A COMET HITS PLANET HEALTH CARE - Forbes · 2013. 10. 29. · The Patient Protection and A ordable...

A COMET HITS PLANET HEALTH CAREHOW THE AFFORDABLE CARE ACTCHANGES AN EMPLOYER’S WORLD

IN ASSOCIATION WITH:

Dear Reader:

The Patient Protection and A�ordable Care Act (ACA) is the

most comprehensive reform of the United States medical

system in almost 50 years. It will change the structure

of American health insurance—and it remains a complex

and contentious issue for the insurance industry, brokers,

employers and the public at large.

We asked Forbes Insights to examine a critical topic: The impact of health care

reform on group benefits. In this special report, exclusive to Sun Life, Forbes

Insights examines whether the new laws can present opportunities for employees,

employers and brokers if we all stay sharp and demonstrate creativity in

responding to the changes.

As a leader in employee benefits, Sun Life Financial is dedicated to providing

insights that benefit employees, employers and brokers. We hope this white

paper will help you stay current when discussing critical benefit plan decisions.

For more insights you can’t find anywhere else, visit us at sunlife.com/wakeup.

And check back often for news—the kind that helps everyone wake up to the true

benefit of benefits.

Thank you,

Wes Thompson

President

Sun Life Financial (U.S.)

FOREWORD

© 2013 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life Financial and the globe symbol are registered trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/us.

SLPC 25327 09/13 (exp. 09/14)

2 | A COMET HITS PLANET HEALTH CARE

CONTENTS

Foreword .................................................................................................................................... 1

Introduction ..............................................................................................................................3

Background ..............................................................................................................................4

Determining ACA Requirements .....................................................................................6

Boom Times for (Some) Brokers .....................................................................................9

You Must Remember (to Cover) This .............................................................................11

Responding to the ACA ......................................................................................................12

The Siren Song of Self-Insurance ................................................................................... 14

Pushing the Doctor’s Pen ...................................................................................................17

A Tale of One City: Will Small Business Storm the Bastille? ................................23

Conclusion: The Comet Hits Home .............................................................................. 26

Expert Panel...........................................................................................................................28

COPYRIGHT © 2013 FORBES INSIGHTS | 3

Although some ACA provisions have already taken e�ect, the curtain goes up in 2014 on the main act: the health insurance mandate for individuals.

Absent some sort of exemption, every American will be required either to buy health insurance on their own or through an employer or to pay a pen-alty. This being America, it’s kind of complicated. Focusing narrowly on employers, however, what we know for sure is this:

If that’s not perfectly clear, one thing just about everyone does agree upon is that the ACA is compli-cated and comprehensive. A big part of the law deals with private health insurance, including the individ-ual, small group and large group markets, but the law also addresses government insurance programs such as Medicare and Medicaid. Then there’s the large por-tion of the law focusing on health care services and products, along with various taxes and fees. In other words, the ACA encompasses the “buyers” and “sell-ers” of health care alike.

Condense all of this into one massive piece of legislation and the ACA becomes a comet whose explosive impact scatters boulders, trees and other debris everywhere. Whether the result when the dust settles is wreckage or renewal remains to be seen. Still,

with employer health insurance covering about 149 million Americans, according to the Kaiser Family Foundation (KFF), and government �gures showing that government health care spending accounts for a little over one-sixth of the U.S. economy, the fallout from the ACA is inescapable.

This Forbes Insights report is designed to help you decide for yourself what the ACA’s impact will be on your business. While it draws upon research, surveys and similar material, it is anchored in interviews with 15 respected experts representing a variety of perspec-tives. Many are nationally prominent; all were selected for their combination of experience, expertise and origi-nal thinking (see “Expert Panel,” page 28). At a time of uncertainty, savvy analysis counts more than ever.

Signi�cantly, this report looks at the ACA’s impact through a wide-angle lens, for changes in one part of the health care ecosystem can create power-ful ripple e�ects elsewhere. Some of the most important e�ects of the ACA on employers will be direct, while oth-ers will be indirect. To extend the comet analogy: when you kill o� the dinosaurs (who-ever they might be), you never know what will arise in their place.

INTRODUCTIONIn 1943, the National War Labor Board ruled that fringe benefits weren’t subject to wage and

price controls, thereby setting the stage for the creation of America’s employer-based health

insurance system. If you weren’t working at a roll-top desk in the company personnel o¥ce

back then, the Patient Protection and A�ordable Care Act (ACA) will bring about the biggest

change ever in your professional career.

The ACA will have a dramatic impact on all employers as its provisions take e�ect…or the ACA’s impact will take years to be fully felt.

Smaller employers will benefit the most, and the boost will be almost immediate…or small employers will su�er the most in ways that are already disturbingly apparent.

As public health insurance marketplaces appear online in every state, brokers will start to go broke…or health insurance brokers will become more important than ever.


BACKGROUND SURVIVOR: OBAMACARE EDITION

The Patient Protection and Affordable Care Act aka The Affordable Care Act aka Obamacare

(mostly by critics, but also at times by President Obama) aka The Health Care Reform Law is a sur-

vivor. It began as one law in March 2010; quickly added a junior companion (a second law signed

seven days later provided technical fixes and tweaks overlooked in the rush to pass the first); lost

the strength of its Medicaid provision during a near-death encounter with the Supreme Court in

June 2012; and then made it through an election campaign that placed its fate in jeopardy yet again.

“Employers are exhausted by the ACA, they don’t want to think about it,” says Paul Fronstin, director of the health research and education program at the Washington, D.C.-based Employee Bene�t Research Institute (EBRI).

Yet think about it they must, even if a remnant of ACA-deniers continues to resist. An Employee Bene�t News interactive timeline lists 18 di�erent provi-sions that a�ect at least some employers beginning in

2014. A few of those have gone by the wayside with the unexpected delay of the employer mandate until Jan. 1, 2015, but the 2014 list remains impressive. For example, pre-existing con-dition exclusions, lifetime dollar limits and stand-alone health reimbursement arrangements all come to an end. At the same time, new rules on employee cost-sharing and wellness

programs come into e�ect. “The ACA is a burning platform,” says Alexander

Domaszewicz, an Irvine, Calif.-based principal in the health and bene�ts practice of consulting �rm Mercer. “In some ways it’s kind of exciting, in some ways it’s kind of scary.”

