Solving the Healthcare Dilemma

Introduction

Concerns over our healthcare delivery system are certainly not new. The FDR Administration looked at “universal health insurance” during the Depression. The Truman and Johnson Administrations also visited the topic. Former President Bill Clinton won election in 1992 with the pledge to solve our national economic crisis by solving the healthcare predicament. ¹ Hilary Clinton brought national attention to the inform as First Lady, valiantly attempting to offer solutions but getting defeated by special interests and “the Bureaucracy.” Now, with the looming Presidential election, concern has become even more heightened. Over these past 15+ years, we are no closer to a solution while healthcare spending is expected to reach 20% of GDP by 2016. ²

The first problem with healthcare is that there are too many problems. No matter what “solution” is offered, there is always someone to disagree and point to something else. “The scrape is Federal and State mandates.” “No, the problem is the third-party payor system.” “No, the problem is the lack of consumerism.” “No, the problem is uncapped jury awards and malpractice insurance costs.” “No, the problem is the 40 million+ uninsureds.” So you see, the first thing that needs to happen is that everyone must agree that “all of the above” is the correct answer! I also understand that many people are “positioning and posturing,” while others are legitimately concerned about their future. We need to agree to find the compromise solution and put aside our individual agendas.

There is itsy-bitsy doubt that the current system is unsustainable. Premium costs continue to increase while benefits and services seem to decline. Just over the past five years, premiums have increased 57% to $5,646 per employee, ³ which now represents almost 32% of employers’ total payroll. Healthcare costs have outpaced inflation for some time now (see supporting chart), and a current Journey Poll identified these increases as the number one financial concern among American families. ⁴ It is also important to imprint that this increasing cost has a direct impact on the increasing number of uninsureds. ⁵
At the same time, medical spending as a percent of Gross Domestic Product continues to increase. When Congress created Medicare in 1965, the estimated cost for 1990 was $9 Billion! The Heritage Institute recently projected Medicare/Medicaid entitlements to advance 11.1% of GDP in 2006 and rise to $2 Trillion by 2030! ⁶

To further complicate the bellow, consumers are unaware of the true costs of care, expect only the best in treatments, and complain about any increase in their shared cost. Recent news headlines decried the reduction or elimination of retiree health benefits for major corporations. The major unions fight an ongoing battle over increased cost-sharing for their members, and Wal-Mart recently fought a public relations battle over the availability of healthcare for its many seasonal, part-time, and transient workers. Every day brings new issues and debate.

The second problem hindering valid reform is that everyone has an “agenda.” Since healthcare affects everyone, everyone needs to agree to some compromise. Doctors need to accept some reduction in pay in return for jury-award caps. Insurance brokers and agents need to accept a shift in revenue sources for medical coverage (fees vs. commission). Insurance and Pharmaceutical companies need to agree to compete in a novel environment. Consumers need to agree to more cost-sharing and become more active in care decisions.

I understand that many will feel that it is naïve to think that such a consensus could ever be achieved. But I say to those people that we are reaching a point where there will be no alternative. Thomas Edison was fond of saying that “Nothing is impossible. – The impossible fair takes longer.” As long as we respect each other’s interests in this debate, and enter the fray with a sincere desire to achieve a long-term solution, what I am proposing herein is truly achievable.

First, let’s understand the cost-drivers.

What Drives Healthcare Cost Increases?

Utilization & Consumer Demand

American employers have offered medical coverage to their workers for quite some time now. In the past, Conventional Health Plans had a improper deductible, e.g. $100 or $250, and 100% coverage thereafter. As costs began to rise in the late 1960’s and early 1970s, employers were forced to initiate introducing “cost-sharing” through HMOs, PPOs, and other similar plan models. However, by then consumers had become accustomed to great care with minimal out-of-pocket expense, and we are still paying for that precedent.

As a result, utilization has increased significantly, and consumers, particularly unions, continue to inquire the best care with the least cost-sharing. The biggest problem with this approach is that consumers fail to develop an idea of the true cost of their care. They go to the doctor, pay a $10 co-pay, and walk out thinking that their visit’s cost was $10!

A second problem is that, because consumers do not know or care about the true cost, they do not “shop” for the best values. This results in high utilization costs and in many cases unnecessary spending. Over the past 15 years, this scrape has been increasingly addressed, most recently by the introduction of the “Consumer-Directed” healthcare models. Conventional Plans have fallen to 3% of the total plans offered in 2006, simply because they are no longer affordable. ⁷ This go toward greater cost-sharing and consumerism, which will be addressed in more detail later, is a move in the right direction but has failed to solve the broader problems.

