I took a nice long bicycle ride around the District of Columbia this past week. A bicycle tour of the massive monuments around the Washington Mall is an exciting ride that harkens you back to high school civics, but in a fun way. These monuments are as much about what we believe are our finest ideals as they are about the humans they memorialize. It was uplifting as I made my way around Presidents Washington, Jefferson, and Lincoln.

I was jolted back into thoughts of the present as I rode around the White House, Capitol Building, and the Supreme Court. The expected Supreme Court ruling on the Affordable Care Act (ACA) on June 28, 2012, will create a storm of activity in all these buildings. The New York Times on June 24, 2012, contained a front-page story that suggests that overconfidence by Democrats led them to underestimate the potential for a successful attack on the ACA. The story speculates about the political and legal miscalculations that might have occurred and the ramifications of these missteps. In a town like Washington, this is the story. Political power is the coin of this realm.

Just one thing -- while the legal and political drama over the ACA (and healthcare reform) has played out over the last three years, something else has been going on. The editors at the New York Times probably feel that their lead story on June 24th about the potential for embarrassment of President Obama and the Democratic Congressional leadership was important because of the election year fall out.

But I suspect that a story in the June 23, 2012, edition of the Washington Post is a much more important story. The Post story is headlined "Inova, Aetna becoming allies in healthcare plan." The Inova/Aetna venture is another in a series of arrangements between payors and providers that have been going on all over the country while the political and legal dance over healthcare reform has played out. Last November, I wrote in detail about some of these transactions in a prior article entitled "Who is Driving the Train?".

In the grand scheme of things, the Post's story is of greater importance to our country and its healthcare system than the political game of who wins elections. It is a vignette about the control of our healthcare system as a whole. Payors that have the funds, proprietary information about providers-and the momentum-are assimilating the physicians and other providers under their respective tents. This is being accomplished through multiple means as outlined in my prior discussion.

Politicians often do not have the political will to make the kinds of hard and, in some instances, hard-hearted decisions that are necessary to parcel out our limited healthcare resources. Before we congratulate the health insurance industry too quickly about seizing the initiative, we should examine what this all may mean.

The rapid consolidation of the healthcare industry has far ranging implications. The health insurance industry is working to remove itself from the risk in the system while at the same time integrating itself further into the service delivery side of the healthcare equation. It does not take a seer to understand that these large payors will gain a substantial healthcare market position as they consolidate the critical players under ever-increasing spheres of influence.

Is it an unreasonable question to ask whether the next step is a single payor system? What if that system is one in which the payors take no risk of loss, receive fees from the government to supply, and manage their networks of healthcare facilities and physicians? What if only the facilities and physicians are at risk for losses on care delivery? Does such a result give the politicians the ability to ration care without taking the heat for the actions of the payors?

The politicized nature of the healthcare reform debate suggests that government will never be able to work out a system to assure an equitable and cost-effective healthcare system. However, please pardon my concerns about a healthcare system administered by large payors who have limited skin in the game. I am hopeful that I have heard the last of "too big to fail" during my lifetime. The massive consolidation now underway places too much control in the hands of the very payors who have been the target of complaints by patients, facilities, and physicians about unfair practices.

They say that history is written by the victors. It makes me wonder if in the future that someone like me may be making a ride around the National Mall one fine day looking at new monuments that have been dedicated to the Presidents, not of the United States, but of a few large healthcare payors.

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