The Paradox: PPACA vs. Value-Based Healthcare


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“You will never understand bureaucracies until you understand that for bureaucrats procedure is everything and outcomes are nothing.” – Thomas Sowell 

PPACA is 2,600 pages of regulations and procedures that, good intentions or not, have caused the opposite of many of its stated objectives, with unfortunate consequences to both the physician and patient.  And therein lies the paradox.  PPACA’s oppressive regulations have placed unaccountable bureaucrats virtually in charge of physician offices with unprecedented control over the practice of medicine, ostensibly to provide “better” healthcare. And these bureaucrats have no concept of what it’s like to run a business or live in the world of their own procedural making.

Over the past two years, physicians have spent enormous amounts of time and money just to be able to continue in the practice of medicine due to regulatory mandates associated with PPACA.  Here are just a few examples:

1) On-going training and software expense of Electronic Medical Records (EMR)

2) Implementation of the ICD-10 coding system

3) Updated compliance rules and software integration for Health Insurance Portability, HIPAA and the Physician Quality Reporting System (PQRS)

4) Additional staff to implement and communicate new regulations

5) Reduced reimbursement rates from private insurance and Medicare

These expenses and lower reimbursements have shifted to patients in the form of shorter office visits, less time with chronic disease patients and limited communication for complex treatment plans. Physicians have to see more patients and spend less time with each just to cover the extra expense of staying in business.  Consumers are waiting longer to see their doctor and spend less time with them when they do.

In a 2015 survey of 400 practicing physicians1:

  • 84% believe quality patient time may be gone forever.
  • 78% say they frequently feel rushed when seeing patients.
  • 87% say the “business and regulation of healthcare” has changed the practice of medicine for the worse.

As a condition of PPACA, government regulators are pressing physicians to practice value-based healthcare. Value-based healthcare by definition is healthcare delivery with quantifiably improved clinical outcomes coupled with a reduction in the overall cost of care.  Treating people with chronic disease accounts for 86% of our nation’s healthcare costs.2 Clearly, the treatment of chronic disease is where the most focus and intensity needs to lie – focus and intensity that requires more time with patients, not less.  And so the paradox continues. PPACA, through its regulations and requirements, prohibits the very issues that it ostensibly requires in order to achieve value-based healthcare.  Mr. Sowell’s comment above couldn’t be more right.

Three significant issues will manifest in the fall of 2015 that will exacerbate the paradox and create more hardship:

1) Individuals and employers will see double-digit increases on their 2016 health insurance plans in almost all cases.

2) Provider networks will become more limited as physicians either drop out of accepting private insurance or insurance companies form more narrow networks to lower their cost.

3) Out-of-pocket costs to consumers will rise as deductibles increase and prescription drug formularies change to higher co-pays.

So What’s the Solution? For physicians, it’s a matter of leveraging their time in order to achieve better clinical outcomes.  For employers having to spend more on employee benefit plans, it’s a matter of reducing utilization on their health insurance. The train has left the station.  PPACA is here to stay.  The question now is “how do we live with it?”  The good news is, there are solutions that are available to physicians and employers alike.  Solutions that are quantifiable, proven and ready to deploy.

We look forward to facing the challenge and helping physicians and employers alike.


About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, TX.   Wellspring offers proven solutions to lower utilization of healthcare services for self-funded entities and significantly reduce out of pocket healthcare costs for individuals and small businesses.  Jim can be reached at or view website at


Medication Management – The Future is Now


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Medication Management – The Future is Now

America’s senior citizens are living longer and more productive lives in their retirement years than ever before. Advancements in healthcare technology, therapeutic treatment and prescription medication continues to push life expectancy to new highs. According to a 2012 study from the Center for Disease Control and Prevention, today’s life expectancy for women is 81 years and men’s is 76 years. The number of people age 90 and older almost tripled from 720,000 people in 1980 to 1.9 million in 2010. And the 90-plus population is expected to more than quadruple between 2010 and 2050.¹

Obviously, this is good news from a mortality perspective but it brings up many questions that seniors and their adult children must begin to contemplate as they plan for the future. And in millions of homes around the country, the future is now.

This article will deal with one topic that is already a significant problem for seniors and their baby boomer children – and will continue to get worse if proper planning is not initiated – that is, medication management for chronic illnesses.

Among Americans age 60 and over, approximately 76% use two or more prescription drugs and 37% use five or more.² The longer we live, the more prevalence of chronic disease – which causes more prescription medication in order to control the disease process. The importance of taking prescription medication as prescribed cannot be overstated; however, the statistics show prescription non-compliance is rampant, costly and dangerous:

♦ In a survey of 1,000 patients, nearly 75% admitted to not always taking their medication as directed.³

♦ Even among chronically ill patients who regularly fill their prescriptions, only about half the doses taken are taken as prescribed by their physician.4

♦ Poor medication compliance accounts for an alarming number of drug-related adverse events that result in hospital admissions.5

♦ Poor medication compliance is associated with up to 40% of nursing home admissions.6

♦ It is estimated that poor medication compliance costs the U.S. healthcare system over $290 billion dollars per year.7

The big question is “why”? Why do those with chronic illnesses not take their medication as prescribed? Let’s put it this way – seniors may only spend a few hours per year in a doctor’s office and spend the rest of their waking hours just living the rest of their lives. To a great extent, out of touch is out of mind. And if they are not monitored by healthcare professionals on a regular and consistent basis, they quietly slip off their medication regimens – intentionally or not – for several reasons:

♦ They forget. Most prescriptions today are electronic. The doctor electronically sends the prescription to the pharmacy and the patient forgets to get it filled because they didn’t have a paper prescription to remind them.

♦ They can’t afford the medication. They will not fill the prescription at all or they will take it every other day or cut the pill in half to make them last longer and stretch their dollars.

♦ Poor communication. Sometimes they just don’t understand what they heard from their doctor. Even with instructions on the pill bottle, the communication link with their doctor didn’t connect.

♦ They feel better so they stop taking their medication. They think there’s no need to take the medication if they feel better or no longer have symptoms.

♦ Side Effects. They stop taking their medication because of perceived or real side effects.

♦ Poor eyesight. They can’t read the label on the prescription so they compensate by self-medicating.

♦ Too confusing. Many seniors take multiple medications and sorting and organizing in the proper dosages, times and amounts is just too confusing.

So, what’s the solution? It’s called chronic disease intervention and medication management. This service is a must for seniors taking multiple medications, those trying to live independently with a chronic disease or for baby boomers / caregivers with aging parents. This service is done by telephone using a ‘care team’ of professionals, including a clinical pharmacologist to monitor, educate and serve as a “quarterback” overseeing the entire field of care. With multiple doctors prescribing multiple medications, all with different instructions, there needs to be one source that can manage the patient and see the entire playing field from a holistic standpoint. Today, too many seniors are left to their own devises to treat themselves, which as we have seen above, ultimately leads to a worsening of their medical condition, increased healthcare costs and perhaps, premature death.

