Subscribe to our e-updates to stay up to date on issues and trends affecting small business, including the future of health care.

The COSE Health Care Scenario Planning Study evaluated possible scenarios and outcomes regarding the potential "futures" of health care. Review these scenarios and learn how these outcomes could impact your business, family and surrounding community.

Scenario 1 - Where's the traction?
Despite growing evidence that the health care system is under severe pressure, there is no major incentive for any of the 'insider' players to reform the system in significant ways. The power of inertia is profound, and leads to a continued erosion of benefits and functioning of the system.

This is a world in which status quo rules. The drive for significant health care reform becomes stalled. For some, it is the result of the power of incumbent players. With cost increases becoming more tolerable, there is no coalition influential enough to force change - despite the continued efforts of many. Other domestic and international challenges distract policy makers while interesting new health care initiatives are proposed but none gain traction.

The problems that are evident in 2006 do not go away, they continue to worsen, and many keen health care observers watch for an impending crisis that never comes. Businesses continue to provide health coverage as a recruitment tool, but overall coverage erodes. Most see only a series of "band-aid" solutions: increasingly large cost-shifting to those left in the system, while the uninsured are the left as "the government's problem."

"Yeah, right," Gabbie said under her breath as the third speaker in the morning's "Health Care Futures Seminar" prattled on about his views of radical change on the horizon for health care. As a career human resources professional, she had heard it all before. First, with the dawn of managed care. Then with the advent of health savings accounts and tax-based incentives. And since the early '90s every candidate for elected office made some promise or another. But here we are in 2020 - the same place we were before.

Well, maybe that's not fair. Some things have changed - or maybe evolved is the better word. Gabbie remembered being on the campaign trail for her candidate in 2008. There were some great ideas being talked about and she remembered that, for the first time in 20 years, she was excited and hopeful that something could happen. Throughout 2007, observers across the U.S. were convinced that the health care system needed radical changes and that it simply could not continue under the current policies and arrangements. The health care debate was reaching a tipping point as costs remained high, demographics threatened in the medium-term, and the current problem of the uninsured loomed ever-larger.

In response to this fervor, and in the midst of a presidential campaign where health care was the key domestic issue, new coalitions were formed amongst politicians, payers, and corporations. Innovative, tax-based initiatives were proposed to provide social safety nets. The biggest of the health care players suggested and implemented new commercial models for providing care. "At last!" commentators opined, "there was energy from the most important players to make the necessary changes happen!"

But, like in so many other things, once the new administration found its feet, there were a lot of other priorities. And, like in the past with health care, the public was excited about what Gabbie thought were actually just incremental changes to the system. When those small changes actually happened, many believed we were on our way to a reformed system and attention and popular opinion shifted elsewhere. The insiders in the industry and in politics also understood that real change would mean real pain - and maybe not intentionally, both signaled they were not willing to risk the reaction by the public or their shareholders to make the bold changes that were needed.

The same players that called the shots in health care over the last 30 years are still in charge now - and that hasn't been all bad. They do have the knowledge and the incentives and the power to make change that helps the system - such that it is. And, there are pockets of progress being made. In fact, some of the big insurance carriers and big provider networks have gotten together to agree on a lot of the basics for improving information flow and productivity in the backroom - and its probably having some effect since rates aren't going up as fast as in the 2000s.

Of course there were other reasons for that as well. One of the reactions to popular opinion in 2009 was a tightening of regulations on prescription drug companies, including the elimination of the consumer advertising that drove so much utilization in the early part of that decade. Drug rate increases moderated, again slowing the growth of rates of insurance.

Those changes slowed the ambition and perceived need to re-invent health care as people just got used to spending what they did.

But Gabbie saw change in other areas perhaps even a little more unsettling. Bigger discrepancies were developing between the haves and the have-nots in health care. While some individual states made progress in reforming the way care was delivered and insurance was accessed for its own citizens, nationally not much took hold in terms of reform. Outside of California, Massachusetts and Maryland where reform started early, most other states simply took on more burden for their low income residents, but still faced significant increases in the uninsured.

Big companies like Gabbie's were fine. As the uninsured increased and providers sought more business from companies like hers, the value of the health care dollar actually increased for her company. She never thought that as an executive she could be sent someplace exotic for an evaluation or routine procedure, but medical tourism was hot and was becoming more the norm for the basic, high cost procedures that were the bread and butter of the high-end U.S. providers a decade ago. That made her job as an HR executive a lot easier for recruiting top talent. Health care was one of the biggest decision points for recruits because of what was happening in smaller businesses like where her husband, Matt, worked.

