The only type of health plan whose membership grew in 2012 was the consumer-directed health plan (CDHP), according to a survey from Mercer, the benefits advisors. Two-thirds of large employers expect to offer CDHPs by 2018, five years from now. 40% of all employers (small and large) anticipate offering a CDHP in five years.

The growth in CDHPs going forward will be increasingly motivated by the impending “Cadillac tax” that will be levied on companies that currently offer relatively rich health benefits. Furthermore, Mercer foresees that employers will also expand wellness and health management programs with the goal of reducing health care spending by improving worker health.

CDHPs typically include a deductible of at least $1,000, bundled with a medical account — a health reimbursement arrangement (HRA) or a health spending account (HSA), based on the definition from the Employee Benefit Research Institute (EBRI). HRAs are funded by employers only, and HSAs, by both employers and employees. As the table illustrates, HSAs are far more popular among employers.

Mercer is concerned that one-third of employers still don’t have a clear idea about the actual cost impact of the Affordable Care Act on their companies. Mercer believes that because the tax penalty for not obtaining insurance coverage will be “only” $95 per worker or 1% of household income (whichever is higher), some employees may choose to opt out of buying into coverage in 2014.

To slow down implementation costs of the ACA, Mercer notes that nearly one-third of employers will deduct more from workers’ wages for dependent coverage in 2014, and 13% will increase premium contributions for single coverage.

78% of companies told Mercer they are worried about the communication requirements in the ACA, “such as educating employees about their choices and supporting informed decision-making,” Mercer reports.

Health Populi’s Hot Points: Take note that the table illustrates greater popularity among employers for HSA — which workers fund through pre-tax wages. While both plan types are growing, more employees as a percent of total offered a CDHP are enrolled in HRAs than HSAs — probably because HRAs are funded only by employers.

This trend reflects some health consumers’ lack of willingness to spend “my own money” on health care given decades of experience of first-dollar, and deeply discounted, health benefit coverage.

The U.S. is not a Saving Nation. The general savings rate in the U.S. was 2.6% in the first quarter of 2013. In the largest European countries, people save at least 10% each year: in 2011, the savings rate in France was 12.3%, in Germany, 10.5%, and in Sweden, 10%, based on OECD statistics shown in the graph.

How keen will Americans be on saving for account-based health plans? If past is prologue, it will be a painfully slow process to educate people on how “my” money is meant to benefit “my” and my family’s health. That most employers are shying away from educating employees will put the onus on health plans and financial service companies to do some of this heavy lifting.

The number of retail health clinics will double between 2012 and 2015, according to a research brief from Accenture, Retail medical clinics: From Foe to Friend? published in June 2013.

What are the driving market forces promoting the growth of retail clinics? Accenture points to a few key factors:

• Hospitals’ need to rationalize use of their emergency departments, which are often over-crowded and incorrectly utilized in cases of less-than-acute care. In addition, hospitals are now financially motivated under the Affordable Care Act (ACA, health reform) to reduce readmissions of patients into beds (particularly Medicare patients with acute myocardial infarction [heart attacks], congestive heart failure, and pneumonia). 
• The undersupply of primary care providers (PCPs) – internists, general practitioners, family doctors, and pediatricians – and the need for those in practice to extend services beyond normal hours to serve patients in more convenient times and locations.
• Health plans that want to provide consumer-friendly health services to enrollees, and channel them to cost-effective levels of care to effectively manage costs and health plan premium dollars.

Dr. Kaveh Safavi who leads Accenture’s health practice in North America calls this phenomenon a “release valve” for the U.S. health system.

Health Populi’s Hot Points:  Health citizens with a strong primary care backbone, such as those in Europe like Denmark, France, Germany and the United Kingdom, have better health outcomes than patients in the U.S. Retail clinics provide additional “bone structure” for the undersupplied American primary care infrastructure. So “release valve” as coined by Accenture is an apropos metaphor.

But does a release valve guarantee continuity of care or a way to fill an immediate need in a convenient, lower-cost package? It’s the latter, which isn’t a bad thing: it’s just not necessarily an optimal solution.