There is no reason or excuse for seniors to have the burden of “managing” their own treatment regimens at a time in life when they’re most vulnerable to error and forgetfulness. With chronic disease intervention and medication management, treatment protocols are followed more closely and medication compliance and adherence drastically improves, resulting in the patient getting better and staying better. And while technology is an integral part of this process, it’s the “human touch” that makes the difference. A caring team of healthcare professionals are consistently monitoring and serving those that need the oversight and accountability that many lack today. The key is regular, consistent communication and education through a high-touch personalized service that builds upon a relationship of caring and trust.

As an added bonus, all prescription medication is sorted and pre-packaged for each patient so there’s never a question about what medication to take and when to take it. Each patient receives a calendar shaped, pre-packaged kit – hand built specifically for each patient – and sent free of shipping charges each month or when needed. No more guessing about what medication to take when, no more missing refills and no more confusion. Each patient has a pharmacist dedicated to them who pre-packages medication for their assigned patients. And communication is a two-way street – patients, children of aging parents and caregivers have 24/7 access to their care team for questions, education and advise.

Problem solved. For more information on chronic disease intervention and medication management, go to or call 888-519-9355. The future is now. The time to take action is today.

About the Author:  Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Jim can be reached at or view website at

²U.S. Department of Health and Human Services, National Center for Health Statistics: Data Brief #42. September, 2010.
³Enhancing prescription medication adherence: a national action plan. National Council on Patient Information and Education. August, 2007.
5Fischer MA, Stedman MR, Lii J, et al. Primary medication non-adherence: analysis of 195,930 electronic prescriptions. J Gen Intern Med. 2010; 25:284-290.
6Peterson Am, Takiya L, Finley R. Meta-analysis of trials of interventions to improve medication adherence. Am J Health Syst Pharm. 2003; 60:657-665.
72010 benchmarks in improving medication adherence. Health Intelligence Network, 2010.

Prescription Medication and Seniors: Risks and Rewards


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Over the past decade, we have seen dramatic improvements in technology that have led to medical breakthroughs and new drugs that have drastically improved the lives of millions of people. As technology improves, the ability to discover new ways of targeting specific diseases becomes a reality like never before. Recent discoveries have led to new medication for the most promising cancer treatment to drugs that reduce symptoms for diabetic nerve pain and restless leg syndrome. And the pharmaceutical industry is spending millions of dollars in television ads to promote their drugs. Patients are walking into doctor’s offices asking for certain medication. Physicians are having to see more patients and spend less time with them, relying on prescription medication to provide instant gratification for symptom relief without spending time to treat the cause. In other words, prescription medication is so widespread that people are becoming desensitized to how many they’re taking. And doctors seem to be willing to accommodate their patients with more drugs.

Maybe a better way to describe the situation is like this: There’s nothing wrong with taking several medications for multiple problems. Medicine is an important tool for allowing us to live well and live longer – but there’s also additional risks the more we take and the older we get. This is where caregivers and senior citizens always have to be alert and very careful since many drugs look alike.

Among Americans age 60 and over, more than 76% use two or more prescription drugs and 37% use five or more.¹ This likely represents the need to treat several chronic conditions as we get older. Clearly, the more drugs that are taken, the more confusion about when and how much to take, adverse reactions between drugs and duplicate medication from multiple doctors becomes all too common. Safety and quality of life is directly impacted by these risk factors.

Risk Factors for Seniors
 Confusion – most seniors have a designated time each week when they organize and sort out their medications in their daily pill holder. Confusion easily occurs if: 1) they’re interrupted while sorting through their meds; 2) there’s a change in color or shape of a pill and; 3) there’s a lack of communication with their doctor. For seniors who do their own sorting, confusion can be one of the most common factors in over-medication, under-medication or duplicating pills that look alike.

 Non-Adherence – Overall, 41% of seniors and 52% of those with three or more chronic conditions reported being non-adherent [not taking their prescriptions as directed by their doctor(s)].² The main factors for non-adherence are: 1) forgetfulness; 2) cost; 3) bothersome side effects; 4) feeling well enough to where they believe they don’t need to take their medication as prescribed; and 5) a lack of understanding of their disease. According to the World Health Organization, medication non-adherence is 50% among those with chronic illnesses. Consequences of medication non-adherence includes a worsening of the medical condition, increased healthcare costs and premature death.³

 Adverse Reactions – Prescription medicine, dietary supplements and herbal remedies can interfere with one another and heighten or reduce the intended effect and purpose of the drug(s). For example, Warfarin, a blood thinner to prevent blood clots, in combination with aspirin, ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDS) greatly increases the risk of serious gastrointestinal problems. Nutritional supplements, such as iron and calcium, can interfere with thyroid medicine.4

 Duplicate Medications (Over-Medication) – Over-medication usually occurs when multiple physicians are involved in the care of a patient. “My cardiologist told me to take this”, they say and “my internist” or “my rheumatologist”, etc. which many times ends up being the same medication duplicated by two or more doctors. Most of the time these physicians don’t talk to one another so there’s no “quarterback” to see the big picture and not duplicate what the other doctors are prescribing . Duplication is often seen in blood pressure medication, sleeping pills, anxiety medication, pain medication and blood thinners. Over-medication causes serious side effects that may resemble other medical problems – ironically creating another prescription medication to treat the symptom of a problem caused by too much medicine in the first place.

 Missing Refills – Another problem created by multiple doctors prescribing multiple medications is missing refills. In most cases, before a doctor will refill a prescription, they need to physically see the patient to assess their condition and make any changes to strength and frequency of their medication. If a patient is taking 6 medications from 3 different physicians, they will need to refill at various times during the year. If they wait until they are out or almost out of their medication, they won’t get a refill until they see the doctor. If they can’t make the appointment for two weeks, they go without their medication altogether until they see the doctor. And the next month the problem potentially begins all over again with a different doctor for another medication since they refill at various times throughout the year. And the cycle continues.

Rewards for Seniors – Now the good news! Technology and innovation have created solutions to all the risk factors listed above. Clearly, many caregivers and seniors need access to “medication management” that reduces these risks and improves the clinical outcomes of those taking multiple medications. Remember the “quarterback” analogy? Now you can get a team of healthcare professionals to manage your medications and chronic conditions that’s available 24/7.

 Personal Care Team – Seniors today can access healthcare professionals who specialize in managing all their medication and creating a personalized treatment plan that reflects their lifestyle and habits. Healthcare is personal so why not have a specific treatment plan that provides on-going support, catering to an individual and their personal preferences? The Care Team oversees all prescription medications and chronic conditions providing a holistic view of each patient’s overall condition. This approach personalizes their healthcare making it far more probable that patients will comply favorably to treatment regimens.

 Education – If seniors understand why they’ve been prescribed a certain medication, they have a far better appreciation for the importance of taking it. Understanding their chronic disease(s) empowers the patient to become an active participant in their treatment. Educating seniors through a personal care team on a regular basis is key to drastically improving adherence and a better quality of life.

 Reduce Confusion – The best way to reduce confusion is to eliminate having to organize and sort out medication in the first place. Monthly pre-packaging of medication is available so seniors never have to wonder when or what pills to take. It’s already done for them in daily dose packs in the shape of a calendar (am and pm) for easy understanding. Hand packaged by their personal pharmacist, the senior has the safety and security of knowing their medication was packaged for them just like their doctor prescribed and in accordance to their lifestyle, habits and preferences.