The �ames and smoke have become a familiar part of life for human resource (HR) professionals. Since 2010, ACA-related rule changes have a�ected areas ranging from a “reasonable break time for nurs-ing mothers” to the tax deductibility of reimbursed medical expenses for executives. Looking ahead,

many plan sponsors are focusing on the excise tax on high-cost, rich bene�t plans—dubbed the “Cadillac tax”—that takes e�ect in 2018.

Employers are also being a�ected by ACA-induced changes in the health care delivery system, which continue to build in importance. In 2014, for example, Medicaid coverage will be substantially expanded in some states (the Supreme Court ruled that expanded coverage must be a state option rather than a federal requirement), and hospitals will face a Medicare payment penalty for infections patients get while in their care (see “Pushing the Doctor’s Pen,” page 17). The impact of those types of changes on demand for care, its cost and its quality will inevitably spill over to the private sector.

Of course, the most-discussed change of all, the requirement that eligible individuals buy health insur-ance or pay a penalty, takes e�ect Jan. 1, 2014. State health marketplaces to help individuals buy a plan are required to be available for the fall 2013 open enroll-ment season. (The government has set up an interactive “wizard” for businesses trying to understand the ACA changes at http://business.usa.gov/healthcare. Or you can follow the Kaiser Family Foundation infographic on page 5 explaining who has to buy coverage and who doesn’t.)

“The ACA is changing the way we’re going to live, whether it’s the employer or the individual,” says Ruthann Laswick, president and founder of Blue Water Bene�ts Consulting in Scottsdale, Ariz. “It’s changing the fully insured market, but it’s changing the self-funded market, as well. I can’t think of a pop-ulation that isn’t going to be impacted by reform.”

“The ACA is a burning platform. In some ways

it’s kind of exciting, in some ways it’s

kind of scary.”

— Alexander Domaszewicz Principal, Mercer


THE REQUIREMENT TO BUY COVERAGE UNDER THE AFFORDABLE CARE ACT BEGINNING IN 2014

COURTESY OF THE HENRY J. KAISER FAMILY FOUNDATION

www.k�.org


If you have from two to 10 full-time employees, you could be eligible for a small business tax credit if you o�er them health insurance. If you have 25 or fewer full-time employees, you may be eligible for a par-tial credit. And apart from any tax credit eligibility, companies with fewer than 50 full-time equivalent workers are exempted from any penalty for not o�er-ing health insurance to those employees.

Fifty or more full-timers? Welcome to the Big Business club.

You should also remember that “full-time employees” means 50 full-time equivalent, non-sea-sonal employees of a�liated groups, with “full-time” de�ned as an average of at least 130 paid hours of ser-vice (including vacation, holiday, illness, incapacity including disability, layo�, jury duty, military duty or leave of absence) with respect to any month, and the status of seasonal employees is calculated by…well, you get the point. This being America, it’s kind of complicated. (Or you can follow the Kaiser Family Foundation �owchart on page 7.)

Karl Ahlrichs, a senior consultant for Gregory & Appel Insurance in Indianapolis, boils down the impact this way: “If someone is large and stable, there isn’t going to be that much tangible impact [in 2014]. There’s going to be some record keeping.”

Says Ahlrichs, who regularly speaks about the ACA to gatherings of the Society for Human Resource Management, “The people who are really going to be a�ected are the ones with a lot of part-timers, like a ski resort or a university with a lot of adjunct professors and coaches.”

Although the delay in the employer mandate until Jan. 1, 2015 represents a red tape reprieve, experts agree it has more political than practical impact. “I think most of the bigger employers had

already made their plans and gotten their ducks in a row,” says Mercer’s Domaszewicz.

The 96% of U.S. companies that employ fewer than 50 people weren’t a�ected, because the delayed requirement never applied to them in the �rst place. On the �ip side, 96% of the companies that do employ 50 or more people already o�er health insurance any-way. Cutting the numbers more closely, a KFF study shows that 98% of �rms with 200 or more employees o�er health coverage to at least some of them.

Gretchen K. Young, senior vice president for health policy at the Washington, D.C.-based ERISA Industry Committee (ERIC), says her members are looking beyond 2014. ERIC members, typically companies with 20,000 or more employees, “are looking at 2018 and thinking that the Cadillac tax may actually go into e�ect,” says Young. An article in the journal Inquiryestimated that the tax could initially a�ect about one in six health plans and, by 2025, roughly half of all indi-viduals with private health insurance.

The ACA’s impact on small business constitutes a much more contentious topic. Linda J. Blumberg, a senior fellow at the Washington, D.C.-based Urban Institute, says their analysis shows fears over the law’s impact are overblown. “I’m not saying nothing is going to change, but cataclysmic statements [about the ACA] are inaccurate,” she says.

“Cataclysm,” on the other hand, comes very close to describing the consequences of the ACA for small business foreseen by Robert F. Graboyes, senior research fellow at the Arlington, Va.-based Mercatus Center at George Mason University (see “Tale of One City,” page 23).

DETERMINING ACA REQUIREMENTSTWO SIZES FIT ALLFor the definitional purposes of the ACA, there are two types of businesses: small and large.

Are you a small business? It depends.

(continued on page 8)


COURTESY OF THE HENRY J. KAISER FAMILY FOUNDATION

healthreform.k�.org

PENALTIES FOR EMPLOYERS NOT OFFERING AFFORDABLE COVERAGE UNDER THE AFFORDABLE CARE ACT

healthreform.k�.org


Where there is no disagreement is on the cen-trality of small �rms to the ACA’s ultimate goal of expanding a�ordable coverage to all Americans. Workers at small �rms that do o�er health insurance tend to pay a larger share of the total family premium than workers at large �rms while simultaneously confronting higher cost-sharing, as well, according to a KFF report. Even with that greater cost-sharing, the premium cost for small employers can be daunt-ing; small �rms are much less likely to o�er coverage than larger ones. In 2012, about half of small �rms not o�ering health insurance cited cost as the pri-mary reason.

Under the ACA, small businesses will be able to use a special health insurance exchange called the Small Business Health Options Program (SHOP) marketplace. The SHOP is a web portal intended to enable businesses to easily compare health plan options while controlling what coverage employees are o�ered and the business’s share of costs. It also allows employee choice of plans while consolidat-ing those choices into one bill that the employer can then easily pay. Underwriting for all policies is con-strained to factors such as geography, age and tobacco use, and there are limits even within those categories.

As for the impact on premiums, a di�erent law provides the answer: the law of averages. If you limit underwriting, then plop a bunch of very di�erent small groups into one large risk pool, here’s what you get, according to an analysis by the American Academy of Actuaries:

Premiums could go up in small groups [that are currently �lled] with a disproportionately high share of young and/or healthy workers and down in small groups with a disproportionately higher share of old and/or unhealthy workers. The smallest groups, which are currently often charged higher premiums than larger groups, could see premium reductions, while larger groups could see premium increases.