Technology & Medical Advances

In order to deliver the best possible care, providers need to keep up with technological advancements. Over the past 20-25 years, these advancements have come very rapidly and at an increasingly higher cost. This is not expected to change and is generally considered as part of the “cost of doing business.” However, we need to also examine that other industries also face rising technology costs and do not experience the higher-than-inflation cost increases seen in the healthcare market. Thus, this is clearly only a contributing factor.

Aging Population

As the general population ages, with Baby Boomers now facing retirement, utilization increases. This is also generally accepted. Some studies have posited that 80% of our total healthcare costs are driven by 15% of our population. ⁸ This too has become a generally celebrated fact, i.e., that our aging population will continue to require more care.

Federal and State Mandates

As a former Benefits Consultant, I straddle both sides of this fence. Many mandates are necessary and do indeed provide care where none would otherwise exist. However, over the past 20 years, many mandates have been introduced at the urging of various groups which have added to the cost of care. This problem has been further complicated by the many Space mandates that exist. As of the end of 2005, there were 1,824 state mandates nationwide! In many ways, this accounts for part of the reason coverage might cost under $2,500 in Iowa or Wyoming and over $6,000 in New Jersey.

Inflation (CPI)

Another driver of cost is inflation. Little can be done to change this. As the costs of materials and labor increase, providers must also increase fees. So inflation will remain a part of the cost.

Litigation & Malpractice

Medical providers walk into situations every day that involve split-second decisions affecting their patient’s very survival. Sometimes, mistakes happen. The unusual case inspiring a celebrity’s infant children receiving the wrong medication is a perfect example. The manufacturer of the medication in question used blue labeling for both the 10mg and 10,000mg bottles, with miniature incompatibility in font size. The only difference between the two bottles was that the 10mg bottle used a lighter shade of blue.

Is this actionable? Against whom? The manufacturer, or the pharmaceutical administrator at the hospital that dispensed the wrong medication? Perhaps the nurse that administered the medication without noticing the dosage level? Or the hospital itself? The reality in today’s litigious society is that everyone will get sued. Perhaps, some deserve to be. But the “rush to sue” is the root dilemma here. Not all mistakes are, or should be, actionable.

That said, calls by various lobbies for laws restricting one’s “suitable to sue” are misguided. There needs to be an injection of “reasonableness;” however, everyone should have the right to seek redress if warranted by the details.

What if I now told you that this same mistake was made before, at another hospital in Indiana? Following that mistake, which seriously threatened three infants and cost the lives of three others, the manufacturer failed to recall the existing stock of drugs. Nor did they issue a request to existing known buyers of these drugs to post warnings advance the bottles or to segregate existing stock. All they did was add a red warning mark to new stock. Does action against the manufacturer now seem more actionable???

My point here is that in every instance there will be a point at which, when crossed, the “mistake” becomes actionable “negligence.” What is needed in our healthcare system is a law mandating a process to flesh this out before cases can move to the courts.

Pharmaceutical R&D

This leads to a major cost driver – the high costs of medication. No one can argue that the use of medication should be controlled by anyone other than the doctor. And the availability of medication choice is one reason why America enjoys some of the best care on the planet.

So what is the problem? Why must Americans pay $115 per pill for a drug available from Canada for $40?

I glean as fact that pharmaceutical companies need to invest significant sums into R&D in order to bring a drug to market. I also accept as fact that these companies deserve to be reimbursed for this expense through the sale of the drug. The problem, as I see it, is in the lack of oversight in establishing this R&D cost and/or the fair market price for the drug. When a pharmaceutical company claims that it had to spend $2 billion dollars in R&D, who is there to verify this? Who is there to ask for the financial records to prove the claim? This may cry out for increased funding and help for the FDA, perhaps increasing the bureaucracy that will support our new system. But it is imperative to success that we assume the restrictions to fair competition that currently exist in regard to pharmaceuticals and stop allowing these companies to charge “whatever the market will bear.”

It should be recognized here that the FDA does perform an important function. Recent contamination discovered in the drug Heparin, manufactured in China for Baxter International in a depart to increase profits (they didn’t lower their price!) illustrates the need for greater oversight. However, this contamination occurred because the FDA did not have sufficient funding to inspect the plant in China or the drugs that it imported. If we are to allow for originate competition and the importation of drugs, we must also allow for the FDA to grow sufficiently in manpower and funding to protect the American public as they have done in the past.