 Benefits of Pre-Packaging – Because a pharmacist does the pre-packaging, drugs that may cause adverse reactions are virtually eliminated. The pharmacist dispenses and packages medications prescribed from all physicians (prescriptions and over-the counter) so a “quarterback” sees the big picture and eliminates adverse reactions between drugs. Also, the pharmacist can help eliminate duplicate medications prescribed by different doctors, often resulting in less cost to the patient. Overmedication is a real problem – both physically and financially. With the cost of drugs these days, eliminating those that aren’t needed helps seniors feel better and save money!

 No More Missing Refills – Part of the medication management program is to synchronize all prescriptions from each doctor so they can be refilled at the same time. This eliminates several different medications needing refills at various times throughout the year. The care team and pharmacist works with each doctor’s office to line up all prescriptions so they can be refilled without missing any medication.

 Free Home Delivery – The Pre-Packaging is a great solution to eliminating many problems. Most firms who specialize in medication management offer free home delivery – in calendar shaped pre-packaged, daily dosage kits for easy use. Not only does it show up on the doorstep at the appropriate time but it also eliminates multiple trips to the local pharmacy each month.

 Feel Better, Get Better, Stay Better – Seniors who have experienced the care team approach and medication management typically have far better clinical outcomes than those who don’t. Having a care team as a quarterback who sees the big picture is far more proactive than waiting until a problem arises that could have been prevented. These seniors experience fewer doctor visits, emergency visits and hospitalizations. They have a more productive lifestyle and typically experience an improvement in how they feel.

Fortunately, today’s healthcare can be far more interactive, personal and convenient. We must acknowledge the potential problem of taking too much, too little or unnecessary medication. If there isn’t a healthcare professional that can see the whole picture, the patient is susceptible to unnecessary risks associated with prescription medication. The good news is, today, that no longer has to happen. Medication management is a proactive way to live a better and healthier lifestyle throughout the aging process.

About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Jim can be reached at or view website at

¹U.S. Department of Health and Human Services, National Center for Health Statistics: Data Brief #42. September, 2010
²Ira B. Wilson, MD, Cathy Schoen, MS, Patricia Neuman, Sc.D et al. Physician – Patient Communication about Prescription Medication Nonadherence: A 50-State Study of America’s Seniors., Journal of General Internal Medicine, January 2007, 22(1):6-12.
³Chisholm-Burns MA, Spivey CA. The “Cost” of medication non-adherence: consequences we cannot afford to accept. Available at:
4National Council on Patient Information and Education. Fact Sheet: Medicine Use and Older Adults, October 2010

©2015 Wellspring Benefits Group. All rights reserved.

“Back to the Future” Healthcare


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Americans of all socioeconomic classes are now realizing there’s a big difference between buying health insurance and accessing healthcare. The first part of the equation – buying health insurance – is financially easier if you qualify for a federal subsidy and financially harder if you don’t. One group pays more so the other group can pay less. The second part of the equation – accessing healthcare – is less prone to socioeconomic differences. It’s just hard on everyone. Deductibles, copays and coinsurance are so high that the value proposition between buying health insurance and still having to pay out of your pocket for healthcare services doesn’t seem to add up. “What am I paying for?” seems to be a common question. It’s a hard sell and a difficult purchase to pay more for a product and get less services in return. And if you don’t purchase health insurance, you get a tax penalty; and if you do, you get taxed on the subsidies. Is this really about fixing a broken healthcare system or the power to tax? Whichever, the middle-class is paying the price.

And it’s not just impacting those who purchase health insurance. More and more physicians today are opting out of accepting health insurance and going strictly cash pay. A 2014 survey by the Medical Group Management Association, a consortium of independent practice associations (IPA’s) and multi-physician medical practices, offered an alarming unintended consequence of Obamacare. The survey, taken as of May, 2014, estimates over 214,000 doctors will not participate in the Affordable Care Act (ACA) exchange plans going forward. This number appears to be growing as more physicians experience the unsustainably low reimbursement rates, increased risk of non-payment and excessive regulations and administrative requirements associated with ACA. According to the Kaiser Family Foundation, there are approximately 894,000 practicing physicians in the U.S. The simple math would indicate at least 25% of physicians nationwide are opting out of accepting Obamacare plans with more expected in 2015.

So consumers are paying more for health insurance; paying for health services is largely an out-of-pocket expense; and physicians are opting out of Obamacare – clearly an unsustainable model. So what does the future of accessing healthcare look like? Answer: A return to the by-gone days when health services were paid in cash – at a fraction of the price of what they are with health insurance.

Today’s insurance regulations and mandates cause all services to cost more (and it’s called the Affordable Care Act). “We realized that insurance paying for primary care is akin to using car insurance to try to pay for gasoline,” says Dr. Doug Nunamaker, Atlas MD’s chief medical officer. “It’s something that’s otherwise fairly affordable until you try to pay for it with insurance: My premiums would be much higher because they wouldn’t know how much gas I would need, they would tell me where to get gas, and I’d have to preauthorize trips out of town.” Insurance means more regulation, more administrative expense and more oversight of when, where and how a claim is paid. Cash pay takes the added costs of insurance and reduces it down to an affordable balance between overhead, cost of service and actual value.

There are large national healthcare networks specifically designed for cash pay benefits. This is the future of accessing commonly-used, routine healthcare services. These networks bring physicians and outpatient service providers large volumes of patients and consumers pay cash for healthcare services at pre-negotiated savings and discounted rates – without the added cost of insurance. It’s “Back to the Future” healthcare – when access meets affordability, everyone wins.

For more information, go to



About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Jim can be reached at


©2015 Wellspring Benefits Group. All rights reserved.

Healthcare Access – New Concerns for Obamacare Exchange Plans


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Healthcare Access – New Concerns for Obamacare Exchange Plans
Jim Jones, President, Wellspring Benefits Group

A 2014 survey by the Medical Group Management Association, a consortium of independent practice associations (IPA’s) and multi-physician medical practices, offered an alarming unintended consequence of Obamacare. The survey, taken as of May, 2014, estimates over 214,000 doctors will not participate in the Affordable Care Act (ACA) exchange plans going forward. This number appears to be growing as more physicians experience the unsustainably low reimbursement rates, increased risk of non-payment and excessive regulations and administrative requirements associated with ACA. According to the Kaiser Family Foundation, there are approximately 894,000 practicing physicians in the U.S. The simple math would indicate at least 25% of physicians nationwide are opting out of accepting Obamacare plans with more expected in 2015.

What’s even more alarming is what’s happening in the state of California. It’s estimated that 70% of California’s practicing physicians are not participating in Covered California1 (ACA exchange plans). There are people all over California paying premiums for ACA exchange plan health insurance and have little or no access to care.

Let’s look at the major causes of physicians opting out:

1. Reimbursements to physicians accepting ACA plans are at an all-time low. It’s estimated that where private or employer sponsored plans pay $1 for a service, ACA exchange plans are paying about $0.602. So in effect, ACA exchange plans are cutting physician reimbursements by up to 40%. Over 7 million consumers have purchased exchange plans3, many after not having health insurance for years. These patients appear to be utilizing their plans more frequently due to previously untreated conditions. Physicians, in turn, are spending more time treating more patients and being reimbursed at rates that cannot support their overhead.