Her husband's employer - a small accounting firm - actually followed a trend that many other small businesses adopted, offering a set dollar amount for benefit coverage and encouraging its employees to seek solutions through their spouse or in the individual market.

A lot of those small business employees actually didn't buy any real coverage or maybe just one of the new $10,000 deductible plans that are reserved for super-catastrophic issues. For the most part, they went to the walk-in clinics that were so popular these days. Sort of like the Jiffy-LubesTM of the '90s.

For those with even more limited means, "wellness" and "prevention" played a greater role in health care. It might be all they really could afford. Maybe because the cost forced them to, many people realized that their best health care plan was their own effort to maintain the body they'd been given. And, a lot of new kinds of services had sprung up to support these folks but none of the big players really could leverage the synergy of those services because health care information and tracking remained splintered. As the rate of job turnover increased with a degrading economy, employers and employees alike were left to wade through a morass of incompatible medical record standards and systems.

Gabbie knew that this lack of connectivity in the broader system created missed opportunities for improving the way the system worked. Her own data gave her enough information about the health of her employees and the use of medical services that she could make some great connections between that activity and her costs. But, since there was no big player in information management and spotty progress there in the last 10 years, no one could see across the system to capture those bigger opportunities for the general population. Data was so fragmented that it made it really hard for companies to move from one provider to another and their capabilities were so different that most didn't risk it.

"Hmmm," thought Gabbie, "further keeping those in charge today, in charge tomorrow."

Scenario 2 - Don't just stand there - do something!
In a tricky and volatile economic environment, the pressure on the health care landscape results in a politically irresistible drive that forces the federal government to intervene and guarantee a minimum level of health care for all Americans.

This is a world in which aligned popular demand (suffering from intolerable health care costs) drives powerful players into making quick but far-reaching decisions about health care. The urgency for reform is too pressing to resist, so the U.S. government is called on to develop and enact significant changes to the health care system - especially its financing. A new deal is brokered between politicians, insurance and big business and a variety of new initiatives arise connecting key players.

As employer mandates and price controls become more prevalent, this system gradually evolves into a minimally federally subsidized program. Coverage is ensured for all through a complex, tiered system. As a result, individuals and small businesses are caught up in a rapidly changing, confusing policy and benefits environment. There is constant energy from some to move toward a comprehensive system of universal coverage.

Wendell A. Johnson, Ph.D. - Health Care Czar. His mom would have been proud of her son. Great title, high profile, but a really tough - almost impossible - job. Little did he know in 2006 when he agreed to lead the work on health care policy for the leading presidential candidate, that he would have to live with the ideas that he pulled together. Not that they were bad ideas. They were just big and hard to implement - but mostly just big.

He had the perfect opportunity. All the forces were aligned to drive significant health care reform from 2006 onwards. As the biotech revolution finally gained traction, research & development costs fueled a continued rise in health care costs. At the same time, the number of uninsured also began rapidly increasing due to a softening economy. To those looking further forward, they saw the looming problems of obesity, mental illness and an aging population putting even more strain on a buckling system. Pundits and politicians far and wide began to search for and offer solutions to the current and future crisis. The 2008 presidential campaign confirmed the primacy of health care reform in the domestic political agenda. Something just had to be done!

The real action in 2006 and 2007 was the unveiling of a range of state initiatives aimed at providing universal assurances of coverage to their citizens. While Massachusetts, California, and Pennsylvania may have been the first, as time passed and the benefits were quantified, more and more states put plans in place. But far from satisfying the appetites for reform, these developments only served to increase the demand for a more comprehensive nationwide approach to solving what was becoming a more urgent set of health care problems. Large employers, fearing a relapse of uneven regulation like they experienced in the electric deregulation debacle of the late '90s and early 2000s, were at the forefront of these efforts, as they feared a loss of competitiveness if they had to deal with an uneven patchwork of state regulations.