Federal & State Regulation

The sad fact is that, without some regulation, many providers would simply take advantage of consumers. Greed exists, and it is silly to pretend that it does not. Without regulation, scam artists and disreputable practitioners would be free to “take whatever they could get.”

However, after over 50 years of regulation, there are many regulations that should now be removed or relaxed. This includes many of the filing, licensing, and manufacturing regulations that permeate all aspects of the current system. When multiple participants must increase costs in order to offset these regulations, healthcare costs increase exponentially. A simplified regulatory environment would go far to removing this problem.

National licensing of insurance companies, brokers, and agents would allow centralized and standardized regulation while opening competition across state lines. Simplifying FDA regulations in bringing a drug to market would back ease R&D costs. Removing restrictions on buying drugs from non-domestic sources would help competition and drive down drug costs. I am certain that the FDA can find some way to guarantee quality and collected allow such imports with proper funding.

These are just a few examples of how Federal and State regulation can be addressed. The debate that I hope will reach from this article can certainly flesh out more.

Fraud & Abuse

This is an yell that applies to many levels of the current system. Consumers “abuse” the unusual system if they have access to, and can afford, healthcare but go without, knowing that hospitals won’t turn them away if they need care. As stated earlier, greed also drives many providers to “milk the system” in regard to false treatments, inflated claims to insurers and Medicare, and other well-documented scams. Furthermore, some insurance companies are only in the business of making money and not “paying claims.” This is also a type of fraud that needs to be stopped.

There will always be people looking to “get over” other people. It is a unlit indictment of society over the past 30 years that this is just how some people are raised. No proposed system will be able to eliminate this cost driver completely. However, if everyone had access to care, the reasons to “scam the system” would be greatly diminished.

What In The Current System Works?

When this article was first written in 2004, health care wasn’t even on the national radar; now, there are many “solutions” being proposed. Most proposals try to maintain what is good in the current system, and rightly so. There is distinguished pleasant.

First, we have the freedom of choice, not only between carriers and providers but also in regard to plans and coverage levels. Any solution that proposes removing this freedom is, I feel, doomed from the start. Thus, proposed “solutions” that include mandated concept designs are, I feel, misguided.

While most people would express dissatisfaction over the cost of healthcare, the fact is that the new system does use Market-Driven Pricing. Individuals and employers have the freedom to decline coverage that they consider too expensive. Carriers understand this and must price their plans competitively; otherwise, they will erode market share and eventually face reduced profit.

Finally, the current system includes Market Competition. While this market is dominated by a handful of national providers, the current system also allows small regional providers to offer competitively-priced alternatives. This in turn forces the big nationals to be more careful in pricing themselves where this competition exists.

The successful solution needs to retain these elements.

Can We Achieve A Long-Term Solution?

So, you might well ask if we can ever gain control over our healthcare costs while still delivering acceptable levels of care. The answer is an unequivocal “YES!” The solution however must include sacrifices from all participants: (1) the providers of care; (2) the carriers; (3) the insureds; (4) plan and network administrators, (5) employers, and (6) the brokers/agents. Most attempts at serious change have failed to come by a solution savory to all parties, thus leading to lobbying and political in-fighting and eventual failure. I believe that the following proposal, while level-headed requiring some sacrifices from all parties, can achieve the necessary balance to allow for success.

The Basic Structure

I propose that we bustle our national health system just like the major corporations of the world run their plans. Think of it like a huge self-insured plan covering 281 billion people. Yes, — it sounds “daunting.” But it is possible.

As in any large, Fortune 100 health plan, there exists the following participants: (1) the providers of care (doctors, nurses, surgeons, labs, etc.); (2) the carriers; (3) the insureds; (4) the plan administrator, and (6) the broker/agent. The broker/agent initiates a Request For Proposal (RFP) and sends it to all vendors that might be able to supply the required services. Responses are analyzed and the top bidders are presented to the client. A selection is made, and implementation begins.

There is no reason why a similar process cannot acquire place for our National Healthcare System. With the structure shown in Figure 1 below, nine (9) carriers can be contracted with 3-year terms to provide three (3) plans each. Plan 1 can be a PPO, plan 2 can be an HMO, and the carrier can be free to offer any Plan 3 it wishes. This will promote freedom of choice in coverage levels.

After the initial 3-year Phase-In, three carriers would come up for bid each year. This will promote competition and allow new players to access the market in the future. In order to announce immense National coverage, carriers will be forced to manufacture their networks competitive or negotiate with regional networks. During the transition, all existing plans, both public and private, would continue to operate in order to minimize disruption. This would also allow current players the time to adjust to the new market environment.