2. If you purchase private health insurance (not on the federal or state exchanges) and you stop paying your premiums, you have a 30 day “grace period” before your coverage ends. If you pay your premium in the first 30 days, your coverage continues. If not, you no longer have insurance. However, ACA exchange policies are under different government rules. Insurance companies have to cover ACA consumers for an additional 90 days after they have stopped paying their premiums. The insurance company still covers the first 30 days but it’s up to the doctor to recoup payment for the next 60 days. Currently, over a million people have stopped paying their ACA premiums. So doctors are treating patients for months that have stopped paying premium but must still continue to treat them. If the patient is unable to pay, the doctor has no way of being compensated for potentially months of service.

3. For those consumers that qualify for a federal subsidy, many have chosen the lowest cost “metal” plan (Bronze) which has a high deductible. Many of these consumers are in lower income households or don’t understand their benefits and rack up thousands of dollars in cost before the deductible is met – once again leaving the physician in a position to not get compensated. So, physicians are asking themselves a simple business question when it comes to ACA exchange plans, “Am I willing to take sicker patients for significantly less money with the risk of not getting paid at all?”

4. If physicians accept Obamacare exchange policies, they must also accept the mandatory regulation and administrative overhead of ACA compliance. There are stringent administrative procedures for data capture, reporting, documentation and compliance of electronic health records that must be a part of each physician office. While the ultimate goal is to improve communication and help patients, the regulations were written by federal bureaucrats that have no understanding of what it takes to run a medical practice. Since these requirements must be met and there’s only so many hours in a day, the outcome is a significant decrease in the amount of direct contact with patients and more administrative overhead that must be absorbed by the physician.

So what does this mean to consumers who purchase ACA exchange plans? First, it’s very possible that the network associated with your ACA plan will be very limited in physician and hospital choice. It’s also possible that more physicians will be leaving these already limited plans putting more consumers at risk of finding a local provider. As a consumer, you need to understand the upside and downside of ACA plans. You may get a subsidy which lowers your premium (upside) but you may have limited choices in physicians and hospitals (downside). Having access to healthcare, no matter how much the subsidy lowers your premium, is still a major factor in the value you get for the money you pay.

There are some solutions. One of the most convenient and inexpensive ways of accessing healthcare for routine, non-emergency illnesses, is telemedicine. Telemedicine provides unlimited access to physician consultations by phone with a board-certified doctor who will diagnose your condition and if needed, call in a prescription to your local pharmacy. It alleviates an office visit and the out-of-pocket fees involved in physically going to the doctor’s office. And since telemedicine does not rely on a “network” like your insurance plan, you have access 24/7 on your terms. In the past, telemedicine has been mainly available only through employer or affinity groups. Today, individuals and families can get telemedicine for a fraction of the cost of paying out of pocket for routine healthcare. Many other products and services are available that can help lower out of pocket costs in addition to telemedicine. These products and services become more valuable as consumers experience the unintended consequences of Obamacare.©

About the Author: Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare business, he has developed a business model that integrates insurance products and healthcare services for individuals and small businesses to manage their costs and coverage with customized plan options. Jim can be reached at


1 Richard Pollack, Doctors Boycotting California’s Obamacare Exchange, Washington Examiner (December 6, 2013); available at

2 Roni Caryn Rabin, Doctors Complain They Will Be Paid Less by Exchange Plans, Kaiser Health News (November 19, 2013); available at

3 Sam Baker and Sophie Novack, 7.3 Million People Have Obamacare Coverage, National Journal (September 18, 2014); available at


©2014 Wellspring Benefits Group. All rights reserved.

If We Could See the Unseen

Everyone has a story. We are a combination of the successes, failures, hurts, experiences and treasures of life. And everyone is a living story, molded by the tapestry of their life experiences into who they are today. If we could only see the unseen, how would it impact our relationships, respect and communication with each other?

I have two great uncles, both of whom served in the Pacific during World War ll, that recently gave me their stories in their own words. One was shot at close range by a Japanese soldier on the island of Luzon in the Philippines. The other served on Okinawa and the Solomon Islands as a front line soldier. I have a friend, Mr. Tim McCoy, who was assigned to the submarine USS Grenadier in World War ll. Tim and his crewmates were bombed by a Japanese plane which caused everyone to abandon ship and into the waters of the Pacific. They were captured and held as prisoners of war for nine months of unspeakable hell.

The Korean War, the Vietnam War, Desert Storm, Afghanistan, Iraq and whatever is next. People living their lives all around us with what they’ve done and seen and never complain or even bring it up. The unseen scars, the unseen service and valor. And yet their lives are a function of what makes them who they are.

The single mom working two jobs – but you only know about the one she works with you. The classmate sitting beside you that grew up with an abusive parent. The relative who’s fighting cancer. The neighbor that has a handicapped child. You. Me.

Many times we don’t see these parts of their lives. They’re unseen. And if you don’t struggle yet, it’s just a matter of time. So what’s my point? Love your neighbor. The Romans 12:10 kind of love. Respect. Honor.

Our country today is full of political discourse that divides us into Red and Blue. And while it’s okay to disagree, it’s not okay to be disagreeable. I have to confess that I don’t always follow my own rhetoric. Our passions and emotions get the best of us at times and we say things we wish we could take back. Or we ignore the person next to us because we’re “too busy” to say hello and look them in the eye. Or worse yet, we’re looking at our SmartPhones so much we ignore those around us. And being ignored is the ultimate put down.

But in order to communicate, we must put aside political correctness. There is a radical element in our society today that have become such speech police that it’s hard to have a meaningful conversation and not be demonized for saying what you think – but with respect and honor for those around you. We should be able to discuss both sides of gay marriage, abortion, freedom of religion, race and bigotry and many other social issues without being demonized for taking a traditional or conservative stand. The speech police, the media and our college universities are constantly trying to change our culture from the freedom and liberty that made us a great nation to a secular progressive society where there is no right or wrong. If we allow the secular progressives to change our speech because we’re “afraid” society will label us as bigots, then what else can they do to our Constitutional rights? “We The People” have the final say. Let’s not allow the insidious nature of secular humanism to transform our culture into a godless state where our freedoms are compromised. So go Washington Redskins! And Merry Christmas to all (admittedly a little early).

If we could see the unseen, what would your life story say? Sacrifice? Service? Giving? Or is it time to write a new script? I’d like to encourage you to perform a random act of kindness for someone you don’t particularly like. It’s hard to criticize someone you disagree with that’s not disagreeable. We’ll never be remembered for the money we made, the cars we drove or the house we lived in. We’ll only be remembered for the lives we touched – seen or unseen.

So with all the issues burning around us – from the Middle East to Asia and back to Ferguson, MO, it’s my belief we should take a 9/11 type of rallying point in the midst of the chaos. Relax the political discourse, do something kind for someone you ordinarily wouldn’t and appreciate the stories of so many that contribute to the overall greater good without being seen. We truly live in an exceptional country with exceptional countrymen. Let’s not forget in the midst of everything going on around us that there are incredible stories walking by in the form of incredible people.


Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare industry, he has developed a business model that integrates healthcare services that lowers insurance utilization, improves clinical outcomes and lowers overall healthcare spend. Jim can be reached at

©2014 Wellspring Benefits Group. All rights reserved.

