11/15/2013 06:05 pm ET Updated Jan 23, 2014

The Balkanization of Consumers in American Health Care

The latest Gallup Poll finds that more Americans cite health care and costs as the most important problem facing the nation, ahead of the economy and jobs. The proportion of people in the U.S. citing health care as a top problem nearly doubled between September and November 2013 (from 10 percent to 19 percent). Gallup notes that this is the first time since 2007 that non-economic issues topped the #1 and #2 spots in Americans' list of the country's biggest problems.

Might this be the start of people in the U.S. finally flexing their health consumer muscles into a movement?

The news that only 26,000 people successfully enrolled in health plans in October has led Americans to see the utter failure of the Affordable Care Act's (ACA) Health Insurance Marketplaces to launch according to plan. Coupled with the recent and costly government shutdown, we've a collective impression of American government dysfunction.

In 2011, Paul Krugman wrote in the New York Times that patients are not consumers. In fact, the phrase "health care consumer" doesn't sit well with a lot of people. Some opponents to the concept say that no one really wants to "consume" health care. Other detractors point to the reality that there's not a lot of price or product transparency in health care that supports real markets and true consumerism that enable people to shop around for health care. A third camp notes that health care is too complicated a decision making process to allow the naïve and health illiterate American populace too much of a role in health care choices.

In fact, between 2 and 4 million people -- engaged health consumers who want to consume health care in the form of buying health insurance -- received notices that their health insurance companies are cancelling their plans.

This unintended consequence is creating a cadre of willing health care consumers who may generate another scenario of unintended consequence. In what would result in the opposite intent of the Affordable Care Act, this group of highly-engaged health shoppers would buy into the slenderest of health plans, opting to pay cash out-of-pocket directly to a growing number of health providers (themselves, opting out of providing care to the newly-enrolling patient seeking primary care), setting up concierge and direct-pay health care practices.

If this happens, then we would have the further Balkanization of health care access between haves and have nots in a land of continued health service fragmentation. The endgame here: Those who would be "health consumers" would take on that mantle. And those who would not, or could not, would fall further into the net-less safety net.

President Bill Clinton told the website that President Obama should "honor his commitment" and let people keep their health insurance. Just two days after this interview, President Obama has back pedaled, pulling back the requirement for health insurers to upgrade plans to meet ACA requirements. We'll see a lot more health reform tango between the president and his critics -- which number many in his own party.

But it's the wild card of engaged health care consumers, whom Gallup says are putting health care back on the front-burner, who may finally coalesce into a force for meaningful, bottom-up health reform.