Now let’s look more closely at the components:

The National Healthcare Commission

A “National Healthcare Commission” [NHC] should be formed to conduct the selection process and run the program. It can be made up of industry leaders representing the many interest groups, such as pharmaceutical manufacturers, hospitals, the AMA, the American Bar Association, insurance carriers, Pharmaceutical Benefit Managers, labor groups, AARP, etc. Congress can also create a new Cabinet Level post for the National Health Director, who could be non-partisan and appointed in much the same scheme as the head of the Federal Reserve or a Supreme Court Justice. Seats on the NHC should also be non-partisan. At the end of the three-year transition, we would have nine carriers involved, with three coming up for re-bid each year thereafter. This would ensure ongoing competition and tag efficiency. Plan designs would be at the discretion of the carrier subject to a minimum standard set by the NHC and including those mandates that are determined to be of value.

Such a system would allow people to select networks and use doctors of their bear choosing. Claims would continue to be processed by the participating vendors. Pricing would composed be driven by administrative efficiency and network discounts. It would also allow vendors such as Multiplan, Beechstreet, and other national network administrators to compete. I am certain that enterprising and intelligent people “out there” would find ways to achieve additional pricing efficiencies that would allow them to compete under this new system. I also envision that such a change would lead to mergers and acquisitions within the industry among networks and carriers, which would also lead to additional efficiency as well as market growth.

Furthermore, as we know with any self-insured plan, the administrative National Healthcare Committee and the Healthcare Director would also have all the tools they would need to track and manage utilization, implement early intervention, utilize Disease Management or Work/Life programs, and implement any of the many cost controls currently available in the industry. What they would NOT be empowered to do is dictate coverage beyond the basic mandates or establish reimbursement levels.

So, we would have a national healthcare system in which: (a) Doctors continue to operate noteworthy as they do now, (b) Carriers continue to operate much as they do now (with forced efficiency), (c) Insureds bewitch providers and plans like they do now, and (d) The levels of care and benefits are peaceful dictated by the market, not the government. What we would get rid of is waste and inefficiency. The only government involvement would be in the annual RFP process of selecting carriers, the collection and disbursement of funds (like any Fortune 100 employer), and the data analysis that would lead to contracting initiatives and future cost savings. Because of the size of the plan, there would be immediate “credibility” in negotiating premiums. The NHC could also negotiate bulk pharmaceutical discounts. This proposed system would provide the greatest efficiency and the best use of existing technology in controlling costs.

Employers

The largest beneficiaries of this proposal would be employers. Yes, they would still need to participate in some funding mechanism. However, they would be freed from the administrative and HR burdens associated with the current system. Furthermore, for many it would mean a net savings from current healthcare costs. This should result in pay increases as well as increased profits, which in turn should generate additional discretionary consumer spending and market expansion.

Enrollment

Although carriers would no longer be paying a “commission,” there would still be a need for them to pay service fees per participant to the broker who enrolls and services that participant. With employment remaining the primary access for most eligible citizens, it is also reasonable to suggest a 6-week “open enrollment” every year beginning in mid-October during which all employers would be required to allow their brokers to enroll their employees into the National Health Plan. Those brokers with existing books of group health plans would therefore have each and every employee on these plans as a possible client and receive an “enroller” and “service” fee for each.

Providers and Hospitals

Since claims processing and payments would still come from the carrier rather than the government, providers and hospitals would continue to function very much like they do under the current system. In many ways, at the end of the transition when existing plans like Medicare, Medicaid, and the Federal Employees Health Plan would be folded into the new National Health Care Plan, hospitals and providers would be freed from the administrative burdens imposed by these existing plans and may even regain additional revenue from higher payouts.

Carriers and Plan Administrators

This proposed plan would require carriers, plan administrators, and network administrators to change their business models slightly. However, the ruin result would be greater efficiencies and the opportunity to allege on a National Contract. Regional network administrators would negotiate with carriers to help improve the carrier’s efficiency. Inefficient vendors unable to make this transition would have to look to different markets. Mergers and acquisitions would probably be the long-term result, but this too would lead to greater market efficiency.