Healthcare, Obamacare and Misuseonyms



I’m going to make a point so stay with me. Words mean things. Today’s accepted normalcy of texting in acronyms and single letters to replace actual words has been known to make a few English teachers want to LOL to keep from crying. Let’s explore for a moment another area that challenges our vernacular. Take synonyms for example. A synonym is a word or phrase that means nearly the same as another word or phrase. And in some cases, the continual misuse of two words that are used as synonyms has been known to become synonymous – even though they’re not – which I’m calling a misuseonym, which, BTW, is a word I just made up.

The federal government has spent nearly $700 million dollars¹ in media advertising over the past twelve months to promote Obamacare, and in doing so, has continually referred to Obamacare as “healthcare” (as in instead of “health insurance” (which it is). As a result, many people now consider “healthcare” and “health insurance” to be synonymous – which is a classic misuseonym.

Let’s define the difference between the two and then address why it’s so important that they are not used synonymously. For purposes of this article, “healthcare” is defined as “medical services, tests or procedures performed by licensed or accredited providers”. “Health insurance” is defined as “the financing of insurance due to loss incurred for illness or injury”. As you can see, these two terms are fundamentally very different even though they are commingled to have the same meaning on a regular basis.

It is important that their meanings are defined and understood as two mutually exclusive issues. The business model of medical practice, access to healthcare and the health insurance industry are all rapidly changing due to Obamacare. Examples of exciting changes in healthcare include:

  • New technologies are delivering chronic disease management to rural markets where access to healthcare has been sparse;
  • Physicians are leaving the traditional practice model for cash-only concierge medicine;
  • Telehealth and telemedicine has become mainstream in acute care treatment.
  • Medication management has shown outstanding results in improved clinical outcomes of chronically-ill patients.
  • Access to cash-pay medical and dental services on a (non-insured) pre-negotiated savings and discount basis saves significantly on first-dollar, out-of-pocket expenses (whether insured or not).

It is important to note that all of these examples are defined as healthcare – not health insurance so they’re easily accessed and far more affordable than insurance.

Now let me be clear. I believe health insurance is an absolute necessity. No one can predict when their appendix is going bad, when the other car is going to cross the center stripe or when that nagging problem becomes a diagnosis of cancer. That’s what health insurance is for. But let’s turn our attention toward the combination of healthcare and health insurance working in conjunction to provide a solution to a national problem – accessibility and affordability.

Obamacare, depending on who you ask, has either been a tremendous help or an unsustainable burden. For those it has helped – people who receive federal subsidies that pay for most or all of their premium or for those that have serious medical problems – now have the ability to get health insurance without restrictions. The problem is this doesn’t solve the problem. The federal subsidy isn’t paid by the federal government – it’s paid by the American taxpayers. The federal government re-distributes the money to pay for those that fall under a certain income level. The problem is, someone has to pay more so someone else can pay less. This absolute tenant of Obamacare in effect cost-shifts the problem of accessing health insurance from those that previously couldn’t afford it to those that used to have it but no longer can afford it. So depending on where you fall, Obamacare can be a blessing or a curse. No matter which side you fall on, more and more physicians are opting- out of taking Obamacare patients so accessibility is becoming a very significant, unintended consequence.

This article is not about that debate. However, it’s clear that Obamacare has created the same set of problems (accessibility and affordability) to a different class of people (middle-class).

The solution lies in a common-sense approach to addressing the problem instead of pandering to a political base. I do not believe Obamacare is sustainable in its present form. It costs too much for middle-class Americans who make just enough to not qualify for a subsidy but not enough to afford the skyrocketing premiums. At the same time, we are the most prosperous nation on earth so we should provide health insurance for those that can’t afford it. Solution – change the law (Obamacare) to address both issues.

First, let’s all agree that it’s ridiculous to think that all Americans needing individual health insurance fit into four metal plan categories (two of which are so expensive they really aren’t choices to begin with). Second, let’s agree that everyone doesn’t need or want the ten essential benefits (look them up if you don’t know what they are). Third, it makes no sense that true catastrophic health insurance is not even offered by health insurance carriers today because of the restrictions of Obamacare.

Let’s take the good aspects of Obamacare and combine them with the needed changes above. The issue of accessibility and affordability would no longer be an issue, insurance premiums would level or come down and more people would end up being insured – and isn’t that the purpose of health insurance reform?

You would then have the accessibility and affordability to buy health insurance for the unexpected, catastrophic things and healthcare for the predictable, commonly-used services that happen over the course of the year – and pay a lower price for the things you need and want. It’s time to keep our vernacular straight – healthcare is not health insurance and vice versa, but together they form a great solution to a current national problem.

¹, July 23, 2013

Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare business, he has developed a business model that integrates insurance products and healthcare services for individuals and small businesses to manage their costs and coverage with customized plan options. Jim can be reached at


©2014 Wellspring Benefits Group. All rights reserved.

Breaking the Bonds of Status Quo



Healthcare Solutions for Employer Groups

Breaking the Bonds of Status Quo

“Status Quo, you know, is just Latin for “the mess we’re in”. ~ Ronald Reagan

Ah yes, Status Quo. It’s a demagogue’s standard operating procedure and a CEO’s nightmare. Nothing can be more frustrating than doing the same thing over and over, expecting a different result. Yet in healthcare, many employers still think in terms of group insurance as the solution to cost containment. The latest grasp at cost containment is wellness programs. Insurance companies, TPA’s and large employers are going to great lengths and expense to encourage employees to “get fit” as a way of improving their health and filing less claims. Yet how many employees actually change their unhealthy habits? What is the cost of the wellness program amortized against the ones that actually change? Wellness programs are just fine but how do you quantify their results? And from the employer’s perspective, how do you monetize the wellness program as an asset?

Here’s my point – wellness programs and case management are examples of cost containment. And cost containment is status quo. It’s a noble effort to try to reduce the cost of a known expense. But it’s retrospective, hard to quantify and hard to monetize.

Employers are experiencing dramatic increases in the cost of health insurance whether self-insured or fully-insured. Insurance companies look at past claims experience as it relates to expected losses and then applies increases to cover the loss, cover the current expected claims and their profit margins. In other words, retrospective, reactionary pricing on a pass-through basis – a model that’s clearly not working for employers. And that’s no slap at the insurance industry – it’s just status quo.

Defining the issue

There are the two main contributors to insurance over-utilization that drives up costs: acute illnesses based on frequency of claims and chronic illnesses based on severity of claims. Both are hard to predict and skew the actuarial metrics when either or both are out of balance with expected losses. And in an effort to be competitive, insurance companies tend to price new business on an optimistic basis knowing full well that they’ll make up the difference upon renewal. As stated above, retrospective, reactionary pricing on a pass-through basis.

The solution is not solely “cost containment” of either type of claim (acute or chronic). The solution is filing far fewer insurance claims to begin with – less utilization – notwithstanding the prevalence and frequency of acute illness and chronic disease. Now stay with me – remember, we’re not talking status quo.

Accessing healthcare outside health insurance

The terms “healthcare” and “health insurance” have become somewhat (wrongly) synonymous in our current lexicon. “Healthcare” is based on access. “Health insurance” is based on risk and entitlements. And while they may be synonymous in the minds of many people, they are very different with respect to pricing and affordability.