After a bit of grumbling, most small businesses could more or less accept the new situation. Or those whose costs increase could shy away from SHOPs, causing premiums of groups that remain to shoot up. Individual workers might be turned loose by small employers, going from SHOP to shopping for them-selves at a public marketplace. Or the marketplace might provide new solutions, perhaps from private health exchanges.

What our experts did agree upon was that the availability of a�ordable health insurance to indi-viduals through the public marketplaces should signi�cantly level the labor market advantage larger �rms now enjoy. That, in turn, has implications for employers of all sizes.

“There are a lot of entrepreneurial professionals in big organizations who would love to join a smaller group or start something of their own,” says Ahlrichs of Gregory & Appel. “What’s holding them to their desk is the handcu� that’s health care [bene�ts].”

It turns out that the sturdiness of those handcu�s is also much on the minds of the larger companies.

What our experts did agree upon was that the availability of a�ordable health insurance to individuals through the public marketplaces

should significantly level the labor market advantage larger firms now enjoy.


Immediately after the law’s passage, brokers were su¥ciently worried that a Time arti-

cle examining their prospects was headlined, “The First Victims of Health Reform.” The

establishment of the online American Health Benefit Exchange for individuals and the

Small Business Health Options Program (SHOP) marketplace prompted immediate com-

parisons with web-based travel sites such as Expedia and Priceline, which decimated the

ranks of professional travel agents (see “Cafeteria Plans Gone Wild,” page 21).

In reality, buying insurance on an exchange won’t necessarily resemble grabbing an air-

line ticket from New York to Chicago. For plan sponsors, it might be more like booking

a trip from Boise to Buenos Aires using air, rail, auto and ship transport, multiple hotels,

frequent traveler points and varying currencies.

“It’s not going to be like travel agents,” says Linda J. Blumberg, a senior fellow with the

Urban Institute. “These exchanges could have literally hundreds of plan options. There

might be 13 carriers, with 10 to 15 plans at di�erent levels. You’re talking about a huge

amount of information even in an Expedia context.”

Karl Ahlrichs, a senior consultant for Gregory & Appel Insurance in Indianapolis, says

his in-box illustrates why expert advice will be irreplaceable. “I get 150 pages of guid-

ance each week from the Department of Health and Human Services, the Department of

Labor and the Internal Revenue Service,” says Ahlrichs. “When they passed the ACA, they

launched a ship. Now, they’re building it.”

The ACA permits brokers to be paid through the public marketplaces for individual and

small group policies that meet requirements of a “qualified health plan.” Each state

determines whether those commissions will, in fact, be paid and how they’ll be man-

aged; that is, paid by the marketplace or directly by the carrier. Brokers must also reg-

ister with the marketplace.

What a broker cannot do is become one of the navigators who explain to individuals

how the marketplace works. Those who are fulfilling this role, defined by law in the

ACA, cannot be paid by an individual insurer and are expected to come primarily from

community organizations.

BOOM TIMES FOR (SOME) BROKERS

Contrary to some initial fears, the launch of health insurance exchanges

will not be accompanied by the sound of brokers locking their doors and

going broke. Unexpectedly, the A�ordable Care Act could actually bring

boom times to some brokers.


Similarly, the private health insurance exchanges

springing up under the sponsorship of consulting firms

and insurers don’t have to include brokers, either. How-

ever, in both public and private exchanges, brokers are

expected to be eagerly welcomed for their ability to

smooth a confusing transition.

“There’s a very strong attachment between the broker-

ages and the small businesses because they provide

services other than health insurance,” says Blumberg.

“The states realize the brokers are going to have to be

on board to do the outreach and the enrollment.”

Some states, she adds, are already encouraging brokers

to reach out to industries where health insurance typi-

cally is not o�ered, like restaurants, to help them get

employees to use the exchanges.

Moreover, says Ruthann Laswick, president of Scottsdale,

Ariz.-based Blue Water Benefits Consulting, “many

consumers still want a human being to be involved,

so when something is not right they can pick up the

phone and deal with it.”

For their part, brokers must adapt to the ACA’s new chal-

lenges, including, for example, helping workers under-

stand how to think about their new coverage options.

Says Blumberg, “They’re going to have to be more com-

puter savvy and adapt to an electronic environment

that involves the worker as well as the employer.”

“There is a big opportunity here for insurance brokers

to be the translators in the user interface that makes the

exchanges work well,” says Dr. Robert Kocher, a partner

in Palo Alto, Calif.-based venture capital firm Venrock

and a former health policy adviser to President Obama.

Venrock recently invested in Zenefits, a digital broker

that allows users to create new plans while serving up

quotes for group coverage across health, dental and

vision insurance.

While Kocher believes traditional brokers will continue

to serve a niche, he adds, “Now that everything is elec-

tronically priced and filed and there’s no underwriting,

there’s a need for new brokers who can use the web and

scale more radically.”

Separately, brokers could face threats from care deliv-

ery system changes prompted by the ACA. For example,

direct-access primary care, with contracting between

a provider group and employers, “disrupts insurance

as a middle man and disrupts brokers,” says Dr. Jason

Hwang, the Sunnyvale, Calif.-based co-author of The Innovator’s Prescription, a book about bringing “disrup-

tive innovation” to health care.

Amidst all this change, financial pressure on brokers

is ratcheting up as commission fees become transpar-

ent and more clients consider fee-for-service payment.

Adaptation is critical, and there will be consolidation.

“Brokers,” says Mercer’s Domaszewicz, “must continue

to add value.”

“There is a big opportunity here for insurance brokers to be the translators in the user interface that makes the exchanges work well.”

— Dr. Robert Kocher, Partner, Venrock


The purpose of health insurance is to provide a�ordable access to health

care, but exactly what care should plans in the public health insurance

marketplaces be required to cover? The ACA’s answer was “essential

health benefits (EHB).” It was then left up to the Department of Health and

Human Services (HHS) to define what that meant.

After collecting a cornucopia of comments, HHS put forth its list of essential health ben-

efits. As with many ACA requirements, there are certain parameters within which each

state can customize its own set of rules.

