Late on Friday, the Administration laid out a series of new details on the contraceptive mandate that has caused such controversy over the past several weeks. And it turns out that the White House determined that they could not enforce the mandate on self-insured plans (plans where individuals pay directly to the organization, which then purchases health care from that pool), which represents a large minority of plans at self-endowed colleges. Therefore, nearly 200,000 out of the 1 million Americans on student plans at their colleges and universities will not be eligible for birth control coverage free of charge under the mandate, though their self-insured college could provide it to them if it so chose.

Many religious institutions, including universities, have complained that the rule requires them to provide a health service that conflicts with their beliefs. For instance, Georgetown University excludes birth control coverage from its student plan. And because that policy is not a self-insured plan, the birth control mandate will soon apply.

That came as welcome news to Sandra Fluke, a law student at the university who has been lambasted by conservative media personalities — and celebrated by women’s health advocates and President Obama — for speaking out against her school’s policy.

However, Fluke expressed concern that schools with self-insured plans will still be able to deny their students contraceptive coverage.

“I’m confident that students . . . on campuses across the country are going to make sure their universities know that they need this coverage,” she said.

Sarah Kliff is told that most self-insured university plans have generous benefit packages anyway. But this brings up a larger point about the Affordable Care Act.

There may well be nothing for the Administration to do on the contraceptive mandate under current law with respect to self-insured plans. But that’s true for self-insured plans generally, a large section of the employer market at giant corporations. None of the federal insurance regulations apply to these plans, and no effort was made in the Affordable Care Act to deal with that. In general, states oversee self-insured plans, with varying degrees of aggressiveness.

This is a major weakness in our fragmented health care system, or actually health care systems, all happening on a parallel track without integration. And those systems are constantly shifting. The employer-based system, for example, is withering before our eyes. In 2001 nearly 70% of Americans got their health insurance from an employer. By 2010 that number fell to 53.5%, and if anything the trend is accelerating. This means a larger insurance exchange or larger Medicaid or a larger segment of uninsured Americans, or perhaps a larger percentage of employer plans in the more stable self-insured sector. This fragmenting necessarily makes health care more expensive in America, without better results. It reduces bargaining power over providers, and it creates a nightmare to try and maintain continuity for those who must shift between the systems due to employment loss or changes in an employer’s carrier or eligibility for new programs.

It’s a problem that the ACA didn’t attempt to solve. It tried to keep all these balls up in the air, using exchanges for the nongroup market, strengthening Medicaid and Medicare, and applying a weak employer mandate. The ACA tried to work with the health care system(s) as it (they) exist. But no sane person would come to the United States and say that the health care system(s) deserves to remain untouched.