Don’t get me wrong here: I’m a fan of growing retail, convenient, lower-cost high quality health formats in the community where people live, work, play and pray. What would make my evaluation more positive is seeing the opportunities Accenture hints at come to fruition with the patient encounters getting captured into a continuity of care record. In so doing the person’s health visit gets recorded into a health information system where a medical home, regular care coach, or PCP can track the patient’s full health picture over time.

Adding more fragmentation to an already-episodic health system won’t solve the cost-and quality- problems of the U.S. health system. But if retail health clinics can become integral partners in accountable and value-based care ecosystems in local communities, bring on the Welcome Wagon for these part-time medical homes.

The notion of consumers’ greater skin in the game of U.S. health care — and the underlying theory of rational economic men and women that would drive people to greater self-care — permeated the agenda of the 2nd annual Consumer Health & Wellness Innovation Summit, chaired by Lisa Suennen of Psilos Ventures.

Lisa kicked off the meeting providing a wellness market landscape, describing the opportunity that is the ‘real’ consumer-driven health care: people getting and staying well, and increasing participation in self-management of chronic conditions. The U.S. health system is transforming, she explained, with payors beginning to look like computer companies, hospital re-forming into payor groups (e.g., Accountable Care Organizations), and technology companies wrapping health services into their bundles. The industry has been built on throughput, not personalization and people, she said; “we have a system designed around financial incentives giving little credence to consumer desires.” This un-consumer health system is ticking like a time bomb, Lisa asserted — not like a Swiss watch. That’s because of the negative drivers of increasing costs along with public policy that un-does public health in the form of corn and soy subsidies, and a skewed food system that encourages Big Soda where ”soda and sugar are a bigger security threat than Al Qaeda,” in the politics according to Lisa (and I agree with that assessment), But on the positive side, Psilos has found that U.S. consumers have been doing more to enhance their health in the past year, and employers are offering more wellness programs which aim to help reinforce consumers’ individual good intentions.

The day featured a gathering of the investment community, consumer advocates, mobile and digital health innovators, retail health players, health plans and consumer goods companies. Pepsico was a sponsor along with AARP, Cooley LLP, and Qualcomm, among other partners.

Say what? Pepsico? Indeed, and very appropriate. The food system is an integral part of the larger health ecosystem, so having Pepsi at the health and wellness table is as appropriate as a pharmaceutical manufacturer, an employer benefits planner, and a mobile health strategist. This ecosystem underpins the consumer skin-in-the-game scenario: health is, as our Surgeon General Dr. Regina Benjamin has said, where we live, work, play and pray.

Witness a few of the programs mentioned during the day:

• Walgreens’ new “pharmacy 2.0″ model of Well at Walgreens, bringing fresh food to food deserts and moving some of their 27,000 pharmacists in front of the counter, described by Dr. Jay Rosan, innovator at the pharmacy chain.
• Zipongo, a food-health start-up trying to “make it easy to eat well,” working with Google’s wellness group and other clients to drive healthy food choices for people shopping national grocery chains (tagline: “Health Yourself”).
• SoloHealth kiosks, located in retailers like grocery and Big Box stores, where Lisa said she saw people waiting in line to use at a Giant supermarket last week.
• Mayo “outside the Clinic,” discussed by Jeff Cross as the organization’s strategy to attract consumers who aren’t affiliated with the Clinic. In Jeff’s words, the goal is to “help with interactions with the health system, including how to stay away from it.”

Another theme discussed throughout the day was the role of brands in the era of consumer-driven health. Do consumers view health brands the way they do consumer goods? AARP’s John Santa observed that “Atul Gawande [the physician-turned-New Yorker columnist) has established himself as a brand. Dr, Peter Provonost at Johns Hopkins involved in hospital safety has his own brand separate from” Hopkins. But the most important health brand to patients, Kim Goodwin of PatientsLikeMe asserted, is “other patients.”

Although Google is well-used for health searches – as in “Paging Dr. Google” — the jury is out on whether it is a trusted brand for health. Amanda Goltz of Aetna thought it ironic that Google is a trusted search engine in health, but works on the proposition of people giving the company “all of your data.” Yet on the health plan side, consumers are deeply suspicious of giving an insurance company “a little of your data, which is protected by HIPAA and in return we’ll give you tools to manage health.”

