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Once more unto the soup?

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Many of us are familiar with Charles Darwin’s 1859 book, “Origin of Species.” Darwin wrote several other books subsequent to that seminal work. In 1871, he addressed hominid (humans and our predecessors) evolution in “Descent of Man.” Though many thought Darwin to be the preeminent naturalist of his day, his central thesis in “Descent” was presaged eight years earlier by someone whose name remains virtually unknown.

In 1863, Darwin’s fellow Brit, Thomas Huxley, a biologist, wrote “Evidence as to Man’s Place in Nature.” Unless this was your field of study in college, you may never have heard of Huxley, but you are probably familiar with an illustration — or a parody of that illustration — from the opening pages of Huxley’s book. Benjamin Hawkins, a sculptor and artist of the day created a drawing of a sequence of skeletons progressing from lower to higher stages of development.

In the 150 years since Hawkins created that illustration, we have seen countless parodies of it. Some start with a hunched over ape and sequence through man standing upright reading a book before ultimately ending with an ape-like human in a posture similar to the first ape, but hunched over a computer instead. The caption is, “Somewhere, something went terribly wrong.”

Last night I had dinner with a bunch of non-insurance friends. Despite my best efforts, the conversation managed to wend its way to PPACA. Somewhere between cocktails and the main course, someone asked a question that brought to mind a health care-related play on that very same cartoon. Drawn by award-winning cartoonist Roger Schillerstrom for a 2004 issue of Business Insurance magazine, it showed health care rising from the ooze, becoming an HMO, then a PPO, and then — walking upright — the fully evolved Consumer-Driven Health Care.

My friend mentioned Sen. Max Baucus’ (D-Mont.) recent comment that he is “very concerned” exchanges won’t open on time, and even if they do, consumers won’t have the information necessary to make informed decisions. Challenging Health and Human Services Secretary Kathleen Sebelius, Baucus said, “I just see a huge train wreck coming down.” He continued, “The administration’s public information campaign on the benefits of the Affordable Care Act deserves a failing grade.” He told Sebelius, “You need to fix this.”

Another of the folks at dinner asked if he was recalling correctly that Baucus was one of the prime authors and drivers of PPACA in the Senate. I affirmed his recollection, and he asked me the question that too few have asked: “How in the hell did we get here?”

Hoping that his question was rhetorical, I summoned the waiter and bought another round of drinks. They had not even arrived when he pressed, “When I was a kid we didn’t have all of this crap, mom just took us to the doctor and paid the bill. So how did something that worked get so fouled (not his exact word, though his started with the same letter) up? Explain that to me!”

I took a big gulp of air (and a bigger gulp of my bourbon) and suggested that if he were to ask the same question of a group of benefits pros, he would likely receive many different answers. Somewhere between kindly Marcus Welby (Google it, youngsters!) and today’s maelstrom we created — or at least aided and abetted — the development of a completely untenable, unsustainable and unimaginable tangle of competing interests that ultimately served no one’s purposes.

Some of those practitioners would likely point to the IPA (independent practice association) model, where an HMO or insurer contracts with individual physicians. Mix the complete and total inefficiency of multiple, repetitive physicians’ offices with massive amounts of litigation resulting in seven (or more) figure settlements. Add in a completely disconnected information grid and a system lacking even the most rudimentary ability for those disparate physicians to work together on diagnosis or treatment and you have the beginnings of the recipe for disaster.

PPACA isn’t the problem
Yet none of that was why I thought of Roger Schillerstrom’s nine-year old cartoon, which has been hanging on my bulletin board since I sliced it out of that long-ago issue of Business Insurance. It was that last image in the cartoon — proudly standing on all fours, walking confidently and labeled Consumer-Driven Health Care — that drew me to my answer. Those of us who were practicing in that arena had an innate sense that the last, best hope for correcting the mess that passed for a health care “system” was the consumer.

Try to imagine any other industry that size where — due to what amounts to an accident of history — consumers had no voice in a market in which they participated and was arguably the most critical market in their lives. An employer with 35 employees became one consumer, not 35. Think of how consumers have moved other markets and you’ll begin to understand how completely devastating the absence of consumer impetus was to this marketplace.

Instead of enjoying the evolutionarily induced creative disruption of other marketplaces, our health care system became hidebound and ineffective. Inefficiencies in markets breed competitors ready to build and market the proverbial better mousetrap. Ineffective markets often are not similarly blessed. Too often they become the kind of moribund mess we have. Consumer-driven markets are (or quickly become) both effective and efficient because consumers just won’t tolerate less. Markets without consumers become extinct.

Even those who authored and passed PPACA knew the importance of consumer power. Remember all of the earlier opposition to HSAs by that same cohort? Dogs do not bark at parked cars.

Even today, three years into the implementation of PPACA, consumers still yearn to exert their influence over this market. A recent study of 259 employers conducted by eHealth reveals the majority of respondents do not want to be forced to buy health insurance through any single source — regardless of whether that source is public or private. Nearly three-quarters (71 percent) say that they want to buy coverage through the source of their choice.

The survey also concluded that only 18 percent of small employers understand what an exchange is. Two-thirds don’t understand exchanges at all, and only 20 percent have a vague understanding of the role exchanges are expected to play.

Train wreck is the most charitable expression to describe the current state of PPACA implementation. “The problems,” I told my friend, “began long, long ago. PPACA isn’t the problem. It’s just the wrong solution, which, left to its own devices, will ultimately put us back in the primordial soup we crawled out of many years ago.”

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