The Audacity of Greed: Profiteering in American Medicine

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With the advancements in medical science and technology, why do Americans still suffer the brunt of an ineffective health care system? The patient is not the priority in today's medical world. The Doctor is not heeding the Hippocratic Oath --- but instead is motivated by money. Medical profiteering has driven medical costs to unsustainable levels while eroding the quality of care.

Russell Andrews' book Too Big to Succeed: Profiteering in American Medicine   provides an interesting analysy of this trend. He reveals the rotten core of health care system hidden from outsiders. Discover why health care costs are increasing while medical benefits are dwindling.

Problems arise when there is a mismatch between reality and our perception of reality. In the scientific world, there are paradigms that guide the pursuit of knowledge. Experiments are constructed based on rules (guidelines based on prior experiences) to further support or disprove those paradigms. Based on how ingrained a paradigm is (“Is it based on fact or on ideology?”), changing the paradigm can be very difficult. Examples of paradigm shifts from the scientific world include the shift from “the earth is flat” to “the earth is round” and the shift from “the earth is the center of the solar system” to “the sun is the center of the solar system.” People have paid dearly for their correct but unpopular point of view (e.g., Galileo was placed under house arrest for insisting that the sun, not the earth, was the center of the solar system). Scientific paradigms may not shift easily, as documented by Thomas Kuhn in The Structure of Scientific Revolutions.1

Similar problems arise in the socioeconomic world when there is a mismatch between reality and our perception of reality. Here there is not only ideology that may hinder acceptance of the mismatch, but also one’s perception of his or her own personal economic benefit. In the game of life, societal good rarely trumps personal gain (or, perhaps more accurately, one’s perception of personal gain). This appears The current health-care system in the United States has a significant mismatch between the reality of the health care provided to the populace as a whole and the perception of that reality—at least the perception in the minds of many people in this country.

Though we spend 50% more on health care per capita than other developed countries, a multitude of measures—such as life expectancy and infant mortality—indicate that we in the United States are not getting health-care value for our money. Yet many argue, often with religious fervor, against change in our health-care system. One must have “choice” (more accurately, perceived choice rather than actual choice) not “socialized medicine” (whatever “socialized medicine” means) at all costs—even if adequate health care becomes a dream for the majority of Americans because of the phenomenal personal expense. When an industiy constitutes upward of one-fifth

Medicine today in the United States is big business. To see how far it has deviated from its origins in the Western tradition, we do well to consider the Hippocratic Oath:

Understand how we can change the trend in doctor-patient relationships all over the country, where individuals can start to realize that great emphasis should be placed on “the healing art and science of medicine,” instead of on the profitability of the health care delivery system.

We need to learn how the profit has trumped the patient in American medicine, and fight back.  Profit is now the most imporant agent of change for real health care in America, which corrupts the whole system. We need to know the typical pitfalls and fight against them. In the US medical system the patient life is often depends on how well he/she understand the ropes. Yes, your life depends on it! It is very early to gat expensive and unnecessary surgery in the USA those days. Which can be deadly. The number of  cardiologists sentenced to jail in the USA is in dozens. And they are just the tip of the iceberg. Cardiatic stents are probably the most glaring example. But other "lucrative" areas, in such field as gastroenterology exists too.  Another huge area is pharmacology abuse ("big-pharma" corrupting influence).

Dave Zweifel, The Capital Times (Madison, WI)

Here's another one to remember when someone tells you that our "private" health care system works: The Wall Street Journal ran a front-page story last week with the headline that said it all: "As Patients, Doctors Feel Pinch, Insurer's CEO Makes a Billion." The story, datelined Minnetonka, Minn., was about William McGuire, a doctor who stopped practicing in 1986 to take a management job with UnitedHealth Group Inc., one of the largest HMOs in the country.

He's now the chief executive officer of the corporation, makes $8 million a year in salary plus bonus, has personal use of the company's private jet and has amassed what the Journal describes as "one of the largest stock options fortunes of all time." According to the newspaper, those options total $1.6 billion.

"Even celebrated CEOs such as General Electric Co.'s Jack Welch or International Business Machines Corp.'s Louis Gerstner never were granted so much during their time at the top," the WSJ story said.

But the gist of the story is that while McGuire and other UnitedHealth execs are raking in millions, their company is putting the squeeze on everyone else.

"Dr. McGuire's story shows how an elite group of companies is getting rich from the nation's fraying health care system," the bible of the business world reported. "Many of them aren't discovering drugs or treating patients. They're middlemen who process the paperwork, fill the pill bottles and otherwise connect the pieces of a $2 trillion industry."