Another successful consumer brand, Virgin, was represented at the conference by Chris Boyce of Virgin HealthMiles, who said that Richard Branson (Virgin’s founder) pushes the promise of health and changing behavior for the long-term. “For 6 years,” Boyce said, “Virgin has fought to find its place” in the siloed health market of the U.S. His experience working with Virgin HealthMiles in the employer market has led him to believe that “it’s tough to align across silos,” so Virgin has begun with employers to move the needle of workers’ health. Some companies working with Virgin have appreciated the organization’s ability to change employee health so they’ve asked Virgin to move into other employee benefit areas, such as financial wellness and social good.

Cautioning the use of branding in health was Malcolm Bohm of Liquid Grids whose business it is to observe online discussions among health consumers and make sense out of the billion-plus mentions of health online. Malcolm’s team believe that of the 1 bn consumer conversations, only 2% are about ‘brand.’ Instead, Malcolm noted that health consumers talk about health experiences: “from a brand perspective, you have to appear to what the dialogue is about — it’s not about brand, it’s about ‘them.’”

Confirming that approach was Bryce Williams of Blue Shield of Calironia, who believes that “health and wellness are the ultimate meritocracy. We can be field guides,” he counseled — “that’s what I aspire to.”

Health Populi’s Hot Points: The meta-message of the day is that consumers – people – are already part of the health system. But the system isn’t designed for consumers, as manifested by:

• Cumbersome and logistically difficult navigation for health insurance, care and diagnostic services
• Uninspired tools and products that don’t motivate initial adoption and ongoing engagement and use by well people and sick patients and their caregivers
• An employer sector, one-half of the key funding source for health insurance in America, that lacks innovative and novel approaches to inspiring employees’ total health and wellness, continuing to use Old School health plan designs (even though “value-based benefits” are in vogue).

A popular channel strategy cited by most of the companies serving the wellness market at the conference was marketing to and through employers. But with so many vendors going after employers, finding traction may be challenging. I recognize that most employers are now focusing on wellness as a cost-bending strategy – covered often in Health Populi, most recently here and here.

But the evidence for employer-sponsored wellness programs (1) improving workers’ health outcomes and (2) reducing health claims costs is sparse. The RAND Study on the topic, published in 2012, found little proof of the ROI for wellness in the workplace.

“Wellness is the new kid on the block,” observed Erin Rech of Ridgeview Medical Center. They’re forming a joint venture with a senior housing provider, deploying technologies in that facility to keep people out of the emergency department 2 miles down the road. This is the right move, bringing together a health provider with consumer technology and a housing developer. Health – where we live, work, play, pray, as Surgeon General Dr. Regina Benjamin has said.

Lisa talked about the original Fortune 500, when only 2% of companies operated in health care. By 2013, 25% are solidly in health, and 50% have aspirations in serving some aspect of the health market: Apple, Verizon, and Walmart among many others. This is the future of wellness and the real consumer-directed health — if the siloes that are the burdensome legacy of U.S. health care can be broken.

Health, happiness and engagement among employees are closely-linked and drive productivity in the workplace. But there’s a gap between the kind of wellness services employers offer workers to bolster health, and the programs that people actually want.

The current state of employer wellness programs is described in a survey conducted by Virgin HealthMiles and Workforce, The Business of Healthy Employees: A Survey of Workplace Health Priorities, published in June 2013.

There’s a gap between what workers want for wellness and what employers are offering. Most-demanded by workers are health on-site food choices desired by 79% of employees; but, only 33% of companies offer that healthy food that workers say they want. On the other hand, one-half of workplaces offer smoking-cessation programs, but only 13% of workers are interested in those. Fitness centers – desired by 3 in 4 employees – are offered to less than 1 in 3 employees.

The key findings from the survey are that:

• 87% of employees consider health and wellness offerings when picking a job
• 7 in 10 employees say wellness programs positively influence work culture, and 58% of workers believe their participation in wellness programs have a positive influence on colleagues, friends and family
• Incentives are important: while for 78% the #1 reason for participating in a wellness program is to improve health, 61% of employees also say incentives earned through wellness programs are a key reason they participate
• Most communication about wellness programs is via email, but employees don’t feel too clued into the program offerings
• Measuring ROI on wellness continues to challenge companies offering the programs. Only 31% of organizations deploying wellness programs are satisfied with the metrics they use to measure success of the benefits.