Brokers and Agents

It is moral that this proposal calls for a phased end to the current system over three years from its inception. I expect that it would take two years from the decision to implement this system for all of the parties to work out the details and get the National Director and NHC in plot. Thus, we are looking at about a five-year time horizon here. Many brokers and agents who rely on medical coverage will need to seek new revenue. That said, these same brokers and agents would be in a position to receive enrollment fees from carriers for their existing books. With nine competing carriers, the carrier’s profits would improve with higher participation; thus each carrier would be incented to offer “enrollment fees” to brokers and agents would could assert them enrollees. Brokers and agents would also continue to act as consultants to their clients for all other benefit matters. The money employers and employees would save from no longer paying medical premiums could be re-allocated toward Voluntary Worksite Benefits, non-qualified fringe benefits, and pensions.

So, yes, there would be a important adjustment. But it wouldn’t be the “end of the world” many in the insurance industry predict.

The Uninsured

Since anyone with a Social Security Number would be eligible for coverage, there would be a significant reduction in the number of uninsured. Those who remain uninsured would probably do so because they distrust the system, they are in the U.S. illegally, or they enjoy they can scam the system. In any of these cases, these people would eventually risk needing care, at which time they would need to establish their financial ability to pay. This new system may also drive those here illegally to become correct citizens. One critical aspect of any new system, however, is the raze to “free care” for all but the most needy.

Consumerism

“Consumerism” comes the closest to addressing a root cause of the problem: the lack of involvement on the part of the healthcare user. It must therefore have a part in any long-term solution.

The concept finds its roots in the legislative authorization for Medical Savings Accounts [MSA], an idea that never gained widespread acceptance in large piece because of the restrictive contribution limits. EBRI began researching the issue at its 49^th Policy Forum in May of 2001. In 2002, at a National Symposium in Baltimore on healthcare, Johan Hjertqvist of The Timbro Health Unit in Stockholm addressed consumerism in the pharmaceutical industry as a way to simultaneously: (1) mutter improved outcomes in medical care, (2) meet social and moral obligations, and (3) improve Quality-of-Life.

The 2004 Economic Report that was commissioned by President Bush then took the view that those without insurance are, in fact, “efficient buyers of healthcare services” since they only incur expenses when they are truly needed. The report asserted that the insured population is actually over-insured and their behavior is wasteful. It is this philosophical stance that now drives us toward Consumerism, in an attempt to gain the insured more like the uninsured. The point is to provide incentives to the insured to make more carefully-reasoned buying decisions – in the process making them pay for more services out-of-pocket like the uninsured.

Essentially, all Consumer-Driven Health Care [CDHC] models involve the same components: (1) a high-deductible health plan [HDHP], (2) a reimbursement account, and (3) consumer tools.

Consumer Tools are the critical component. They will determine the level of consumer involvement and the success of the outcomes. Common offerings include: (1) Employee Assistance Programs [EAP], (2) Discount Programs for vision, dental, convenience items, and prescriptions, (3) Disease Management and early intervention programs, (4) online provider performance measures, and (5) personal “MyHealth” web pages where consumers can manage their own medical histories, download documents, track claims, and manage their reimbursement accounts.

Incorporating these characteristics into the new system will also be critical to its success.

Now the Funding

As for the collection and administration of the funds, I would suggest that computer systems exist that are fully capable (with some new programming and a very large storage capacity) to administer such a plan. As for where the money would come from, I am not an economist or an actuary, and I am sure there are many people better qualified than I to “flesh out” the funding details if this proposal sparks some interest. However, I will offer some general observations.

In a recent article in Life, Health & Disability, distributed by the Society of Financial Service Professionals, Malcolm Gladwell of The New Yorker stated that the uninsured “consume, on average, $934 a year on medical care. . . . Those of us with private insurance, by dissimilarity, consume $2,347 worth of health care a year.” ⁹: He also points out that “The United States spends more than $1,000 per capita per year – or close to $400 billion – on healthcare-related paperwork and administration, whereas Canada, for example, spends only about $300 per capita per year;” This leads one to assume that significant savings can be achieved through increased efficiencies.

Americans spend $6,700 per capita on health care every year ¹⁰, over three times the industrialized world’s median of $2,193; Many of the “naysayers” in the debate on national healthcare point to the $2 trillion plus per year that we currently spend on healthcare, saying that funding such expenditures is insurmountable. I suggest that the funding needs are indeed attainable and the actuarial analysis that I ask to occur must allow for fresh inefficiencies.

Since per-capita spending is expected to reach $12,300 by 2015, ¹¹ I would suggest starting out funding for about $7,500 per capita. The latest population number identifies a total United States population of 299,199,906. The Department of Labor lists total healthcare spending at around $2.1 trillion in 2006. Using these numbers, all the actuaries have to do is figure out how we can regain $7,019 per citizen per year.

