Alain Enthoven on fragmented American health care

 Writing in Health Affairs, Alain Enthoven notes that most American workers insured through their jobs work for self-insured employers, i.e. employers who themselves pay for the health care of their covered lives. This means that many of them are relatively small buyers of health insurance, which leads them to deal with fee for service providers, rather than big health maintenance organizations, which might be a better model for a national health care system.

Employer Self-Funded Health Insurance Is Taking Us In The Wrong Direction by Alain C. Enthoven

"The 2020 Kaiser Family Foundation Survey of Employer Health Benefits reports that 67 percent of employed, insured workers are covered under self-insured, or self-funded, arrangements. Under these arrangements, the employer, not an external insurer, directly bears the financial risk for the cost of employee health care.

Self-funded arrangements have grown steadily as a share of the insurance market over the past 15 years and now include many employers with less than 200 employees. While this may be the most cost-effective decision for individual employers under the current regulatory framework, it has the effect of locking in uncoordinated, open-ended fee-for-service (FFS) and locking out comparatively economical Integrated Delivery Systems (IDS)."