As the roll-out of state initiatives correlated with an increasing sense of urgency for comprehensive change, opinion polls began to suggest - first tentatively, then overwhelmingly - that the U.S. population wanted the federal government to intervene and act upon the emerging crisis. Though the country did not want the government to be the sole provider of health care services, it did want the government to be the safety net to ensure everyone had coverage of some sort. Facing a range of options to secure coverage for the uninsured and control medical costs, the federal government first proposed the enactment of employer mandates. This ensured that all employees had coverage, and any employer failing to comply was subject to large penalties. That was intended to deal with the most overwhelming problem of the "working uninsured." The business community reacted angrily and in a coalition effort unprecedented within that community, small business effected a change in the rules that required citizens to have health insurance but made employer participation in that process a voluntary action that was incented by tax advantages. Both their active advocacy on the issue and a measurable protraction of small business employment allowed their case to be heard. Wendell hadn't counted on that in his initial ideas about change, but in retrospect the changes that were created had strengthened the system.

The advent of the individual mandate put a greater requirement on the government and the health care providers they regulated to provide better consumer information and quality information to individuals. In the past, employers were often the information intermediary. The new responsibility placed on individuals to select their providers and their plans - public or private - and to deal with the administration of their premiums required a stronger information infrastructure and a more standardized approach to information management.

For individuals, taxes, deductions and benefits were simplified and integrated into a single system of procurement and payments. Built on top of the next generation of credit and financial monitoring applications, individuals could now track and shift their health care benefits across employers, geographies, and benefits programs (vision, dental, medical, HSA, etc.) using a seamless online interface. This was all really great progress, but it was hard keeping it on track and the changes were unlike anything Wendell ever envisioned in a "white paper."

And, information about cost, outcomes and health trends were much more accessible and much more uniform. While the benefits of those changes were still becoming evident, all the academics were sure that strong links between costs, outcomes and variations among players would be very useful in years to come.

"Dr. Johnson, is the system better?" Wendell recalled the question from the Senate Committee on The U.S. Health Works at his recent review of progress made in the last 10 years. He remembered how complicated he thought that answer was.

Everyone now has access to some level of coverage - so that's good. The coverage itself, though basic, allowed everyone to see a doctor and be covered for at least the worst-case issues. Even though people were covered, providers were still frustrated that many who really needed preventative care still insisted on showing up at the ER in crisis.

The vast information systems work was expensive and full of challenges, but the national database of information, trends and outcomes would more than pay for that in reduced system costs in the long term. So that's good as well.

It was the confusion that was bad. Delivering education to hundreds of millions of Americans on a system they had little familiarity with and in lots of cases low exposure to was very difficult. Being able to respond to the inquiries and the need for support was much more expensive and labor intensive than before. And, the emergence of preferred care networks for those that could afford coverage above the national standards was driving a division in the provider network - a two-tiered system - that wasn't anticipated. The term "government doctor" was not being as positively associated as Wendell would like - but the market was responding as markets do.

While there weren't lines at the borders with patients seeking care in other countries the way that the opposition predicted, there was still a complicated set of policy initiatives that had to be dealt with for prioritizing care, treatment protocols and provider capacity. Those discussions were challenging in lots of ways as the government had to begin to figure out how to ration care given the budgeting available for it.

And, the government role in the system had required a reliance on lots of other large partners for implementation. This discouraged the kind of upstart companies and innovative ideas that smaller health care providers offered. Fixing that would be key both to responding to the critics of "big health care" and to bringing some new ideas to the current solutions.

"A little better, Mr. Senator," he had answered, "but we all have a lot more work to do."

Scenario 3 - No news ... good news?
In a relatively stable economic climate, the risks of health care are shifted even more to the individual - which causes many difficulties - but also leads to a proliferation of market-based phenomena(transparency, low-cost innovations, alternative therapies) that helps many end-users bypass a complicated health care system.

This is a world in which evolutionary change happens, with no great fanfare, disasters or radical breakthroughs. The immediate urgency for reform, so prevalent in 2007 and 2008, recedes as health care takes a backseat to other domestic and international political issues. As health care retreats from the headlines, costs become more tolerable.

Driving this shift in cost and severity is the acceptance that consumers take more control of their health and health care. The health care industry, slowly, begins to look increasingly like other industries, where market forces (competition and information) gradually and almost imperceptibly bring change. Providers, employers and consumers learn to adjust gradually to the realities of long-term changes in the health care landscape as alternative health care slowly makes inroads and IT improvements bring benefits over time.

Fatima was nervous, but excited. Being out of her physician practice for 10 years to raise her kids had put her out of the day to day changes in health care that had occurred - other than the interventions that every "Dr. Mom" had to make for her own family.

Back in the mid-2000s after the birth of her second child, it seemed the presidential election would certainly take her industry and her profession in a radically new direction. That hasn't really happened, however, and today's system - while a little better - isn't a lot different from where we were then.