Of course, I am over-simplifying to beget a point. Naturally, you cannot query a family of five to pay over $35,000 for their coverage. Under the current system, funding is provided through the following: (a) Employer premiums to insurance carriers, (b) Employee payroll deductions to their employers, (c) Insured copayments to providers, (d) Medicare/Medicaid premium deductions from SSI, (e) Individual premiums to insurance carriers, (f) Federal subsidies to carriers and providers, or (g) Federal subsidies to States.

Under a National self-funded Health Plan, we would be paying for actual claims plus administration only. Claims would be paid by the carriers and reimbursed through standard, self-insured claims reports. I expect that some combination of collection methods will be necessary, since payroll deductions cannot work for the unemployed. Some collection methods that I believe can work include: (a) Employer’s Quarterly 940 or 941, (b) Corporate 1120s, (c) Employee Payroll Deduction, (d) Tax Assessments on Individual 1040s, and (e) A separate billing mechanism similar to Property Tax collection.

I would also expect that a dual-pricing strategy would be necessary to maintain the pricing for current Medicare participants and those covered under the current Federal Employees Health Benefit Plan. The proposed “phase-in” would allow for a smooth transition for the participants of these and other existing programs.

Co-payments and coinsurance would also provide a fragment of the funding. This of course would be driven by thought design and participation, but these are issues faced every day by those running large self-insured medical plans.

The point is that the size of the task should not deter us from trying. Furthermore, funding for $7,500 would allow for a possible surplus, which hopefully would also be grown through cost savings and efficiencies. All I suggest is that there are brilliant actuarial minds in this country who I am distinct can advance at a workable funding solution. The first step, however, is in believing it is possible.

Conclusion

By now you are wondering why an insurance broker who specializes in Employee Benefits would be proposing an approach that will effectively raze this market as we now know it? The answer in part goes back to my opening statement about “sacrifice.” Yes, there will be some adjustment. I believe this plan reaches the needed compromise to satisfy all participants. Carriers would be forced into efficiency but essentially continue to operate as they do now. Hospitals would be freed from mighty of the bureaucracy that currently hinders profit levels. Consumers would access health care from carriers and process claims much as they do now. Brokers and agents would give up “commission” income but pick up consulting fees. The National 6-week enrollment period would provide brokers and agents with additional enrollment fee income. Doctors and other providers would join networks and function the same as they currently do. Malpractice insurance premiums would advance down following reforms in the system.

There has been a saying that I am sure many readers have heard before: “There is always a reason not to do this.” I now say to you that there are far more reasons to put our differences aside and secure this done. So the next step is to allow that this could actually work and . . . begin the dialogue that could lead us to a actual and long-lasting solution to the healthcare problem!

Endnotes

¹ Gallup Organization, “What Do You Think Is the Most Vital Problem facing this Country Today? ” Gallup Poll Most Principal Problem Series, Oct. 11-14, 1990, through Sept. 14-16, 2007.

² John A. Poisal et al., “Health Spending Projections through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs, 26, no. 2 (2007).

³ Mercer Human Resource Consulting, “2005 Survey on Employee Benefits.” Please note that there is a methodological discrepancy between the Mercer numbers and the trend as reported by the Hay Benefit Group, which I maintain is based in the weighting methodology used by Hay.

⁴ Gallup Organization, “What Is the Most Important Financial Problem Facing Your Family Today? ” Gallup Poll Social Series, July 12-15, 2007. http://www.galluppoll.com/content/? ci=28384.

⁵ Todd Gilmer and Richard Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured through 2013,” Health Affairs, 25, no. 6 (2006).

⁶ James G. Lakely, “Spending Escalates Under GOP Watch,” The Washington Times (November, 2003).

⁷ Kaiser Health Research & Education Trust, “Employer Health Benefits 2006″ Kaiser Family Foundation, 2006.

⁸ William Copeland, Jr., Ed. “The Catalyst For Health Care Reform,” Deloitte Consulting LLP, 2006, Pg. 12.

⁹ Malcolm Gladwell, “The Moral-Hazard Myth: The Poor Idea Behind Our Failed Health Care System,” reprinted with permission from The New Yorker, Life, Health & Disability (December, 2005).

¹⁰ William Copeland, Jr., Ed. “The Catalyst For Health Care Reform,” Deloitte Consulting LLP, 2006, Pg. 3.

¹¹ Ibid.

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