Two-thirds of the incentives used in wellness programs are “carrots,” and 29% offer both carrots and sticks to induce involvement in the programs. Only 3.5% of employers use only “sticks” as incentives to motivate.

The top 10 benefits employee perceive from participating in wellness programs are,

1. Feeling healthier and happier, among 55%
2. Improving overall well-being, 54%
3. Losing weight and/or lowering BMI, 49%
4. Having more energy, 48%
5. Receiving financial rewards, 29%
6. Improving control of chronic conditions, 27%
7. Fewer sick days, 22%
8. Lowering health care premiums, 21%
9. Improving morale, 21%
10. Supportive social connections, 17%
11. Reducing dependence on meds, 9%.

The biggest obstacles to deploying successful wellness programs include the lack of ability to measure their impact, budget, concerns about changing employee behavior, and access to data needed to make decisions.

Health Populi’s Hot Points: Here’s a case where if you build it, only some employees will come — not because they’re alienated or turned off by wellness programs, but because a plurality of workers are simply not aware of the services available that can help them improve their health, and ultimately the health of the workplace. Health is social, the data from this survey show: workers like not only feeling energetic and positive about health, but the impact the programs have on co-workers and workplace morale. That’s faulty communication between employer and employee.

There’s a second aspect of communication that might also prevent the full realization of benefits and outcomes from wellness programs: this is communication about the Affordable Care Act between the Federal Government (White House and Department of Health and Human Services) and employers. That’s because most employers do not plan to take advantage of the wellness incentives that the ACA affords them. That incentive is that in 2014, companies offering health insurance with wellness programs can earmark financial incentives from 20% to 30% of the company’s total health plan costs. That percentage will be 50% for smoking cessation programs.

And, employees who smoke, we recently learned, cost an employer $6,000 more a year than workers who never smoked.

So there’s a simple-to-calculate hard ROI that’s calculable on targeting smoking through a wellness program, taking advantage of a very generous financial incentive.

In the $3 trillion economy that is American health care, the role of information technology is central to transforming this huge piece of U.S. fiscal activity. This week convened the fourth annual Health Datapalooza (HDP) in Washington DC, with the underlying theme, “health engagement is the blockbuster drug of the 21st century” (quoting Leonard Kish).

This meeting of over 2,000 registrants – huge growth from the first year’s 400 attendees — is organized by the Health Data Consortium (HDC) , whose CEO Dwayne Spradlin kicked off remarks on Day 2 of HDP4. He described the HDC, a public-private collaboration led by Robert Wood Johnson Foundation, the Department of Health and Human Services, the Institute of Medicine, and a growing list of commercial companies driving health innovation including but not limited to Sanofi, athenahealth, and others working together with a common vision. The meeting brings together health data competitions and challenges, and a diversity of participants: patient groups, biotech, VCs, data scientists, pharma, government reps, and health care providers.

The British Secretary of State for Health, Jeremy Hunt, was an early speaker on Day 1. He commended the U.S. for moving toward providing universal health insurance to all U.S. health citizens. Continuing his patient-centric message, Secretary Hunt described the program in the National Health Service to move patients to the center of health care, invoking the words of Dr. Joslin, father of innovation in diabetes care in the U.S., who said of the person with diabetes, “he who knows the most, lives the longest.”

Secretary of Health and Human Services Kathleen Sebelius spoke to the importance of developing health data tools and transparency for fully implementing health reform on a broad scale. She described the opportunity as a long overdue unleashing of innovation in American health care.

A key theme throughout the two days was the importance of unlocked health data trapped in institutions still using inadequate technology, Spradlin said. Current practices and payment may limit the sharing of information. Neither culture nor technology change is easy, he recognized: “We have our work cut out for us.” But health transformation is a national priority, Spradlin noted. Economic strains are a forcing function, he described, which compel the health care industry — and all stakeholders — to participate in this transformation.

