The more I think about it, the more I start believing that state health insurance exchanges and the subsequent the move toward an individual market could be the ultimate catalyst to bring that major change in U.S. health care industry everyone is waiting for. But it could simply be the wishful thinking on the part of an increasingly frustrated, middle-aged health care professional.

I’m going to throw out a few thoughts and would love to hear back from you readers if they make sense or read like idle daydreams.

Why do these exchanges have to cost anything to states at all?

We all know that states are not in robust financial health, and imposing another new liability on them for operations of exchanges may not be a great idea. I’m not proposing that the feds ante up for these costs either. Look at the whole health care system and try to find who actually has money (and I’m being relative here). The states don’t.

The feds are already footing 40 percent of the health care bill, with the $13 trillion in national debt sitting on their heads, they don’t have money to burn either. Providers barely eke out a living these days. So that leaves the payers. Mind you, I’m talking about this whole thing in relative terms. Now that the payers are being pushed to maintain the 85/15 medical-loss ratio, and every single cent of administrative spending is under scrutiny. Taking into account these realities, let me propose a slightly radical idea …

What if payers actually fund the exchanges?

Before you all from the payer side pull out your daggers, give me two minutes (i.e., six to 10 lines) to explain. Four to 5 percent of the cost of sale goes toward broker fees, which if considered as a part of the administrative side of the 85/15 MLR mandate is a significant chunk of money.

 Now the controversial question: What’s the need for traditional brokerage services under the exchange concept? Brokers are traditionally adept at group services, and individual services typically do not require collective-driven considerations. Look at auto insurance sites. Look at travel sites. Look at home mortgage sites. For that matter, look at income tax filing.

Sure, there are consultants available to facilitate these processes, but they’re optional and could be either provided by the sponsor (via call centers akin to what insurers Progressive or Geico use) or could be paid for by the prospective buyer (H&R block, etc). But they’re not the first step of the process, which allows the sponsors to reduce the overhead costs drastically, thereby passing portions of the benefits back to consumer. Why can’t the same be done for health care insurance individual markets?

The biggest argument is that individuals may be prone to make “adverse” selections, which is a more serious issues when it comes to health care coverage as opposed to auto insurance or tax filing. But I disagree … has anybody ever tried to fill in their tax returns while running a non-profit for the wife and sending the kids to school and, unfortunately, making a bit of money in the stock market? Filling in a health insurance questionnaire has nothing on it J!

On a serious note, the question I like to ask in response to this argument is: How much time does an individual need to spend with a broker for the broker to understand their unique health requirements and for the broker to ensure that there is no adverse selection?

I can’t imagine a brokerage model working on that principle. So why not provide an intelligence built into the platform itself that can significantly reduce the probability of adverse selection? Why not leverage the clinical data specific to the individual and make plan recommendations for their unique health requirements? Of course there’s no guarantee this will eliminate adverse selections altogether, but it can’t do any worse in most cases than having a broker-assisted environment. For special cases, there could always be a broker/consultant option.

If this pans out, the cost of sale can easily be restricted to 2 to 3 percent with a decent profit for the exchange operating agency. I’ll go a step further and suggest including Medicaid in this exercise and save even further by leveraging the economies-of-scale while providing a single, streamlined enrollment process for consumers.

The bottom line is that states don’t have to pay anything for the exchanges. The consumers don’t have to pay anything, and they get a single point of access to all government-sponsored initiatives as well as subsidies. The providers don’t have to pay anything. The exchange operator makes a decent living. And payers save critical dollars that go toward the reduction of their administrative-loss ratio.

So where’s the downside? I have through long and hard and still can’t think of one. May be you guys can point it out to me.

Rajiv Sabharwal is the chief solution architect in the Healthcare and Life Sciences unit at Infosys Technologies LTD. He can be reached at


Register or login for access to this item and much more

All Health Data Management content is archived after seven days.

Community members receive:
  • All recent and archived articles
  • Conference offers and updates
  • A full menu of enewsletter options
  • Web seminars, white papers, ebooks

Don't have an account? Register for Free Unlimited Access