As technology, legislation and healthcare have changed, alternative methods of accessing healthcare have emerged that provide more convenient, less expensive, quality care than the traditional, expensive insurance model that is adversely affected by utilization. The key to employer acceptance is stepping out of status quo. The key to employee acceptance is incentive (more on this later).

Telemedicine and Telehealth for Acute Illness

Many employers already use some form of acute care telemedicine service as a product in their group benefit plan. Employees can contact a physician by phone and get a consultation for acute, non- emergency illnesses with prescription medication if needed. This is an outstanding service and is essential to reducing insurance utilization. The problem is that most employers offer this service with $25 – $40 copays per consultation. The employee has a choice of going to their family doctor, an urgent care clinic or calling for a physician telephone consultation – all at basically the same out-of-pocket costs. Given no difference in incentive, health insurance will be utilized over healthcare because it’s status quo and there’s no incentive not to. Acute care telemedicine should be utilized through incentive with $0 out-of- pocket costs vs. being perceived as just another product that employees can choose. In other words, telemedicine should be a strategic way to reduce insurance utilization instead of just another product offering.

Let’s do the math. Let’s assume a group insurance plan of 1,500 employees. Half are employee only and half are employee plus family. Each office visit for an acute, non-emergency illness has a $35 copay to the employee and an additional $140 to the self-insured company (total $175 office visit). If between employee only and employee and family, there are 9,000 office visits over the course of the year, the self- insured company has an expense of $1,260,000 in acute care office visits. If 50% of those visits were utilized through telemedicine, the employer would save $540,000 to the bottom line (even after paying for the benefit) and the employee would have an incentive ($0 out-of-pocket cost) for the convenience of on-demand, 24/7 healthcare. The employer saves tremendous amounts of cash and at the same time lowers utilization on their health insurance. Everyone wins.

Telemedicine and Telehealth for Chronic Illness

In study after study, roughly 20% of any group is responsible for approximately 80% of the overall healthcare spend. Knowing this hasn’t materially changed the way chronic disease is managed. Status quo is getting case management involved as soon as the insurance company becomes aware of the claim (retroactive and reactionary).

Chronic disease care in America goes something like this…..a person gets to feeling a little bad and goes to the doctor. The doctor runs a series of tests and diagnoses a chronic disease (ie: diabetes). The doctor has a conference with the patient about losing weight, exercising and taking their medication. At that point, the conference is over and an appointment is made in six months for follow-up lab testing. The patient then goes to his local retail pharmacy, purchases medication and then goes home and tries to get in a “new normal” frame of mind. The patient does their best to change their lifestyle but over a short period of time, they fall back into their usual habits. Many times they self-medicate to save money or take their medication only when they start feeling bad. The chronic condition gets worse causing far more insurance utilization with the potential for living in a serious disease state. And the cycle continues.

That common scenario happens every day in America. And it costs employers and employees tremendously in time, money, productivity and quality of life. Here’s some empirical data that is the root cause of poor outcomes in chronic disease patients:

  • 30% of prescriptions never get filled¹
  • 50% of Americans have difficulty understanding and acting upon health information¹
  • $213B or approximately 10% of healthcare spend is avoidable²
  • 68% of avoidable healthcare spend stems from medication non-adherence²
  • 15% of patients account for more than 75% of healthcare spend³

The solution is two-fold: 1) Chronic disease and medication management and 2) patient education and accountability. Both must be built on relationship and trust. The patient (employee) must be a willing participant vis-à-vis education so they understand their disease state, how it impacts their physiology and why it’s important for them to become compliant and adherent to their clinical treatment.

Chronic disease and medication management is the process by which clinical outcomes drastically improve through education, accountability and adherence and compliance with treatment protocols. With monthly consultations to ensure adherence, 24/7 access to your clinicians, consultations between the clinical pharmacologist and physician if needed, copay assistance program if needed, no hassle medication refills and monthly, pre-packaging of medications sent to your home free of shipping charges. And in the process, clinical outcomes are drastically improved, overall healthcare spend is reduced and the patient gets better, feels better and stays better.

Or, you could stand in line at your local retail pharmacy and live with status quo.

With chronic disease and medication management, patients drastically improve and the root causes of poor clinical outcomes are addressed: approximately 90% reduction in hospital readmissions, reduced first-time admissions, fewer doctor visits, fewer emergency room visits, measurable improvement in medication adherence and associated lab results and a measurable reduction in overall healthcare spend. Prospective. Forward-looking. Lower utilization. Lower healthcare spend. It’s time to break out of status quo.


Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare industry, he has developed a business model that integrates healthcare services that lowers insurance utilization, improves clinical outcomes and lowers overall healthcare spend. Jim can be reached at


¹Institute of Medicine of the National Academies
²IMS Institute for Healthcare Infomatics
³Parata Systems



©2014 Wellspring Benefits Group. All rights reserved.

ACA: Flawed Law





ACA: Flawed Law

By: Jim Jones, President, Wellspring Benefits Group


“I make just enough money to not be able to afford health insurance.” That was a very interesting quote from a man I spoke to last week named Jason. He’s 37 years old, has a family, works hard and just wants to do what any middle-class American would like to do – support their family and the laws of their country at the same time. He doesn’t qualify for a federal subsidy because of his income. But after paying for food, mortgage, utilities and trying to save for a college education for his children, he has very little disposable income and not nearly enough to pay for an ACA policy. “So I guess I’m going to get fined and have the risk of being on my own for getting sick or having a catastrophic accident. I’m doing everything I can and should for my family and yet I’m getting penalized and putting my family at risk. That’s not right.” He’s the classic example of why ACA is so flawed.

It Sounds Good!
The whole premise of ACA is centered around three basic principles: 1) all Americans must have access to health insurance regardless of their current health or pre-existing conditions; 2) all Americans must purchase health insurance if they do not have it or be subject to a tax penalty if they don’t; and 3) all health insurance policies must have 10 essential health benefits as defined
by ACA.

When you read those three principles, they appear to be plausible objectives toward a noble and worthy cause. After all, those with pre-existing conditions need health insurance the most and in a country as wealthy and compassionate as ours, there should be a mechanism for them to access it.

So What Happened?
Clearly, the time had come to reform some of the antiquated ways of the health insurance industry. On the surface, each of the three principles appear worthy of our collective support regardless of income status, political preference or age. But as we’ve heard so many times – the devil is in the details. Unfortunately, ACA was written and developed from the standpoint of political ideology that has done more to divide the country than reform health insurance.

Let’s begin with a statement I believe we can all agree with: Your health status is a universal equalizer. It is agnostic to income or politics. There are just as many conservatives with adverse health problems as there are liberals. There are just as many Democrats with Jason’s story above as there are Republicans. Health problems and/or income status has no political preferences. Yet too many people of all political persuasions are finding ACA to be more of a problem than a solution. Let’s look at each of the three principles and explain why ACA is so flawed – regardless of its intent.