Deven McGGraw of the Health Privacy Project for the Center for Democracy & Technology presented the first health data Liberators Award. The HDC evaluated many candidates for the award: the winner was Dr. Nirav Shah, NY State Health Commissioner, who is making health data publicly available for apps, tools and services for New Yorkers. With a budget of $50 bn a year, Dr. Shah is using existiing data to develop targeted health care projects for public health. In March 2013 he led the launch of the nation’s first open data site: Health.Data.NY.Gov.

Always a highlight high-energy speaker at HDP, Todd Park has the coolest title in town: the CTO of the USA, says Thomas Goetz. Park is the standard bearer of Data Liberacion! and has played a key role inspiring health stakeholders to improve care through the innovative use of data to improve outcomes, save lives, and lower costs. “There has never been a better time to be an innovator at the intersection of health, data and IT,” Park said, calling out four key reasons:

1. Through payment policy changes under ACA and commercial payers, the emergence of a smarter health system focused on quality, not quantity of care – avoiding mistakes, driving patient health engagement, Accountable Care Organizations (now over 250 serving 4 mm Medicare enrollees), and medical homes. What these models all have in common: they’re rewarded for delivering coordinated care that optimize the health of patients. Park says these models “Reward the stitch in time” that saves patients and improves quality of care.

2. Historic increases in adoption and use of electronic health records – empowered by the HITECH Act and the hard work of doctors and hospitals. Over half of doctors and over 80% of hospitals are now using EHRs. “At long last the manila folders are turning into electrons,” Park said, with “huge positive implications.

3. DHHS making available a growing supply of key government information from charges and quality to regional health statistics and the latest science, available in computer readable downloadable form — especially important for entrepreneurs to corral and apply to innovation. This is, as Park deems it, the “CMS Office of Data Liberacion!” aka the CMS Office of Information Products and Data Analysis

4. The launch of Health Insurance Exchanges, where Park says small businesses will have similar opportunities as big companies to accessed whole new health insurance plan models that use data to improve customers’ experiences. Park challenged developers to “use ingenuity to rethink health insurance plan design and to sign up young people,” who will be crucial to have enrolled in plans to ensure a balanced risk pool.

Next year’s Health Datapalooza will be June 1-3, 2013, in Washington DC. If you’re involved in some way at the intersection of health, patients, and information, it is a must-attend meet-up.

Health Populi’s Hot Points: This fourth year of HDP exhibits tremendous growth in numbers of attendance, and in the breadth of participant stakeholder groups. One example: Pfizer’s Craig Lipset, from the Big Pharma sector, talked about moving patients from their role as “subjects” in clinical trials in R&D to patients as participants. Lipset noted that only 4% of physicians participate in clinical trials, and 7% of patients said their physicians have talked with them about participating in a trial. Pfizer is joining the Blue Button+ initiative to allow patients to access clinical data. In a recent study by Weitzman, 91% of patients said they’d welcome the opportunity to share their health data. Pfizer’s launch of this project is a big milestone in pharma’s involvement in health data access and transparency.

The expansion of participants in number and type in the HDC and focus on the patient-person at the center of health data innovation is exciting and inspiring. Those of us working at the intersection of health-consumers-information-tech are not Pollyanna’s about the heavy lifting and hard work involved in continuing to move from paper-based data and siloed information toward data liquidity and patient access to their own health information.

Dr. Shah spoke of “the freedom to own our own data.” This is increasingly become the reality for American health citizens owing to adoption of data standards,  cloud computing, democratization of devices (e.g., growth of smartphones and tablets among both providers and consumers), aligning payment for quality, and consumers’ growing self-tracking and consumerization in health care.

Tablets, wearables, smartphones, video and QR codes: these are fast-growing platforms moving data around the global economy. They’re also fast=growing platforms for health care where we live, work, play and pray.

Mary Meeker‘s annual presentation on Internet Trends at the D11 Conference, is fresh off the virtual press in its shiny new 2013 version. Meeker has been with the investment firm Kleiner Perkins Caulfield Byers (KPCB) since 2011, and was with Morgan Stanley from 1991 to 2010. She’s a veteran who’s watched the Internet basically from The Beginning.