The law requires non-“grandfathered” health plans o�ered in the individual and small

group markets, both inside and outside health exchanges, to also cover essential health

benefits. (Large groups have a di�erent set of rules, including first-dollar coverage for

preventive services.) Those benefits are defined as items and services within at least the

following 10 categories:

As for the level of coverage, any qualified health plan (QHP) o�ered by a marketplace

must o�er the essential health benefits in a manner “substantially equal” to those of a

benchmark plan selected by each state to reflect a “typical employer plan.”

HHS guidelines define how that benchmark plan can be chosen. Separate from coverage

issues, other regulations cover a QHP’s cost-sharing features, such as deductibles, copay-

ments and coinsurance.

YOU MUST REMEMBER (TO COVER) THIS

10 CATEGORIES

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including

behavioral health treatment

6. Prescription drugs

7. Rehabilitative and rehabilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care


“The ACA is causing organizations to start with a clean sheet of paper and in many cases redesign their human capital business plan,” says Ahlrichs. “That’s good.”

At ERIC, Young agrees. “Our members are tak-ing this as an opportunity to look at workforce strategy, total compensation and the role bene�ts are going to play.”

Firms face two immediate decisions. The �rst is “drop or not”—that is, whether to stop o�ering health insurance to employees, turning them over to the public marketplace and paying a per-worker pen-alty as a result. If the bene�t is retained, the second decision is whether and how to redesign it for the post-ACA world.

DROP OR NOTEarly worries that the ACA would set o� a stampede away from employer-sponsored plans now look prema-ture at the very least. One reason is employer hesitancy to rely upon untested public marketplaces. At least as important, however, is a renewed consensus that the business case for providing bene�ts remains strong.

“Recruitment and retention are important, and training costs are high,” says EBRI’s Fronstin. “If employees have good bene�ts, they stay longer. That’s what employers have been doing for the past 70 years. They’ve seen value before, and they still see value.”

RESPONDING TO THE ACATAKING CARE OF BUSINESS

If one theme repeatedly emerges in conversations with expert thought leaders, it is this: the

ACA represents a golden opportunity to seize business advantage. Benefits are a tool, and the

advent of the ACA gives human resource executives at companies of all sizes a fresh chance to

examine whether that tool is accomplishing its purpose.


Fronstin says that’s particularly true in the current tight market for skilled labor. It’s a viewpoint echoed by Dr. Robert Galvin, CEO of New York-based Equity Healthcare, which manages the health care costs of 40 companies in which private equity �rms have taken a stake. Those companies cover 315,000 lives and spend $1.5 billion a year on care, yet not a single one will be sending its workers to a public marketplace.

Talking with company CEOs, “I have never heard labor competitiveness be at such a sharp edge,” Galvin says. “Almost above everything else, people cannot a�ord to lose really good employees. If your labor competitiveness is high, people really care about their health bene�ts. If it’s low, it’s a nuisance.”

That view seems widely shared. In a recent Challenger & Gray survey, not one of the 100 HR executives polled said their company was drop-ping health coverage. In a recovering economy with decreasing unemployment, “companies that continue to o�er health insurance in 2014 could have a clear recruiting advantage,” Challenger & Gray said.

That doesn’t mean the status quo is stable. In the 2013 Towers Watson/National Business Group on Health (TW/NBGH) “Employer Survey on Purchasing Value in Health Care,” just 26% of respondents said they’re very con�dent that health care bene�ts will be o�ered by their organization 10 years from now. Much is seen as depending on what happens with health care costs, the public market-places and other highly variable factors.

Still, for the present, University of Pennsylvania economists Mark Pauly and Mark Duggan, writ-ing in the journal Health Management, Policy and Innovation, o�er this advice to “the pressured and puzzled employer currently o�ering bene�ts”:

It is easiest to say what not to do: do not base the decision on the simple but misleading arith-metic that just compares “cost” for bene�ts now being paid with ACA penalties if they are no longer o�ered. Rather than using this as auto-pilot, think about the more di�cult question of how much more in cash wages you would have to o�er the workers you want to keep (taking account of their di�erent incomes, preferences and taxes) to make them as well or better o� using the exchange compared with your current o�ering (and its tax breaks). And think about whether you want to retain this workforce or what kinds of workers you want to attract.

“I think we have had two years of emotional decisions,” says Laswick of Blue Water Bene�ts. “If you’re going to make decisions, make them for the right reasons.”

“If employees have good benefits, they stay longer. That’s what employers have been doing for the past 70 years. They’ve seen value before, and they still see value.”

— Paul Fronstin, Ph.D. Director, Employee Benefit Research Institute, Washington, D.C.



Self-insurance is seductive, singing a siren song of freedom.

There’s more control over the benefits o�ered, flexibility to

directly contract with providers and possible savings from an

administrative services only (ASO) fee. Not to mention an ERISA

preemption from state mandates and escape from some ACA-

mandated changes.

The ACA is widely expected to accelerate the self-insurance trend. Even com-

mercial insurers are jumping into the game: UnitedHealth and Humana will

be o�ering self-insurance to small business customers with, in UnitedHealth’s

case, as few as 10 workers. Still, our experts warn small businesses setting out

on the self-insurance voyage to beware of hidden hazards that can sink those

who don’t navigate carefully.

“You can save a lot of money, but take on a lot of risk,” cautions Dr. Rob-

ert Galvin, CEO of New York-based Equity Healthcare. “You don’t have cata-

strophic cases one year, you think you’re brilliant. You get one case the next

year, you pay up.”

The percentage of private-sector workers with health coverage in plans that

are partially or completely self-funded increased from 44% in 1999 to 60%

in 2012, according to the 2012 Kaiser Family Foundation/Health Research &

Educational Trust (KFF/HRET) survey. The gradual increase has been driven

primarily by firms with 1,000 or more workers. At the opposite extreme, the

percentage of workers in companies with 3 to 199 workers in a self-insured

plan was just 15% in 2012, little changed since 2009 and up only a bit from

13% in 1999.

The ACA, however, brings big changes, including a new sales tax on health insur-

ers that will be at least partly passed on to customers. Benefits consulting firm

Oliver Wyman estimates the tax will initially raise premiums by 1.9% to 2.3%.

That tax will “tilt employers away from traditional commercial health insur-

ance” toward an ASO and a reinsurance policy, predicts Bruce M. Fried, a

health policy expert and managing partner of the Washington, D.C., o¥ce of

the Dentons law firm.

Our experts warn small businesses

setting out on the self-insurance voyage to beware of hidden hazards that can sink

those who don’t navigate carefully.

THE SIREN SONG OF SELF-INSURANCE


Mike Ferguson, chief operating o¥cer of the Washington, D.C.-based Self-

Insurance Institute of America, agrees there’s increased interest in self-insur-

ance from small and midsize employers.

