Insight, analysis & opinion from Joe Paduda

< Back to Home


Obamacare’s success is NOT about enrollment

At least not ONLY about enrollment.

What’s missing from the reporting on and discussions about how many and who and where they signed up for health insurance is a much more important issue – what are the health plans doing to improve health and control cost?

You wouldn’t know that from the press or pundits.

The are fighting the proverbial last war, and are not thinking about what it will take to succeed in this one. Amidst all the back-and-forth about young invincibles and risk corridors and subsidies is this reality; the basis for health plans’ financial success has changed – dramatically.

Health plans will no longer succeed by underwriting; that’s dead.  Yes, pricing is critical, but it can’t be used to drive demographics and enrollment, and neither can benefit design.

These tools – benefit design and underwriting – had been the fundamental business drivers for decades.  Now, they no longer exist.

They have been replaced by population health management.

Going forward, health plans’ success will be driven by much-improved, streamlined, integrated health care delivery systems focusing on population health management.

This means identifying those members with chronic health conditions and reaching out – assertively and proactively – to those members.  It means keeping them healthy; the annual cost of an asthmatic that has an acute episode is 20x more than one who doesn’t. Hypertension, diabetes, depression, COPD are all major contributors to health costs, and those health plans that get their members to higher health status will win.

They will have lower total medical costs, and will be able to offer lower premiums, which will drive more enrollment, including enrollment of younger, healthier (that means cheaper) members.

The “how” to do this is incredibly complex, requiring multiple stakeholders to completely change their thinking and success criteria and financial orientation.  To wit:

  • Docs will no longer be motivated to admit/treat/prescribe, but rather to work with patients to get those patients to “do the right thing”
  • Hospitals will want fewer transplants/surgeries/ER admits
  • Medical people will run insurers and health plans
  • In some markets, health plans all become appendages of delivery systems, while the big national players will continue their efforts to partner with local health care delivery systems.
  • Expect much faster and deeper adoption of evidence-based medical guidelines as health plans and their provider partners rely on science to drive improved outcomes.
  • Some smart health plans may actually figure out how to market themselves.  Seriously, it is possible!  Yep, after many, many years of underinvesting in marketing, branding, positioning, health plans are going to spend tens of millions in an effort to brand themselves and achieve “mind share” among consumers.
  • Employer involvement in arranging for employee health benefits will diminish – a lot.

This is already happening – it isn’t pretty, there are lots of starts, stops, and dead-ends, plans will fail and providers go belly-up, but the market will determine the winners. Notably, this wouldn’t have happened without guaranteed enrollment and pre-set benefit plans.

What does this mean for you?

The current flattening of health care trend will continue due to this transformation.

With clear boundaries set by Obamacare, health plans will succeed – or not – based on their ability to do what they should have been doing all along – deliver the best outcomes for the lowest cost.


5 thoughts on “Obamacare’s success is NOT about enrollment”

  1. Joe, you truly are an optimist. Based on the pitches we’re getting the quick money is betting on getting the community rated populations to opt for selfinsured plans when they can qualify–and opt back into the pool once things turn sour. Just exactly what happened with Small group reform previously. They count on everyone suffering from the Lake Wobegon illusion.

    1. John – undoubtedly there will be lots of efforts to make the best of any situation. however, these are fundamental and deep changes that will affect far more than the insurance markets; this isn’t about the funding mechanisms rather it is about the health care delivery industry.

      insurance is just how some of the care gets funded.

  2. Joe, You are absolutely right on this. The determinants of success have clearly changed. Health plans do not even have the tools to do the new job. Bob

Comments are closed.

Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



© Joe Paduda 2023. We encourage links to any material on this page. Fair use excerpts of material written by Joe Paduda may be used with attribution to Joe Paduda, Managed Care Matters.

Note: Some material on this page may be excerpted from other sources. In such cases, copyright is retained by the respective authors of those sources.