Of the 117 slides in her informative, gargantuan deck (a Meeker hallmark every year), at least 10 speak to some aspect of health; I’ve synthesized Meeker’s themes for health as follows:

• Video, where Big Brother meets Big Mother (THINK: remote health monitoring and safe aging at home)
• Social sharing for, say, health and wellness (where Jawbone UP meets Yelp!)
• The growth of fitness wearable devices
• Changing health behaviors for impacting premature death (which I addressed here on Health Populi)
• The advent of sensor-enabled wearable computing to emerge in 2014
• QR code scanning for nutrition and other applications
• The publication of TIME’s Bitter Pill story, covered here in Health Populi
• The growth of Medicare and health care and other spending that will overtake economic growth sooner rather than later.

For the mobile health lens on Meeker’s views, see Brian Dolan’s take in MobiHealthNews here.

Health Populi’s Hot Points: Consumers’ growing adoption of Meeker’s many platforms, from phones to tablets to social networking and wearable sensors, will enable daily quantification of a variety of activities, from food tracking and safe and consistent drug dosing to social networking to bolster healthy choices. Consumers’ taking on the role of more self-care is a form of self-service vertical industries outside of health care are taking advantage of: consider self-checkout at the supermarket, photo development online via Shutterfly, stock-trading on Vanguard.com, and online bill paying.

Pushing these functions out to consumers helps lower transaction costs for companies serving these market segments: grocers, photography services, financial services, and retailers.

Will healthcare self-service by health-engaged consumers lower costs for providers?

The right context for that question is value-based health care and risk-management, where a growing proportion of doctors and hospitals are taking on financial risk for population health management. The more consumers can do for themselves in remote monitoring, on-time efficacious self-care, and safe aging at home, the more providers can manage their financial risk for that patient’s condition(s).

As Judith Hibbard pointed out in the February 2013 issue of Health Affairs, greater patient activation can result in lower costs for a health plan.

While having money in the bank is always a prescription for feeling well, having a bank account is a precursor to getting health insurance under the Affordable Care Act. That fact could prevent millions of people who are eligible for health insurance premium subsidies under health reform from enrolling in a health plan.

The issue of banking the un-banked in health is a little talked-about detail that, if overlooked, will scuttle the best-laid plans for health reform. That’s because if people enroll in health insurance, their monthly premiums will need to be debited from a bank account. So, without a bank account, the newly-enrolled  in a health plan won’t be able to pay ongoing premiums.

Think about it this way: workers who receive their health insurance through their employer have their monthly plan premiums deducted from their paychecks. In this way, the employer’s accounts payables function is playing the role of medical banker.

For people who obtain health insurance through a health insurance exchange under health reform, premium payments are expected to be paid through personal bank accounts.

Thus, 1 in 4 Americans who is eligible for a premium subsidy under the Affordable Care Act (ACA) could be unable to access health insurance because they are “un-banked,” without a checking account, according to a Jackson Hewitt survey published in May 2013.

In Uninsured + Unbanked = Unenrolled, Jackson Hewitt, the tax services company, details the conundrum: insurance companies can require customers to pay premiums automatically through checking accounts. This lowers administrative costs – which analysts agree is a good thing to do. But the unintended consequence would be that for the 8 million+ uninsured Americans eligible for tax credits under the ACA, insurance remains elusive.

Most of the un-banked consumers live in 11 of the 12 states where Health Insurance Marketplaces (Exchanges, HIXs) will be operated by the Federal government. In Illinois, Jackson Hewitt found that over 1 in 3 uninsured residents probably doesn’t have a checking account. The two most populous HIX’s, California and New York, have the second and third lowest un-banked rates in the U.S. among uninsured people living with incomes 100% to 400% of the Federal Poverty Level.

African-Americans and Hispanic Americans are especially impacted by this situation: they are 43% more likely to be un-banked than white Americans. Statistically, 1 in 3 African-Americans and Hispanic Americans is un-banked. This equates to 5 million of the 8.5 million total people uninsured and un-banked in America eligible for ACA premium credits.