That trend is raising concerns by some legislators that self-funding is being

used to undermine the ACA. Legislatures in California, Minnesota, Rhode Island

and Utah are all considering bills to make self-funding less attractive by raising

the minimum deductibles (attachment points), thereby forcing companies to

take on more financial risk, according to the Boston-based Wagner Law Group.

Stop-loss policies limit an employer’s liability by paying for medical expenses

beyond a specified upper limit for each covered individual in a plan, an

arrangement known as the individual or specific attachment point. There may

also be limits for the plan itself, in what is called an aggregate attachment

point. Supporters of legislation contend self-insurance is being used to avoid

state regulation and the “essential health benefits” mandate of the ACA. They

also point to a Commonwealth Fund issue brief warning that self-insurance

provides “an opening for small employers with healthier workers to avoid

broader sharing of health care risk, isolating higher-cost groups in the fully

insured market” represented by the public health marketplaces.

That allegation about worse risks being dumped o� on the marketplaces “is

a canard,” responds the Self-Insurance Institute’s Ferguson, “but it provides

political motivation” for restrictive legislation. He adds, “It’s bad public pol-

icy for government to dictate risk transfer arrangements for private-sector

employers.” The institute and others also question whether state laws a�ect-

ing self-insured plans are preempted by ERISA.

For some employers, Ferguson adds, “the time could be right to switch to

self-insurance, and this opportunity should not be missed. But equally impor-

tant, self-insurance is not the best option for every employer, so brokers need

to know when to steer their clients away from this decision.”

The concerns about self-insurance may yet prove overblown. When health

reform similar to the ACA was passed in Massachusetts in 2006, the per-

centage of workers in firms with 50 or more employees in self-insured plans

increased from about 54% to about 67%, says EBRI. Interestingly, the per-

centage of the smallest businesses choosing that route since that time has

not greatly changed.


REPEAT OR REDESIGNEmployers that do retain coverage must next decide what to do about their bene�t package. Many might merely tinker with the �ne print by, for example, meet-ing ACA rules on phasing out lifetime plan limits. Others could implement quick �xes of potential prob-lems, plan a long-term strategic overhaul or undertake some combination of both approaches.

Responses will vary by plan sponsor size, geog-raphy (the ACA gives states �exibility in some requirements) and industry. So, for instance, some universities and community colleges have already announced limits on teaching hours of adjunct faculty so they won’t hit the 30-hour mark that makes them eligible for full-timer health bene�ts.

How widespread that will be is unclear. A recent survey from the Federal Reserve Bank of Minneapolis found that just 4% of companies it sur-veyed had moved to a larger, part-time workforce in response to the A�ordable Care Act. A Mercer sur-vey on ACA implementation found that 12% of all employers said they’ll reduce some workers’ hours to limit health insurance eligibility, but 20% of retail and hospitality employers planned to follow that path. The National Restaurant Association and some indi-vidual restaurant chains have been scathingly critical of the ACA’s regulations regarding the hiring of part-time workers.

Companies with large numbers of low-wage work-ers are also more likely to consider “bare bones,” low-bene�t plans that o�er preventive services required by the ACA but little more. A recent Wall Street Journalarticle described plans that might exclude surgery and X-rays while providing $100 a day toward hospi-tal costs. Another cost-containment tactic is o�ering a lower-cost plan just to new hires.

Alternatively, as the ACA brings new workers into the company plan, some employers are raising employee contributions for coverage, particularly for dependents. That trend, already under way before the ACA became law, is continuing. Over the last three years, more than 70% of companies increased the employee share of premium contribu-tions, and dependent coverage costs increased even faster, according to the Kaiser Family Foundation/Health Research & Educational Trust (KFF/HRET) “Employer Health Bene�ts 2012 Annual Survey.” Over the next three years, more than 80% of respon-dents planned to continue to raise the share of premiums paid by employees, the survey found.


A Mercer survey on ACA implementation found that 12% of all

employers said they’ll reduce some workers’ hours to limit

health insurance eligibility, but 20% of retail and

hospitality employers planned to follow that path. hospitality employers planned to follow that path.


The most expensive medical instrument, the saying goes, is the

doctor’s pen. Upwards of 70% of all medical expenses start out

with a doctor’s order. For employers, the challenge has been how

to appropriately influence what gets scratched on the pad or

(hopefully) keyed into the electronic medical record.

The modern era of employer activism began three decades ago, when a finan-

cially strained Chrysler Corp. put employee medical claims through a computer-

ized review that uncovered widespread overutilization, ine¥ciency and fraud.

Though computers have become far more sophisticated, the basic problem has

changed little. The Institute of Medicine estimates that close to a third of the $2.7

trillion spent on health care annually is wasted because of unnecessary services,

excessive administrative costs, prices that are too high, ine¥ciently delivered

services, missed prevention opportunities and fraud.

“Health care is expensive because the health care system is expensive, and we

need to manage that cost,” says Ruthann Laswick, president of Scottsdale, Ariz.-

based Blue Water Benefits Consulting.

The A�ordable Care Act tries to push the provider’s pen in the direction of more

e¥cient and e�ective care through provisions such as Accountable Care Orga-

nizations (ACOs), which align doctor and hospital incentives for coordinated

care; value-based purchasing for hospitals; a bundled payments demonstration

for hospital and post-acute care; reduced payments for some hospital-acquired

conditions; reduced payments for preventable hospital readmissions; and man-

datory physician quality reporting. While these initiatives directly address only

government payments, changed rules by someone writing checks for nearly $1

trillion a year reverberate powerfully throughout the health care industry.

“When Medicare heads o� in a direction, the private sector follows,” says Bruce

M. Fried, managing partner of the Washington, D.C., o¥ce of law firm Dentons

and a former o¥cial with the Medicare program. “It’s an inevitability.”

PUSHING THE DOCTOR’S PEN


Many employers are trying to add to the ACA’s pressure. “Aggressive” strategies

include greater vendor transparency, value-based benefits design (where medi-

cal evidence is used to make certain drugs or treatment choices more attrac-

tive financially) and new reimbursement models for providers—that’s according

to the Towers Watson/National Business Group on Health “Employer Survey on

Purchasing Value in Health Care.” Separately, the group Catalyst for Payment

Reform has put out a toolkit for employers to help achieve the goal of tying 20%

of U.S. health care payments to value by 2020.

“If it’s terrible care, you’re going to pay for it” through increased costs, explains

Gretchen Young, senior vice president for health policy at the Washington, D.C.-

based ERISA Industry Council (ERIC).

