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BLOG: The fundamental problem with health insurance exchange programs
This week may mark the turning point in the health insurance exchange program. United Healthcare Group has announced a sizable expected loss related to the exchange business and is considering withdrawing from the program next year. Other major insurance companies have also reported financial problems related to their health care exchange products.
This should come as no surprise to optometrists. We saw a huge flaw in the exchange products from the very first day when we learned, along with our unhappy patients, that the expected eye care coverage for children was all “smoke and mirrors” and that it evaporated in co-pays and deductibles.
So, am I saying that the health insurance exchange programs are going to be re-vamped because optometrists are unhappy? Wouldn’t that be nice! Although I have touted that the Affordable Care Act has identified optometry as essential, we are not indispensable. However, our problem with the health insurance exchange is a symptom of a much larger problem and, frankly, the reason for their failure.
The fundamental problem with the health insurance exchange program is that the design and implementation is appealing to the sick and unappealing to the well. As such, many more sick people have enrolled than the well. People that are sick consume significantly more health care dollars than the well and, therefore, the health plans, whose premiums were based on a balanced membership of both sick and well, are coming up very short. Unfortunately, the traditional insurance-based solution to this problem will be to raise the premiums to cover the loss, but this will only further compound the problem.
The better answer to the problem is not to increase the premiums but rather to redesign the programs to be more appealing to the well. To do this, the plans must provide for new and creative access to health education, wellness and preventive care.
Perhaps the best way to do this is to use the abundant resources of optometry, dentistry, podiatry, chiropractic, mental health and pharmacy care. These health care providers have independent office space, are well distributed in convenient locations and, although they have specialized training in specific aspects of health care, they can be easily redirected to add basic primary health care services to their existing specialty areas.
The highly desired patient base of healthy or “well” people often use the services of the above group of providers on a regular basis. The problem is that the specialized health education of each of these disciplines has minimized the overall health and wellness of the patient to get on to the traditional practice of the isolated specialty. For most, however, this can be easily addressed with primary health care-based postgraduate education.
Of the above-identified group of health care providers, only the pharmacists have recognized the need to fill the primary care void and have revised their delivery system to add primary health care services. I had my last flu shot from my pharmacist and my last blood pressure test there as well.
Optometrists should be the next profession to step up to primary health care. The changes in the wind this week for the health insurance exchange program could indeed open this door. The lead issue of this blog speaks to the recent announcement by United Healthcare Group about their problems with the health insurance exchange program. We have already seen this company’s progressive position on our role in health care as discussed in “The path forward for optometry.”
Once again, the twists and turns of health care reform may open more doors for our profession if we are willing to watch, learn and change. Don’t be lured into the political shenanigans related to a repeal of the Affordable Care Act. Health care reform is here to stay and will continue to embrace programs to improve the health of our citizens. Be part of that solution.
References:
Bomey N, et al. UnitedHealth warns it may exit Obamacare plans. USA Today. Posted November 20, 2015. Accessed November 23, 2015.
Wilde Mathews A, et al. Biggest insurer threatens to abandon health law. Wall Street Journal. Posted November 29, 2015. Accessed November 23, 2015.