Health Populi’s Hot Points:  There are some 50 million people in the U.S. without bank accounts according to the RAND Corporation‘s 2012 findings on the un-banked in America. But just because folks don’t have bank accounts doesn’t mean they don’t transact personal finance using other tools. Jackson Hewitt calls out prepaid debit cards as one way un-banked consumers make electronic payments, a growing M.O. for people who don’t have traditional checking accounts. The Federal government issues such cards to beneficiaries in Veterans Administration and Social Security programs, and State recipients of benefits also use these cards.

But Federal rules, Jackson Hewitt points out, allow insurance companies to reject debit card payments: the specific legal issue is in the ACA at § 1412(c), as amended; 77 Fed. Reg. 18310, 18471 (March 27, 2012) (to be codified at 45 CFR § 156.270); id. at 18463 (March 27, 2012) (to be codified at 45 CFR § 155.430).

There is language in a letter from the Department of Health and Human Services to insurers from April 5, 2013 stating that insurers must accept payments in ways that are “non-discriminatory,” but since the publication of that letter, Jackson Hewitt found no further clarification on using debit card payments.

The Federal government has the opportunity to fix this oversight, allowing for other types of consumer payment mechanisms beyond checking accounts to include, at a minimum, debit cards.

Real Simple published a helpful article on the merits of checking accounts versus prepaid cards here. They argue that consumers can find “free” checking accounts without fees, discoverable at sites like Bankrate.com. But in 2013, these are few and far between as banks nickel-and-dime consumers on fees.

Still, the un-banked need better financial options, as discussed in the Center for American Progress discussion on the unbanked. The use prepaid cards has reached 27% of the un-banked who used to have traditional bank accounts. Prepaid cards aren’t a panacea but are the chosen financial vehicle for millions of people in America who, for various reasons — financial, trust, and logistical — choose to use them. They need stronger consumer protections and industry standards.

If you have health insurance, chances are you take several actions to bolster your health such as take vitamins and supplements (which 2 in 3 American adults do), take medications as prescribed (done by 58% of insured people), and tried to improve your eating habits in the past two years (56%). Most people with insurance also say they exercise at least 3 times a week.

Fewer people who are uninsured undertake these kinds of health behaviors: across-the-board, uninsured people tend toward healthy behaviors less than those with insurance.

This is The Prevention Problem, gleaned from a survey conducted by TeleVox which has published various reports under the company’s Healthy World initiative. The chart illustrates what TeleVox, a communications support company for health providers, calls out as “The Ugly Truth” — that is, the disparity between the health and wellness status of the insured versus the uninsured.

Other key findings from the survey include:

• Fewer than 1 in 5 uninsured people consider themselves to be extremely healthy
• People without health insurance are less knowledgeable about preventive care: 33% were uncertain what constitutes prevention, versus 16% of insured people
• Still, 91% of the uninsured believe that some form of prevention is important, and 81% of the uninsured say that taking preventive care measures can save patients money
• Nonetheless, 17% of the uninsured who have been given preventive health recommendation gave themselves a grade of “F” when it came to following this information up.

The consumer survey was conducted among 1,015 Americans age 18 and over in April 2013, along with a poll of over 2,200 health providers.

Health Populi’s Hot Points:  Three-quarters of people die from noncommunicable diseases (NCDs) — conditions like heart disease, diabetes, various cancers among them — which are largely amenable to prevention and changing lifestyle behaviors. There are 4 such behaviors that move the needle on chronic disease:

1. Doing more physical activity
2. Eating healthy food in healthy proportions
3. Drinking alcohol moderately
4. Quitting smoking.

Fewer people who lack health insurance tend to make fewer of these healthy choices.

It’s not easy to change health behaviors. The Edelman Health Barometer of 2011 found that two-thirds of people try to change a behavior in a past year, and only one-half sustain that change, lapsing back into the original (unhealthy) choice.

As uninsured people in America are invited to access health plans through health insurance exchanges (marketplaces), folks will be exercising new muscles. First, the lack of knowledge of how to shop for health insurance, and how to evaluate different options across different health plans available in the local marketplaces; and second, once enrolled in a health plan, how to use the health system. This new-new milieu means finding a primary care doctor, versus continuing to use the emergency department for an infection or to investigate a lump that went unchecked for many months before attaining insurance coverage.

