 57% of private employer plans are ERISA self insured plans and are exempted from many of the 2010 health insurance coverage mandates, since these plans are not considered insurance. This means most of the large employers out there will continue to manage their own health care programs as they have in the past. Smaller employers will be the ones most impacted by the insurance mandates and often, they are the least able to pay. The federal subsidies help some small employers, but if you have over 25 employees you are required to provide the expensive first dollar coverage and pay a significant portion of the cost. Perhaps the small employers will elect to pay the penalty rather than play in this pool. It is also worth noting that a lot of start-up companies and nonprofit organizations fall into this size category and their funding is quite restricted.
Cost to Produce the Baseline Surveillance
The impact on the health plan’s cost will of course be a factor in the hiring of new employees. Though it is illegal to discriminate against older workers, one has to wonder why a small employer wouldn’t consider age when it would impact the cost of their medical plan. Even under the Obama reforms age is still a factor in establishing a community rate for the price of a health insurance plan. Yet another nail in the coffin for anyone who is over forty and looking for work. As a student of government policy making I am wondering if the unintended economic consequences were fully considered with this 2010 health care mandate for small employers to buy expensive front-end loaded insurance for their employees.
Encouraging the Desired Effect
I favor the carrot incentive method much more than the punishment stick and keeping the tax deductions for health and welfare plans is critical to employer sponsorship, as well as keeping some flexibility in plan design so the smaller businesses, both for-profit and not-for-profit can participate. The federal subsidies apply only to very small employers with 25 or fewer employees and are targeted to firms with 10 and under workers, which is understandable from a budget standpoint. It is telling that the government considers small business only those with less than 50 employees (the standard most likely to be adopted by the majority of the states), who are exempt from the penalties for not providing medical insurance plans. In the private sector, employers with less than several hundred employees are considered small and in my insurance career, several companies considered all firms with less than 2,000 employees to be small employers. This difference in standards is based on the volatility of the claims performance data and the management required in order to replicate a similar outcome for the smaller firm versus a larger client.
Wellness Care Mandates
Though I understand the importance of providing primary care, which means early detection of costly diseases like high blood pressure (which is a precursor to kidney failure and cardiac problems) through annual exams, perhaps having them provided by insurance companies is not the most effective method. The insurance industry is deft at managing large risks and not at providing disease surveillance or wellness. Any efforts to do so by insurance companies involve add-on commission based products that are provided through a third party and generally not well integrated into program performance. You can bet that plenty of insurance agents are selling wellness programs now that the coverage is a government mandate, but what is the efficiency of this model, other than to make more money for the insurance industry?
Better Way to Provide Wellness Services

Another way to provide disease audit and management could include using public health nurses or clinics to do the surveillance, which would protect the privacy of the individual and provide key surveillance information for a community trying to manage its health care. Since large employers may already use on-site clinics to provide the wellness services, the small employer sector needs a better model for identification of at-risk employees. Also, the public health programs need an infusion of capital and this would be a great way to take the old “school nurse program” and create a community nurse program nationwide. As someone who went through a Minnesota winter with untreated bronchitis I wish there would have been a school nurse in my high school. I would love to see a cost benefit study on using public health programs and federally qualified clinics to provide the wellness services versus the insurance industry products. Everyone likes to complain about the inefficiency of government programs, but the financial support of federally qualified health centers through federal grants has proven so effective it has been reauthorized by three presidencies. Public health programs have been on the front lines in addressing health risks for a hundred years. These programs are effective and they don’t require sophisticated and costly marketing schemes to pitch their results, but they could use your advocacy.
For those of you who have a fear of public health, I can attest to the efficacy of the program as I have been a customer of Seattle Public Health on many occasions, for my travel immunizations (they have the best travel clinic), for primary care treatment when I have been without insurance, and for referrals to other medical facilities, when no one in the private sector would see me. At least with the Obama protocols many of the uninsured will have medical insurance, which will at least enable them to get a private sector physician to schedule an appointment. The Obama health reforms are creating a new baseline for health care design and reporting and maybe in the long run it will empower consumers.
For more information on how the states are reacting and their regulatory authority for the federal health reform mandates, read the September 15th article in my contributing column for the life sciences newsletter of the east coast consulting group at
This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.


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