It’s About the Money
If you begin with funding for ACA by redistributing wealth based on income, you immediately create a set of “winners” and “losers” based on class warfare that does nothing but create political discourse for something that shouldn’t be political (remember, your health status is agnostic to income). Someone has to overpay for their health insurance so someone else pays less for theirs (by getting a federal subsidy). But as we see with Jason’s story, the ones paying full price for ACA can’t afford to pay for their own family’s insurance. So when it’s all said and done, what have you accomplished ?…..the ability to access health insurance regardless of health conditions but its inaccessibility due to cost. So this one flaw makes 2 of the 3 principles of ACA in conflict with one another!

The third principle is the requirement of the 10 essential benefits as defined by ACA. The intent was to require these benefits as a minimum standard so that everyone could have a better quality health plan. The problem is two-fold: 1) to require all 10 benefits in all ACA compliant health insurance plans causes the premium to drastically increase for everyone; and 2) not all people buying an ACA compliant plan needs all 10 benefits so they pay artificially higher prices for benefits they’ll never use (ie: maternity coverage and children’s dental benefits for a couple that doesn’t need or want either).

To make matters worse, there are only four plans to choose from – Bronze, Silver, Gold and Platinum – all with identical essential benefits but varying deductibles and co-insurance. By the time you reach the Gold and Platinum versions, the premium is so expensive that they’re really not choices at all. That leaves just about everyone with two choices – Bronze and Silver. And if you’re like Jason and don’t qualify for a federal subsidy, the premium is so high on those plans that many Americans can’t afford them and go without health insurance altogether. And if somehow you can barely afford the premium – or even if you get a generous subsidy, to access the plan you have to pay such a high deductible that the insurance is virtually inaccessible. As Jason said, “that’s not right” and it’s not sustainable.

ACA was designed under the premise that wealth redistribution would be readily embraced by the American people. But here’s the flaw to that reality – Young adults aren’t interested in a requirement to buy an overpriced policy to compensate for those that are older or for those that qualify for a subsidy. The older adults aren’t interested in buying an overpriced policy for benefits they don’t want or will never use. Small employers aren’t interested in buying overpriced policies that drive up costs, inhibit growth and stifle job creation.

Common Sense
Every American that needs health insurance should be able to get it. The problem, as we’ve seen, is the funding mechanism for making it work for everyone – without regard to income, health status or political persuasion. But it must be funded on a fair, equitable and common sense basis. It can if we change the tax code in America. With the maze of tax brackets, deductions and loopholes, lawmakers have created more problems than have been solved. And today, with the largest social program in the history of the nation failing because of the way it’s funded, the time has come to change the tax laws to make ACA workable for all Americans.

We need a means-tested flat tax where every American, no matter how much they make, contributes to the overall greater good. No tax deductions – no charity deductions, no mortgage deductions, nothing. This way, everyone making an income contributes to the overall greater good, everyone pays their fair share, everyone is subsidized through tax revenue for a portion of their premium and no one has to overpay so that others may underpay.

“Balanced” Health Insurance Reform
There has never been a doubt that reform of the health insurance industry needed to happen. But if solving the problem of what needed to be reformed was the true intent, why didn’t ACA include a balanced approach to help solve the private-sector insurance industry’s need to make a profit? If the insurance industry is not able to make a profit due to ACA’s mandates and regulations, health insurance premiums will continue to rise even further as costs are passed down to consumers. The private sector insurance industry must be able to make a profit if we are to continue in a free-market economy. If not, the only alternative is a single-payer system through the federal government. And if you think the insurance industry is bad now, wait until your healthcare is administered through the feds. You’ll get the efficiency of the postal system with the compassion of the IRS in charge of your healthcare.

Here are several balanced reforms that will make health insurance more affordable without the constant pressure to keep raising premiums:

  • 1) Tort reform for liability and malpractice claims to offset the actuarial upheaval created with guaranteed insurability for those with pre-existing conditions.
  • 2) Have the ability to purchase insurance across state lines included to offset the enormous administrative costs to insurance companies for onerous compliance regulations from both state and federal agencies.
  • 3) Insurance companies should be rewarded for efficiently operating their business instead of having to pay out at least 80% of premium income in claims cost or refund the difference to their policyholders.
  • 4) Allow individuals and small employers to contribute their ideas to solving the accessibility / affordability issue under a free-market economy.
  • 5) Allow the insurance industry to create less expense plan options for ACA – High deductible, catastrophic plans; plans that do not include 10 essential benefits where it doesn’t make sense to have them; plans that have maximum payouts for certain benefits.

Whether you are Democrat or Republican, liberal or conservative, rich or poor, ACA was flawed law even if you believe it had noble intentions. Now middle-class America is paying the price one way or another – purchasing insurance they can barely afford or not buying at all because they can’t, putting themselves at more financial risk than ever before. The net result is that ACA conflicts with its own intent, cost-shifts the uninsured from one income class to another and fails to provide meaningful coverage based on plan design. That is flawed law.

ACA must be greatly modified or repealed with a new law in its place. There is a better way – an American way – and that begins with We The People taking America back.

Jim Jones is President of Wellspring Benefits Group and located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare business, he has developed a business model that integrates insurance products and healthcare services for individuals and small businesses to manage their costs and coverage with customized plan options. Jim can be reached at

P.O. Box 1372 • Colleyville, Texas 76034 • 817-953-3155 • Fax 817-900-9106

©2014 Wellspring Benefits Group. All rights reserved.

ACA: Where We’re Headed



ACA: Where We’re Headed
Jim Jones, President, Wellspring Benefits Group

Last month, I wrote an article entitled “ACA: How We Got Here and Practical Solutions for Controlling Your Cost”. In an effort to continue with the theme of understanding the Affordable Care Act (ACA), this month’s article will lay out a vision for what we should expect as we move forward in the “new normal” of government mandated health insurance. As with any government entitlement, once the law goes into effect, there’s no “undoing” what’s already been done. Yet what’s been done doesn’t solve the problem that the law (ACA) was ostensibly supposed to solve.


One thing that both conservatives and liberals can all agree on is that before the enactment of ACA, the health insurance industry needed major reform and the healthcare system was in dire need of a make-over. That’s where the agreement ends. To liberals, the answer was and always will be more big federal government mandates and regulation. To conservatives, the answer was and always will be allowing individual states to solve their own issues through free market reforms. In the case of something as complex and personal as healthcare, neither will solve the problem. It will take a combination of both. Right now, we’re too heavily tilted toward the liberal, big government approach which is proving to be a debacle for middle-class America.
In a nationally televised address in September 2009, President Obama said, “there are more than 30 million American citizens who cannot get coverage”. He was right. They couldn’t get health insurance because of pre-existing medical conditions that would cost the insurance company more to insure them than they had a chance in collecting premiums to offset the risk. In other words, insurance companies have to make a profit to stay in business. And as I pointed out in last month’s article, prior to ACA, health insurance companies relied on a risk-based actuarial model to set premium pricing vis-à-vis an appropriate underwriting process to evaluate the health risk prior to issuing a policy. We’ll come back to his point later in this article.