Learning to be health literate, and health plan literate, will be Job 1 for the newly-insured. TeleVox’s survey shows us there is much education to be done. Setting up a health insurance exchange — which is heavy lifting in itself — is but one pillar of getting the uninsured insured. Once insured, there’s new workflow for people to embrace and implement. Health behavior change is hard, and one of those behaviors will be shifting newly-insured consumer mindsets from expensive, inappropriate health care settings (namely, hospital departments) to lower-cost, more appropriate and convenient providers (e.g., primary care, retail health clinics, worksite clinics, school-based clinics, and the like).

That’s the health care utilization piece of the puzzle. The other big opportunity is to promote prevention and healthy behaviors where the newly insured live, work, play and pray — in their home and communities. That’s where the local food system, schools, workplaces, retail and community organizations play a huge role on a daily basis to help people access local resources to improve on food choices, increase physical activity, and support smoking cessation (very amenable to social networks and competitions).

While costs of serving the newly insured may raise aggregate health care costs in the U.S. in the first years of health reform implementation, in the longer run, the public’s health burden of disease could benefit from getting people into preventive programs sooner…thus, closing the health/wellness gap that is The Ugly Truth of the insured and the uninsured.

If you have $22,030 in your wallet, you can buy:

• A princess-cut diamond
• A Ford Focus 4-door
• A year’s tuition at James Madison University (in-state, 2013-14)
• A health plan for a family of four.

The 2013 Milliman Medical Index gauges the annual health care costs for a typical American family at $22,030, up $1,302 from 2012 — a 6.3% increase, nearly 6x the all-items increase of 1.1% for the U.S. Consumer Price Index from April 2012-April 2013. That 1.1% includes the costs of food and energy, along with cars, tobacco, shelter, and other consumer goods.

In 2013, the average family will cover $9,144 of that $22K total, representing over 40% of annual costs. And out-of-pocket health costs (co-pays, coinsurance and other cost-sharing) of $3,600, are roughly equivalent to gas costs for a year.

Milliman estimates that $9,144 is just over the annual cost of groceries for that same family of four. This is split between premium costs of $5,544 and out-of-pocket costs of $3,600.

The $22,030 is allocated across the following health care expenditure line items:

• $6,990, doctors and professional services = 32%
• $6,855, inpatient/hospitals = 31%
• $4,037, outpatient/ambulatory health care = 18%
• $3,296, pharmacy= 15%
• $851, other services = 4% (medical equipment, home health, ambulance).

Outpatient services grew the fastest of all 5 categories at 9.2% between 2012 and 2013. Watch this space as more care gets delivered outside of the inpatient hospital setting: costs in this category are fast-growing and for hospitals getting squeezed on inpatient rates, represent a revenue-generating opportunity for the emergency department, outpatient surgery, radiology (THINK: MRI and digital imaging), among other services.

Pharmacy costs grew 7.9% in the year, with specialty drug costs offsetting the switch to lower-cost generics. The average monthly cost of specialty Rx’s is $600 for a monthly supply according to the American Journal of Managed Care’s review on specialty drugs published in February 2013.

Health Populi’s Hot Points:  Milliman’s bottom line, in Health Populi’s lens, is that, “While both employer and employee costs increased, a larger portion of the shared increase was borne by the employee, primarily through the payroll deduction.”

Milliman believes that employers are seeking to lower the costs of care rather than continuing to allocate more costs onto employees. To do this, price transparency of health services may come to the rescue, the actuaries write in the report’s conclusion. The Bitter Pill article in TIME magazine, lauded in this blog on the day of publication, raised the issue of the chargemaster and other arcane and opaque pricing policies in health care.

For transparency to work its magic, consumers must seek, review, understand and act on the information. This is a value chain of activity that needs the skills of artful designers who understand human behavior and how to communicate data in engaging ways via communication channels where people “are.” These skills will be in great demand in the coming months as health insurance exchanges launch and employers and plan sponsors try to usher new and confused health care consumers into the promise of the ACA and employers’ collective wish to bend that stubborn health cost curve.

Thanks and kudos to Milliman for providing yet another year of this important resource.