Series
The Other Side
The Other Side collection tests each component of the small group health benefits architecture against three objectives the employer actually has: protect the company from financial risk, provide genuine health access, and make the arrangement honest. The architecture fails most of these tests. TOS.C1 makes the strongest available case that the replacement is not ready.
TOS.01
The Bundle Is the Problem
The bundled small group health plan packages a network purchasing discount, a pharmacy purchasing arrangement, and catastrophic financial protection in a single wrapper. Only the …
TOS.02
Community Rating Failed
The ACA's adjusted community rating created the adverse selection spiral it was designed to prevent. Unlike 1990s state-level experiments, the exit vehicle for healthy small groups …
TOS.03
Coverage as Retention: The Case for Variable Employer Contribution
Section 105(h) targets enrichment of executives and owners. It does not prohibit varying benefits between other employee classes. Section 2716 has existed since 2010 and has never …
TOS.04
Broker E&O Accountability Is Guild Protection
Compensation disclosure documents what the broker earns but gives the employer no mechanism to contest it. Licensing requirements raise barriers to simpler alternatives. E&O …
TOS.05
The TPA Is the Plan
The TPA writes the plan document, selects the network, sets adjudication criteria, manages prior authorization, and produces the renewal analysis. The employer signs where the …
TOS.06
Stop Loss Carriers Are the Actual Architects of Level Funded Plan Design
Stop loss carriers define what is insurable at what cost. The TPA and employer assemble plan design within those boundaries. Calling this employer plan design is technically …
TOS.07
AI Does Not Assist Brokers. It Replaces the Function They Perform for Small Groups.
For a small group employer, broker function is a bounded decision tree: assess the census, match characteristics to available products, compare on standardized criteria, recommend …
TOS.08
The Convergence: ICHRA, Level Funded, and the Contributory Platform That Replaces Both
ICHRA and level funded are not stable categories. They are two evolutionary paths converging toward a contributory platform where the employer sets a defined contribution, the …
TOS.09
Below 10 Lives Cannot Be Insured Through Any Group Mechanism
Credibility theory requires approximately 25 to 50 lives for any statistical predictive validity. Below that threshold, group coverage is not a product refinement problem. Products …
TOS.10
Consumer Protection Has Become Consumer Imprisonment
Compliance requirements exist to protect employees. Taken together, they have crossed from protective to restrictive. The apparatus creates barriers to simpler coverage …
TOS.11
The Specialty Drug Pipeline Will Break Small Group Stop Loss Pricing Within Five Years
The specialty drug pipeline of 2024 through 2030 is dozens of therapies simultaneously, each capable of generating claims that exceed small group specific attachment points. Stop …
TOS.12
Health Benefits Are Not Health Insurance: The Case for Non-Insurance Employer Health Investment
A $2,575 average deductible at small firms is 5.7 percent of gross income for a $45,000 worker before insurance activates for non-preventive care. An employer spending $4,500 on …
TOS.C1
The Case for the Current System
The bundle solved a real adverse selection problem that voluntary markets alone cannot solve. Healthy people opt out, sick people stay, the pool sickens, premiums rise. The direct …
TOS.PRE
The Employer's Three Objectives
Three questions no CEO has to be told to ask: does coverage protect the company from financial risk? Does the employee get actual health access? Is the arrangement honest? The …
TOS.SYN
The Direct Compact: What Emerges When the Current Architecture Falls
The direct compact: defined employer contribution by class, employee-assembled coverage from a platform, DPC for primary care, transparent pharmacy pricing, catastrophic protection …