But, sometimes, the most notable stories are the ones you don't hear about. Health care has stayed out of the political limelight in the U.S. in recent years - a remarkable feat, given the levels of attention, numbers of initiatives and proposals for reform that were in play back in 2007. With hindsight, it is clear that the incremental gains of the last decade have been just enough to prevent calls for radical change in the system. Although no single initiative or solution proved to be the silver bullet to the nation's mounting health care pressures, collectively they were able to fulfill the calls for change.

The state-based initiatives, announced sequentially through 2006 and 2007, produced a 'domino effect' of incremental improvements for many health care consumers. Although the different flavors of mandated coverage were not widely adopted, both the public and political goodwill generated by the initiatives reduced the mounting pressure felt by policy makers and allayed the concerns of their constituents. Essentially, the reforms enacted by the states - and a political and economic situation which focused attention elsewhere - 'bought time' for the health care system to benefit from the unglamorous yet vital changes that were happening across various parts of the landscape. Quietly and uneventfully, the health care system was developing the ideas, disciplines, incentives and best practices that would lead to more promising future prospects.

A new administration in 2009 continued to provide funding, support and administrative freedom for the states to implement changes in their own backyards to improve health care. More federal money was made available for health coverage, and those dollars were tied to cooperation and support from the states and providers to participate in and pursue better connection of information systems nationally.

Like Fatima, lots of people began to see action by the federal government to pursue change, but not own it. As the situation improved, the loud voices for massive reform were made less impactful.

While the pressure lessened for massive reform, both the federal government and health care leaders demanded results for their continued investment and they began to see them.

Information systems improved significantly. From a computer screen, Fatima now had the ability to see her patients' records, no matter which hospital or clinic in the region had treated them. There was still work to do across state lines, but systems were on a path of improvement longer term. Technology advances helped, too. Within the insurance arena, advances in biotechnology and genotyping increased the understanding of genetic predisposition to disease. Although the treatment of those pre-disposed to disease grew increasingly complex, the increased knowledge-base, combined with expanding programs dealing with wellness and preventative care, promoted a more efficient distribution of health care resources, which gradually began to reduce costs by the end of the decade.

There were even systems and standards now for Fatima's work as a doctor that benchmarked her performance against others in the hospital and in her specialty among the hospitals and clinics in the information network - no matter what hospital they were aligned with.

That scrutiny not only increased her preparation for returning to practice, but it also resulted in reported reductions in cost and new pay-for-performance guidelines with insurance carriers.

Pay-for-performance programs finally began to live up to their name as physicians and other service providers were strictly graded against market-based metrics of patient satisfaction, efficiency and quality of outcomes. Beyond the obvious favorable impact on outcomes that these standards and incentives created, providers, by and large, were happy to comply for two additional reasons. First, the introduction of new information management systems eliminated much paperwork and allowed them to focus on the practice of medicine. Second, global competition and complete online access meant that they might lose an unhappy patient to someone next door, or on the other side of the globe. Either way, providers had greater incentive to improve their previously moderate performance records.

While things weren't radically different, Fatima felt they were better than the system she had temporarily left some time ago.

The customer was smarter, too. Two of six patients she saw this morning were armed with real questions about what to expect - information they had received from web sites. One had already outlined the providers they wanted to use for lab and X-ray services, and even had some initial ideas about the treatment of his condition. WebMDTM, indeed!

IT integration models were brought to bear on wellness and prevention programs, as new health care inter-mediaries - using models hybridized from the financial services industry - developed new and more efficient ways to manage an individual's personal health care history. In the next generation of IT integration, new applications and standards were developed to facilitate the integration of an individual's personal identity, and official identity in medical, financial and legal records. All manner of health care-related affinity groups sprang up according to consumer preference, activity, demographic, commercial interest, etc.

The long-term investment in information technology had also created a sophisticated set of models to manage an individual's personal health care history. People began to look at their health care history in ways as connected as their financial services portfolio or their legal histories.

This wasn't all good of course. For all the new groups and chat rooms that had popped up on the Internet, there was some bad information and some ill-conceived opportunists out there, but in general, there were more positives to further consumer education and the system for delivering better information more broadly was improving every day.

And, though many more people had access to information about care options and the quality and cost of their care, Fatima still saw as many uninsured people as she did a decade before. No one had stepped in to provide coverage en masse for that group and employers had become even more reluctant to own the uninsured. In fact, many employers had pulled further out of the provision of health care insurance and moved to providing resources for their employees to manage and finance their own care coverage.