To avoid wasted expenditures, “there’s more talk about limited networks, high-

performance networks, centers of excellence,” says Paul Fronstin, director of

the health research and education program at the Washington, D.C.-based

Employee Benefit Research Institute (EBRI). “Everything’s on the table.”

The table itself has added a few chairs. Payers and providers have begun talking

more seriously about cooperation. “Physicians and businesses share a common

goal—to advance better health,” suggested a commentary in the Dec. 19, 2012

issue of JAMA. The ACA’s provisions for outcome measures, it continued, “a�ord

the opportunity for a reshaping of the larger context for health care negotiation.”

The authors went on to suggest adding quality measures of interest to employers,

such as a covered population’s workers’ compensation and disability payments.

“There are a whole bunch of di�erent drivers that are changing the environment,”

says Charles P. Kahn III, president of the Washington, D.C.-based Federation of

American Hospitals. Kahn, who previously headed the trade group for health insur-

ers, sees new alignments between hospitals and clinicians and between providers

and insurers. Value-based purchasing rules are making a di�erence, he says, add-

ing, “I hope it leads to better health care.”

Those views are seconded by Dr. Charles Kennedy, chief executive o¥cer for

the Accountable Care Solutions unit of Hartford, Conn.-based Aetna. Aetna

and other insurers are courting health systems as ACO partners. “The dialogue

between delivery systems and health plans, at least those pursuing accountable

care strategies, has changed significantly,” says Kennedy. “We’re having conver-

sations we never had in the past.”

When it comes

to finding a

way to constrain

health care costs,

value-based

purchasing “is the

last best hope.”


The trend has particular promise for reducing chronic care costs. “When you convert physicians to account-

ability for a population, they have a very strong financial incentive to find those diabetics [and others] who are

not compliant and intervene with them,” Kennedy says.

At Ohio’s Austen BioInnovation Institute in Akron, the group’s president, Dr. Frank Douglas, goes even fur-

ther. His group is proposing an “accountable care community” that includes the hospital, clinicians, commu-

nity organizations, government and employers. “We need to have the coming together of public health and

clinical health for the benefit of the community,” says Douglas. “You have to incentivize that.”

Still, there are plenty of doubters about the ACA’s cost-control clout. With ACOs, for example, “the link

between payment and the provision of care isn’t strong enough,” says Dr. Jason Hwang, the Sunnyvale, Calif.-

based co-author of The Innovator’s Prescription. Employer commitment is also “a big unknown.”

Meanwhile, while Kahn and other provider representatives insist consolidation among hospitals and medical

groups is necessary to provide integrated, technologically sophisticated and cost-e�ective care, those on

the payer side of the table view it di�erently. They contend there’s been a lessening of provider competition,

reflected in price increases rather than shared e¥ciencies.

Fried suggests that all parties will remain motivated to work together. When it comes to finding a way to

constrain health care costs, he says, value-based purchasing “is the last best hope.”


FAT CHANCE FOR SAVINGSIn 2014, plan sponsors will also exercise new control over wellness programs. Those programs have become commonplace: the KFF/HRET survey found that 94% of �rms with 200 or more workers o�er some sort of wellness bene�t, as do 63% of �rms with three to 199 workers. However, evidence of the programs’ economic e�ectiveness in reducing health care costs has recently come under scrutiny from health services researchers.

The ACA wellness provision is di�erent, per-mitting “outcomes-based programs” that require individual workers to attain or maintain speci�c goals measured by biometric screening or a health risk assessment questionnaire. In 2014, the ACA lets employers pump up the maximum incentive for goals such as a healthy body mass index (BMI) to 30% of the full cost of coverage (from 20%). That cap can be raised later at the discretion of the Department of Health and Human Services (HHS) to 50%.

However, rules from HHS and the IRS have per-suaded some employers that a wellness strategy may not work out. The rules say “all individuals who cannot satisfy the initial [wellness] standard must be o�ered a reasonable alternative means to qualify for the reward.” In other words, they limit the pain to those who gain (weight).

ERIC’s Young believes the “reasonable approach” loophole makes any reasonable chance of saving money a real stretch. “Employers feel hamstrung about how to control health care costs,” she says. “They want to be able to draw a line in the sand and say, ‘BMI under 30 or you pay 30% more on premiums.’”

But drawing that line may provoke pushback. A Pennsylvania State University wellness program with penalties of as much as $100 per month set to begin in January 2014 has already prompted faculty and employee protests, the Wall Street Journal reported.

Meanwhile, at the other end of the size spectrum, the Mercatus Center’s Graboyes suggests that small business owners would not relish looking a worker in the eye every day and telling him or her to get in shape. “Employers have a lot on their minds,” Graboyes says. “Every hour they spend thinking how can I make our employees thinner is an hour they’re not spending on how can I make my business more pro�table.”


It is the private exchanges’ ability

to o�er a clear choice of defined contribution

products with well-defined price tags that gives them

a glittering appeal to many plan sponsors.

With medical costs still rising at double the rate of general in�ation, many employers see the ACA as a chance to institute “profound change—recali-brated strategy and aggressive action,” according to the TP/NBGH employer survey. Many respondents, it continued, “say they will rethink plan design and improve the quality and e�ciency of member care.”

That approach was also endorsed by our expert thought leaders. Consultant Ahlrichs, for example, says one key target of bene�t redesign should be entrepre-neurial high performers who may be tempted to go out on their own or join a startup once the “handcu�” of employer health insurance is snapped open.

“You have to get smarter about the characteristics of your high performers—perhaps design your bene�t plan to have a lot of voluntary bene�ts that will allow people who by their very nature are entrepreneurial to pick and choose the ones that really �t them rather than a ‘one size �ts all’ kind of plan,” Ahlrichs says. He cites the example of an organization whose high per-formers were from cultures that valued bene�ts such as Eastern medicine and acupuncture.

Fronstin, Galvin, Laswick and Young endorse a sim-ilar strategic view. Says Galvin, “I hate health care costs, but I love an employee who’s good at global or can man-age in a matrix.”

CAFETERIA PLANS GONE WILDOne innovative approach that may help in strate-gic redesign is a new generation of private health exchanges. Compared with the public marketplaces, “they are so di�erent it’s like comparing apples with oranges,” says Mike Ferguson, chief operating o�-cer of the Washington, D.C.-based Self-Insurance Institute of America.

