vances in genetic technologies for identifying individual risk for various diseases is making information available that could be used by insurers or employers to limit coverage for an ever-larger proportion of the population.

Dispersed Power and Accountability

It is in the nature of both voluntarism (as a mechanism for decisionmaking) and federalism (as a form of government) to disperse power, although the degree and nature of this dispersion can be quite variable. For example, the current structure of voluntarism in the health sector concentrates a great deal of discretion with the employer. It also leaves employers free to require employees to select insurance or show evidence of another source of coverage, and many employers do so in order to discourage adverse selection in the organization's health benefit program. Although the structure may not give as much discretion to the employee as to the employer, the employer may be in a better position than the individual to use its purchasing power to secure better prices, services, and disclosure of information from health plans. At their best, employers are available—and have a direct financial incentive—to act as ombudsmen for their employees and to support them in making informed decisions and resolving problems. Such assistance is less readily available to those with Medicare, Medicaid, or individually purchased private insurance.

On the other hand, with power dispersed to organizations of vastly different sizes and resources, large purchasers have had much more leverage than small employers to negotiate with health care providers for discounts and other favorable payment arrangements. One consequence of this heterogeneity is a considerable amount of cost shifting, which occurs when providers are able to offset discounts or other reduced payments from some purchasers by increasing charges for smaller, weaker, less aware, or less concerned purchasers.

Among governments, the power to regulate employee benefits is no longer delegated to the states but reserved for the federal government through ERISA. Because the federal government has, in practice, chosen to leave many important aspects of employee health benefits unregulated, the power to provide, negotiate, and restrict such benefits devolves to thousands of self-insured employers of widely differing competence, outlook, and accountability.


Virtually every employer's program of health benefits differs from every other employer's program in some aspect (e.g., who is eligible for coverage, through what kinds of health plans, for which kinds of services, with

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