Whether Fatima looks at them as competitors or options for her patients, the abundance of walk-in services and the rise of medical clinic chains has been unbelievable. Even Fatima - a doctor herself - had used the services - especially for well child visits, vaccinations and common medical needs that she could do while she was doing other errands around town. While at first it was a little odd, the ease and convenience really suited her. And the information and connectivity with her personal medical record is something that really connects the work of these clinics with her regular primary care physician.

Domestically, cost-shifting and the increasing prevalence of health savings accounts (HSAs) stimulated greater market competition for acute medical care and a gradual stratification of service. For those who could afford it, there was no limit to available luxury health care services. Those for whom luxury was out of reach were serviced by a growing number of large-format retail providers. What became clear was a trend away from large-scale employer-based health care coverage, and toward more customized, individual-based solutions. While employers were still involved in health care coverage, it was mostly to provide incentives for their employees to adopt healthy dietary and exercise habits or administer the benefits employees selected through payroll processes.

These market trends augmented already growing markets in nutriceuticals, alternative medicine and retail clinics. Market forces intensified internationally as well, as generic drugs from abroad increased in quality and availability. At the same time insurance providers around the country began sponsoring medical tourism, and countries off the beaten track were spurred to elevate their level of care to attract wealthier patients from the rest of the world.

As a result of rapid innovations in information management, the supply of health care providers was no longer bottle-necked within traditional providers. For so long, health care was seen as a localized cottage industry populated by large organizations. These advances in technology and a continued 'flattening' of the world, allowed new players and intermediaries to emerge, selling treatments and information-based health services. Financial services companies teamed up with health information providers to offer on-line health insurance and the Health 401(k). More generally, health care had begun, slowly and imperceptibly, to develop into an international industry, with global supply chains, alliances and customer perspectives.

Scenario 4 - New powers, new systems
In a difficult economic environment, individuals, businesses and others find themselves forced to think (and act) radically about health care delivery and financing, as the established players are unable or unwilling to step in and create change.

This is a world in which the magnitude and urgency of the changes required attract large, influential, unconventional players and activities into the system. A gathering critical mass powerfully indicates that the U.S. health care system cannot continue on its present course - costs are intolerable, and the powerful players are seen as part of the reason, not part of the solution.

In the midst of a deteriorating situation, new players and organizations step in to offer a different take on health care and its financing. Surprising new alliances emerge between retailers, insurers and others. Significant changes in practices are used to cut medical costs. Rapid roll-out of health information systems by global players; other leaders - unions, local communities, etc., also rise to the challenge and make change happen.

Dave thought of himself as a "connector" -a new twist on his career spawned by changes in the health care environment that created lots of new players and lots of confusion about how to access and navigate the health care system. He used to be a traditional health insurance broker, but with all the changes that were occurring there was a lot more ground to cover than just helping small businesses and their employees pick a "plan."

To many people, the mass of coalitions, initiatives and sound bites in early 2007 were the beginnings of an 'insider revolution’ in health care in the U.S.. Sprung into action by public opinion, politicians scrambled to be the latest to announce an initiative to solve the deadlock of the system. Large insurance providers looked anew at the landscape and committed themselves to improvement and reform. The urgency of the health care crisis seemed to demand that these established players take immediate action. However, while the politicians, insurance companies and health care providers were certainly not inactive, they were blindsided by the 'outsiders’ who became the real drivers of change across the system.

Things had gotten so bad that everyone was looking for new answers.

In a rousing demonstration of neo-federalism, it was the states who proved to be the public standard-bearers for changing the system. Massachusetts, Pennsylvania and California were the first in a long line of states that placed requirements on businesses to subsidize health care costs. Although the specific regimes differed from region to region, the message was the same - "everybody in." By 2011, articles in Health Affairs reported that uninsured populations in states with reform measures had been reduced significantly, while those states without reforms had remained unchanged or even saw increases in the uninsured. The message was clear - whether you are a Rust-Belt governor or a Lord of Silicon Valley - requiring every employer to play in the health care system was healthy for you and your constituents. Although businesses initially struggled with the conversion to the mandate system, over the long run, many believed efficiency was improved as time and resources were saved across the board for employer and employee alike. As state experiments proceeded with good and bad results, more employers began to opt out of providing benefits directly to their employees. Instead, many opted to pay the required taxes and fees levied on employers and preferred to have employees take responsibility for finding, selecting and purchasing their own health insurance benefits.