To begin with, public marketplaces were explicitly established by the ACA; private ones are marketed as an alternative not subject to ACA rules. They resem-ble a supercharged version of the cafeteria plans of old, o�ered in a variety of �avors by an alphabet’s worth of brokers, consultants and insurers ranging from AonHewitt to WellPoint. The new exchanges are said to possess wondrous properties, but their power has yet to be tested to any extent in the real world.


It is the private exchanges’ ability to o�er a clear choice of de�ned contribution products with well-de�ned price tags that gives them a glittering appeal to many plan sponsors. From labor unions to large corporations, the prospect of the 2018 excise tax of 40% on health plan bene�ts worth more than $10,200 to an individual and $27,500 for a family looms large. No one wants the “Cadillac tax” to run them over. As the Mercer employer survey put it: “Employers have consistently told us they will do whatever is nec-essary to avoid the tax.”

Exchanges could o�er fully insured products or products for the self-insured. Insurers like Aetna see them as a way to introduce consumers to Accountable Care Organizations and similar products that empha-size a combination of quality care and a�ordable cost. “They allow you to create an open marketplace not only for traditional health plans, but for account-able health plans to sell their services to individual employees within this larger marketplace,” says Dr. Charles D. Kennedy, chief executive o�cer of the Accountable Care Solutions unit of Hartford, Conn.-based Aetna.

Others see the e�ort to avoid the excise tax as a boon for supplemental insurance products such as vision and dental care, child care and other “volun-tary” products. Overly rich standard plans can be pruned, while employees are at the same time given the chance to purchase a more personalized menu of additional options. With an online platform, the pro-cess can be made even simpler.

“I think we will see the supplemental insur-ance market grow by leaps and bounds, whether it’s through private exchanges or the individual employ-ers,” says consultant Laswick.

EBRI’s Fronstin cautions employers to be realistic. A private exchange can help with a �xed-contribution approach to plan design, including decisions such as setting the proper contribution level and adequate plan choice. But there are other issues, such as the role of the employer as advocate in coverage disputes or in pushing for care quality improvement, where the private exchange may not be of help.

Initial interest in the exchanges from large employers appears widespread, even if few have yet taken the plunge. And Dr. Jason Hwang, the Sunnyvale, Calif.-based co-author of The Innovator’s Prescription, sees the private exchanges as a potentially powerful wedge. “Exchanges grow a market of con-sumers that will go out and actively shop,” he says. “To create change in the marketplace, you don’t have to educate every single consumer.”

Benefits firm Sibson Consulting describes what distinguishes the private health exchange:

“Any health insurance exchange is a marketplace through which

employees and retirees can purchase health insurance and evaluate the

differences among plan designs and/or carriers....It also includes mem-

ber support tools to help users understand how the exchange operates

and make informed decisions.

“The private exchange model typically uses a defined contribution

approach to health care. Employers provide a set dollar amount toward

health coverage, and the employees use that money toward the purchase

of health insurance from the insurance carriers on the exchange their

employer has selected.”

The Private Health

Exchange


Linda J. Blumberg of the Urban Institute and Robert F. Graboyes

of the Mercatus Center at George Mason University are both

Washington, D.C.-area economists. But while they are not physi-

cally located very far apart, what they see and hear about the

ACA places them at opposite poles. It is the best of times, says one;

it is the worst of times, says the other. It beats the dickens out of

impartial observers whom to believe.

Blumberg emphasizes that under the ACA small business will benefit from access to a labor force expanded by the end of “job lock.” She says:

Small employers have always been less likely to o�er insurance, and the rate of

employer o�er has dropped over the last 10 years. It’s much more di¥cult for

them to hire the same kind of workers that large employers do, since the workers

can’t sacrifice having coverage for themselves and their families by choosing a

job that will be better for them at the smaller firm.

It’s the reforms of the non-group market [with public health marketplaces]

that make it possible for these employers to hire. The marketplaces provide an

adequate, accessible, a�ordable source of health insurance outside the work-

force. Taking a job in the small firm is easier for the worker, and it makes things

in the labor market much more a level playing field for the smaller firm. For small

employers, it’s an incredibly important law.

As for smaller firms favoring part-time workers over hiring new full-time ones:

The way I look at this is, there’s a window of [part-time] employees who will be

a�ected by this. But small businesses have to be thinking about attracting the

workers they want. If they give workers fewer hours, they may not attract the

workers they want. And there’s the cost of having more workers work fewer hours

each versus having few workers work more hours; for example, training and turn-

over and administrative issues.

The vast majority of costs associated with health insurance paid for by employ-

ers is paid by passing down the costs to workers in terms of total compensation.

Over time, we would anticipate the vast majority of costs incurred by the employ-

ers will be passed back through a somewhat slower growth in wages.

A TALE OF ONE CITY: WILL SMALL BUSINESS STORM THE BASTILLE?

With a piece of legislation “so

large and so complex,”

employers need to prepare for

“the law of unintended

consequences.”


Blumberg sees a revolution that may begin with storming the Bastille, but ends peacefully:

A lot of the angst around this in the small business community is going to work

itself out once the change comes through. It won’t turn out to be as big a deal as

it’s made out to be.

Graboyes, until recently at the National Federation of Independent Business, has a far darker view. Looking at the ACA’s impact, he sees a law that directly hurts hiring:

The ACA has made it exceedingly di¥cult for businesses to plan, budget and

estimate the costs of hiring new people. Frankly, a lot of them have refrained

from hiring and growing. It has a paralyzing e�ect on businesses by making it

very di¥cult to gauge what the cost of hiring one additional worker will be. The

ACA creates a lot of firm-specific fiscal cli�s—for instance, if a business owner

has investments in multiple businesses. You hire one more employee, and you

find you have a $40,000 obligation you hadn’t expected. I have talked to any

number of business owners in this situation who say, “I’m not hiring anyone, I’m

not growing, and I’m not taking advantage of opportunities because it’s going to

come back and bite me.”

[ACA compliance] is worse for small businesses, which tend not to have the

accounting or legal departments that can smooth over the red tape. The red tape

is going to be handled by the business owner on their kitchen table after the door

shuts, [or] they’re going to have to pay for expert information.

“A lot of the angst

around this in the small

business community

is going to work itself

out once the change

comes through. It

won’t turn out to be

as big a deal as it’s

made out to be.”


Graboyes is skeptical that health exchanges will truly help small businesses o�er more benefit choices or unlock job lock for individual workers. He says:

We have no clue if they will function. To get them to do so will require what is

probably the biggest single data integration project in the history of computers.

It’s a leap of faith.