Epic Fail

Earlier this month, the non-partisan Congressional Budget Office (CBO) released its latest assessment of Obamacare as it relates to the overall economy through 2024. One of the metrics used to evaluate ACA and its effectiveness is the number of Americans that will be insured; or put another way, the number of Americans that will not have health insurance because of Obamacare. The CBO report reads: “About 31 million non-elderly residents of the United States are likely to be without health insurance in 2024, roughly one out of nine such residents”. That’s a net zero gain that will cost the American taxpayers over the next 10 years in excess of 2 trillion dollars to fund ACA while creating a colossal disruption of our healthcare system – for a net zero gain. If the purpose of ACA was to reduce the number of Americans without health insurance, the CBO report shows just how badly the federal government missed the mark. If you consider the amount of money the American taxpayer has to contribute and the disruption it will create, it’s nothing short of epic fail.

Big Government Logic

I read a cartoon this week that sums up the logic that could only come from bureaucrats that live inside Washington, DC and are completely disconnected from middle-class America. “Obamacare: To insure the uninsured, first we make the insured uninsured. Then we make the formerly insured pay more to become re-insured to insure the uninsured for free”. The redistribution of wealth is clearly closer to a Ponzi scheme than a workable solution for middle-call America.

Not Enough Pain

Consider also as you read this article, many middle-class Americans have lost their health insurance because of ACA and millions more can’t afford their premiums. I spoke to a lady this week who told me she has a decision to make – “buy health insurance or feed my family”. Put in those terms, the decision was easy. I spoke to a man last week who said his ACA premium was more than his mortgage payment and he didn’t know how he could pay both. Bottom line – the big government approach is not sustainable. It will break the back of middle-class America, the economy will falter and the entire process will implode.

ACA’s proponents are telling us that it’s too new and needs time before we’ll see its advantages to society. In the meantime, middle-class Americans are very skeptical and most believe it’s not beneficial for the overall greater good. In a November, 2013 CBS Poll, only 7% of Americans want Obamacare “kept in place”. 48% believe changes are needed and 43% want full repeal. But it’s not yet a crisis because it’s “too new” and the pain factor hasn’t manifested itself long enough. The problem isn’t painful enough to make Congress fear for their congressional lives. Until the government fears the people, nothing will happen. When Congress feels the heat of the American people’s breath on their necks, things will change. Until it becomes a crisis, we’ll just feed the beast.

The Setup

The plan is already in motion. Inside the beltway, Democrats are already formulating the next phase of their incremental plan to take over the healthcare system in America. Ironically, they need Americans to feel the pain – but only in an incremental way – not too much too soon. The madder middle-class America gets over time, the more it plays into their overall plan. You see, middle-class America is being setup by the people who brought ACA into existence, only to have the same people promote the “solution” that will make ACA look like a small government blip on the radar – universal healthcare through a single-payer system.

“It’s the Insurance Companies Fault”

Speaking at a recent conference, Mark Bertolini, CEO and Chairman of Aetna Insurance, announced that the end is near for profit driven health insurance companies. “The system doesn’t work, it’s broke today. The end of insurance companies, the way we’ve run the business in the past, is here.” You see, it’s that profit thing that gets in the way. (See last month’s article on how we got here).

So what’s left of the insurance industry in a single-payer system? A scaled down version of what exists today that contracts with the federal government as a third party administrator for claims payment. Jobs will be lost, the economy will be negatively impacted and a once viable industry will be relegated to the ash heap of big government take-over.

I can hear the single-payer proponents now – “the private sector is the problem because they have to make a profit”. “The insurance companies are the ones who set the premiums that no one can afford…’s not right that an American has to choose between buying groceries or paying their mortgage and buying health insurance”. “If the insurance companies can’t price their insurance to where people can afford it, then let the government do it”. Never mind that there are hundreds of thousands of Americans that make their living for their families in the insurance industry. Never mind that the private sector has to make a profit for those families to keep their jobs. Never mind that insurance is too expensive because of the mandated benefits of ACA that must be included whether you need them or not.

So imagine the efficiency of the Postal System with the compassion of the IRS in charge of your healthcare – when you get treated, where you can go, who you can see, what treatment you can have and what treatment you can’t and who gets treated and who doesn’t. Why would any freedom loving American want such government tyranny over the most critical and personal aspect of our lives?

And when the pain gets enough for middle-class America, when more and more have to choose between buying groceries or paying their mortgage and buying the insurance that the government says they have to buy, they will yield to a government run single-payer system. And in doing so, Americans will admit that the government is the only solution – even though the ACA (government) mandates are the reason for the skyrocketing costs. But that doesn’t solve the problem. If the cost of insurance is too expensive because of the cost of mandated benefits, administrative inefficiencies and the rising cost of healthcare, how does a single-payer system make the cost lower? It doesn’t. But in our belief that the government can solve the problem, we’ve shifted the burden of cost from the private sector that manages its ability to make a profit to the federal government who has the power to tax. Pandora’s box has just been re-opened and We The People will be standing with the key in our hand. The federal government’s solution to all ills is taxing more and spending more. If you think health insurance premiums are high now, wait until Congress has the power to tax under the cover of “healthcare for all”.

What’s the Solution?

As I stated above, a big(ger) government solution nor an individual state solution will solve the problem. Individual states regulate insurance today which is part of the problem. Each state has its own laws and regulations that have to be comingled with the requirements of ACA. That creates an administrative nightmare for insurance companies and adds millions of dollars in excess cost to the price of insurance.

We must and we should find a way for Americans with existing health problems to have access to health insurance without the epic fail of ACA. We have a moral obligation as a nation to take care of those who don’t have the ability to take care of themselves and to have a healthcare system that is available to all Americans regardless of health conditions. But how do you propose such a solution when so many political agendas are tied to every legislative initiative? First, we need the initiative to start outside Washington and work its way back in – not the other way around. With something so personal as healthcare, We The People should have a say in how it’s provided and accessed – not strictly politicians who don’t live in the real world.

A Blueprint

1) Begin a formal plan with stated objectives of what reform measures are needed.
2) Include healthcare professionals, business leaders, insurance executives and a select group of middle-class Americans (no elected politicians) to contribute their ideas about what a health insurance plan(s) should look like, including a provision that members of Congress cannot vote on the law until they have personally read it.
3) Submit the plan to a select, bi-partisan group of U.S. Senators as a working document.
4) Promote Health Savings Accounts (HSAs).
5) Allow health insurance policies to be sold across state lines.
6) Tort reform to keep frivolous malpractice lawsuits from being filed for bogus reasons.
7) Allow different insurance plans to be designed (with minimum standards) based on free market demand instead of government mandates.
8) Eliminate the individual mandate.
9) Require all Americans to pay an additional 1% sales tax to fund a national insurance pool for all people with pre-existing conditions to get coverage.
10) Repeal and replace ACA with the model above.

We’re Still in Control

We The People. We still have the final say. Perhaps we’ll look back one day and say ACA was the catalyst for improving a broken system. If the system we had prior to ACA did less damage than what we have with ACA, then We The People need to speak. We need a private sector health insurance solution that provides the best quality healthcare for all Americans – without government intrusion. “Where We’re Headed” is the title of this article. That’s strictly up to We The People.
Jim Jones is President of Wellspring Benefits Group located in Colleyville, Texas. He is a visionary leader with an eye for emerging markets in a changing healthcare environment. Through Jim’s 30 years in the insurance and healthcare business, he has developed a business model that integrates insurance products and healthcare services for individuals and small businesses to manage their costs and coverage with customized plan options. Jim can be reached at


©2014 Wellspring Benefits Group. All rights reserved.