With everyone looking for new answers and states experi-menting with new approaches, new market opportunities opened up for entrepreneurs like Dave.

His break had come when he became the options information manager for the new Cleveland Health Space Community. The power of the Internet in health care now was unbelievable. He remembered when the kids were playing with MySpaceTM . Sort of like amateur-hour compared to the way the web is connecting people with information and issues in health care these days. It was clearer than ever before that the information, analysis and opinions on the web today could make or break a health care provider at any level.

And, of course, beyond the web itself, there was the MedSoft Consortium. An outgrowth of a variety of records manage-ment and transparency initiatives of the mid-2000s, MedSoft gathered nearly 100 smaller information management and data collection companies and put them to work to collect commonly required information and standards. Collecting it was just the first part - creating the standards and accessibility of the information was the real breakthrough. X-ray or bypass; cost, mortality or related complications - it was all there - you just needed to show you had some kind of insurance coverage to get access to it. And while not everyone in every state was required to have insurance, the rise of purchasing clubs and new niche insurance products put it within reach of most people in the middle class.

But, the uninsured were still a problem. Maybe even bigger than before. Not so much the voluntarily uninsured. New products and services did a nice job getting to the folks who thought they didn't need coverage with options that focused on catastrophe and marketing that made it seem necessary. It was the working poor who continued to go without coverage. The explosion of providers brought more services directly to employees and allowed employers to feel okay about stepping back a little more. Many began to just offer compensation for insurance coverage and provided a set aside account or additional salary and allowed the employee to make their own decision. Then, if an employee decided health care was unaffordable and weren't among the very poorest in the community being covered by Medicaid or state poverty programs, he or she just went without. But generally, the experts predicted that even those people would have suitable options once things settled a little more.

Employees are now inundated with choices - some good and some bad. Now, employers pay toward health coverage as a competitive tool for recruiting to differentiate their company. Their big contribution today is through hosting employee meetings and service offerings. As things got more confusing, people really turned to their employer for help figuring things out - after all employers had been doing "benefits" for years. Finally, the government realized that although it couldn't mandate employers as payers, it could put a responsibility on them to provide assistance and guidance on personal decisions - much like their responsibilities with 401(k) plans. That opened a whole new kind of market for Dave.

Beyond just providing the required information, lots of employers began "bonusing" health care dollars for employees who worked on their health and lifestyle. If nothing else, the data MedSoft pulled together had helped make the link between healthy lifestyles, worker productivity, attendance and attitudes. And, if individual consumers didn't get it, or the employer hadn't seen the results, Dave pointed it out every chance he got.

With more people on their own to buy in the market, the market developed fast. With data transparency high and more responsible consumers, more providers and people with ideas about how to provide services took the leap to creating new products and services for those consumers. From web-based and local community consortium-based buying pools for diabetes supplies, to group purchased diagnostic services or interest oriented nutrition clubs, the competitive nature of providers looking to help consumers spend their health care dollars boomed. The health care provider landscape was also a picture of innovation and turbulence, as the nation's largest retailers - through outfits like RediClinic and QuickClinic - proved that remedial and acute care was a scalable commercial model. Whereas outpatient and community clinics continued to introduce new forms of coverage and treatment innovation, the large hospital systems continued to be plagued by over-bedding, waste and errors. In effect, the large health care providers took far too long to realize that patients demanded either highly personalized care, assembly-line efficiency or both - and nothing less.

By 2015, all but the most complex procedures could be performed at outpatient clinics, health monitoring was conducted within your chosen social affinity group, and the explosion of state-based health initiatives drove the market to make health care records far more portable and accessible.

In fact, many compared it to the Gold Rush of the mid-1800s. There were a lot of "health care towns" out there with very few "sheriffs". The government regulators struggled to keep up with all the new stuff out there - but with all the activity, a combination of the associations, employers, social web sites and guys like Dave continued to be an important resource for identifying and exposing the "bad actors."

While some parts of big picture health care were still relatively expensive, a safety net of affordable coverage driven by an active market made things more competitive, prices more stable and the variations in cost among providers almost commoditized for basic services. Of course, there were the luxury doctors and the medical tourism industry. There was definitely a place for those who wanted to spend big in health care. But that's the beauty of the long list of providers out there today - something for everyone. And, as long as the marketplace boasted lots of providers and lots of information, there would be lots of demand for Dave and his work to help average folks sort it all out!