You may have more [health plan] choices, but you won’t have less expensive

choices, unless you have a subsidy. And the tax credit [to small businesses] is a

highly complex one that is going to do very little good for a relatively few firms.

In this Tale of One City, Graboyes sees a revolution that began with a bloody political battle continuing to bleed the U.S. economy:

The complexities are beyond any piece of legislation in American history. I think

the paradoxes and conundrums will keep bubbling up for years. It means lack of

growth in the economy.

Who’s right? Perhaps both. Real-world business decisions contain a changing

mix of rationality and reactivity. “If a small employer is not hiring and chooses

not to grow because of health care reform, that’s not a business decision, it’s an

emotional decision,” says Ruthann Laswick, president of Scottsdale, Ariz.-based

Blue Water Benefits Consulting. But, she acknowledges, “we’ve seen a lot of

emotional decisions around the ACA.”

Frank Douglas, a veteran pharmaceutical executive who now heads Ohio’s

Austen BioInnovation Institute in Akron, suggests the wisest course is flexibility.

With a piece of legislation “so large and so complex,” employers need to prepare

for “the law of unintended consequences.”

“The complexities

are beyond any piece

of legislation in

American history.

I think the paradoxes

and conundrums

will keep bubbling

up for years. It means

lack of growth in

the economy.”


The ACA, passed into law 100 years later, has often inspired a similar reaction. As the full impact of the ACA comes closer to exploding onto the U.S. system of employer-based health coverage, it has been sur-rounded by a brightly burning mixture of fact and �ction, hopes and fears.

“It’s a big change,” sums up Healthcare Equity’s Galvin, “so there’s been a lot of panic and a lot of craziness.”

Deservedly or not, the ACA will continue to be the object of imprecations, but the main concern now for

HR professionals is implementation. The ACA’s most sweeping provisions are about to take e�ect. In a recent TW/NBGH employer survey, nearly all respondents (92%) anticipated at least modest changes in the health care marketplace over the next �ve years as a result, and nearly half expected either signi�cant changes (44%) or a complete transformation (3%).

The law’s most immediate e�ects could be the least enduring. While plan sponsors cannot predict how many new participants will join or how changes in part-time hiring procedures will a�ect enrollment,

CONCLUSION: THE COMET HITS HOME

When Halley’s Comet swooped close to the earth in 1910, scientists informed the public that

its highly visible tail was partly formed by a poisonous gas. Although the comet was 14 million

miles away, a brief panic nonetheless overtook a large part of the world’s population.


those types of issues will play out quickly and rela-tively straightforwardly.

Long-term e�ects are trickier. Figuring out how to redesign the bene�ts package to attract and retain the right kind of employees in a post-ACA world is a work in progress. The magnitude of change provides the chance to “spark a lot of innovation,” says Hwang. “It’s what the ACA still has room to do”—but still has to show it will do.

More broadly, bene�ts are tied to more fundamental business goals. If, for example, o�ering health insur-ance to previously uninsured workers and their families makes employees more productive, then any rise in health care costs could be more than outweighed by an increase in pro�tability. If the health insurance require-ment disrupts the core business, however, its impact on medical expenses is irrelevant.

Moreover, employer-sponsored plans are only one part of a larger ecosystem. The ACA’s impact is at least as large on health plans and providers and, directly or indirectly, on pharmaceutical companies, device makers, home health equipment suppliers and everyone else in the large, complex and costly health care food chain.

Company executives may fret that the ACA’s impact will turn employer-sponsored plans into another World War II relic, as quaint as Rosie the Riveter. But what would happen to the employer-based system if fee-for-service medicine goes extinct instead, replaced by value-based purchasing? Rejuvenation, irrelevance or something else?

And what about the entrepreneurs emerging to �ll new niches they believe the ACA has created, or the large corporate creatures once lurking on the edge of the health care ecosystem that now see success in the health care marketplace as central to their existence? Will “survival of the �ttest” in the post-ACA world bring new e�ciencies or just new predators greedily gobbling up health care dollars?

HR executives have adapted before, and they will almost assuredly do so again. Laswick, with 37 years as a consultant, o�ers this comforting advice. “When you sit down and actually understand the legislation, and you go through it with pencil and paper, it’s not nearly as overwhelming as it appears to be.”

Mercer’s Domaszewicz, who heads the health care innovation practice, o�ers a �nal piece of perspective:

Every plan sponsor’s objectives and goals are unique. Each one is a kind of microcosm, and health care reform is a pretty big pebble in the pond, with ripples all around. But the pond is still their pond, with their employees and their workforce, and their merger and acquisition activity, and the geographies they’re in, and whether they’re expanding or contracting, and the health issues their workforce has.

And whether the comet that strikes nearby spawns devastation or renewal, each plan sponsor is going to need an HR professional to cope with the aftermath.

And whether the comet that strikes nearby spawns devastation or renewal, each plan sponsor is going to need an

HR professional to cope with the aftermath.


EXPERT PANEL

Karl Ahlrichs senior consultant, Gregory & Appel Insurance, Indianapolis

Linda J. Blumberg, Ph.D. senior researcher, Urban Institute, Washington, D.C.

Alexander Domaszewicz principal, health and benefits practice, Mercer, Irvine, Calif.

Frank Douglas, M.D., Ph.D. president, Austen BioInnovation Institute in Akron, Akron, Ohio

Mike Ferguson chief operating o¥cer, Self-Insurance Institute of America, Washington, D.C.

Bruce M. Fried, J.D. managing partner, Dentons, Washington, D.C.

Paul Fronstin, Ph.D. director of health research and education program, Employee Benefit Research Institute, Washington, D.C.

Robert Galvin, M.D. chief executive o¥cer, Equity Healthcare, New York, N.Y.

Robert F. Graboyes, Ph.D. senior research fellow, Mercatus Center at George Mason University, Arlington, Va.

Jason Hwang, M.D. co-author, The Innovator’s Prescription, Sunnyvale, Calif.

Charles P. Kahn III president, Federation of American Hospitals, Washington, D.C.

Charles D. Kennedy, M.D. chief executive o¥cer, Accountable Care Solutions, Aetna, Inc., Hartford, Conn.

Robert Kocher, M.D. partner, Venrock, Palo Alto, Calif.

Ruthann Laswick president, Blue Water Benefits Consulting, Scottsdale, Ariz.

Gretchen Young senior vice president, health policy, the ERISA Industry Council (ERIC), Washington, D.C.

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A COMET HITS PLANET HEALTH CARE - Forbes · 2013. 10. 29. · The Patient Protection and A ordable...

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