The newspaper's research shows that UnitedHealth has particularly benefited in recent years as health care inflation eased somewhat.

Insurers still raised premiums at double-digit rates. At UnitedHealth, for example, its stock price tripled from January of 2003 to January of this year and its net income rose to $3.3 billion. Hence, the nice board-of-director-approved windfall for McGuire. (Interestingly, former UW-Madison Chancellor Donna Shalala is a member of UnitedHealth's board.)

"In Minnesota, such riches have infuriated some people," the story continued. "Joel Albers, a Minneapolis pharmacist, regularly impersonates Dr. McGuire at state fairs, donning a tuxedo, holding up an enlarged picture of Dr. McGuire on a stick and handing out leaflets denouncing corporate greed."

Of course, this is just one more anecdote that serves to describe our broken health care system, which leaves more than 40 million Americans without coverage and an embarrassment of riches for those who know how to milk that system.

On one hand we have Medicare, which provides universal single-payer coverage to all Americans over age 65 at about a 2 percent administrative cost. On the other hand we have a hodge-podge of plans with layer after administrative layer that gobbles up close to 20 percent in overhead costs (Dr. McGuire's just a piece of that) and leaves millions out in the cold.

How hard can it be to choose in which direction we need to go?

Dave Zweifel is editor of The Capital Times. E-mail: dzweifel@madison.com

Copyright 2006 The Capital Times

Source: The Capital Times (Madison, WI)
http://www.madison.com/tct/opinion/column/index.php?ntid=81491&ntpid=0

 

November 13, 2003 Home Doug Dowd Economic Historian by Doug Dowd

The HMOs and their managed care systems -- first supported in the Nixon years -- ballooned from a headache to a plague beginning about ten years ago. Their pitch was that they would end the inefficiencies of the past.  However, the period in which they have come to dominate the health care system is precisely that in which its costs -- and its inefficiency (unless you count mountains of paperwork something other than waste -- began the acceleration that continues.

Some of the rising costs were due to factors other than the HMOs, not least the gouging prices set by the pharmaceutical giants. OK, but all of them are part and parcel of the "for-profit health care system." Nonetheless, the HMOs have done at least their share in bringing about today's mountainous costs.

What started out as annual one-digit overall cost increases became two-digit as the 1980s ended, rising to 15.3 percent for 2002. Not good enough: In mid-2002 the NYT reported that "Health maintenance organizations are demanding rate increases of 22 percent in their ongoing negotiations with employers for 2003... which will be passed on to consumers." They were "passed on," and they continue to be.

As the tendency of always higher costs and prices continues, it needs repeating that the provision of health care to the average person has decreased both quantitatively and qualitatively. What's good for their profits is bad for our health.

What is it about the HMOs that such is the case? What was the system they presumed to replace with great savings to all, and profits to them as a reward? It was called the "fee-for-service" system: Other than those covered by Medicare and Medicaid, health insurance for those who had it was selected and paid by one's employer, which used to be so for about two-thirds of workers.

As the numbers of insured rose from the 1950s on, so did doctors' incomes: the insured could choose their own doctors and the doctors soon realized that the more treatments they gave the better off they -- but not necessarily their patients -- were. As Ellen Frank pointed out two years ago, "American doctors performed invasive tests and procedures at rates far exceeding international norms....Caesarean sections, surgerized ulcers, hysterectomies and tonsillectomies far above the rates in other countries, etc." (Dollars & Sense, 5/6, 2001)

Adding to that, past and present, is the friendly corruption between doctors and labs and drug companies. The pleasant consequence for doctors from 1960 to 1990 was that their incomes rose two to three times faster than the nation's, bringing them up to a lovely $200,000 annual average. So that's what the Hippocratic Oath was about!

One might think that such an evolution -- or, better, devolution -- would have led everyone but the doctors and labs and drug companies to open their minds to a national health service/single-payer system. But that overlooks certain large facts:

1) Employers as a whole tend to have a knee-jerk negative reaction against anything do with government (unless it is in the nature of a subsidy), and just as "instinctive" a response in favor of "private enterprise," which is what HMOs are;

2) the average citizen lives in the same society, and has been taught to think in much the same way, if not for the same reasons;

3) the major insurance companies have always been opposed to any form of social insurance -- beginning with their adamant fight against social security from 1935 to the present; and

4) this created a new industry for thousands of lobbyists. They have been very successful indeed in their efforts on behalf of the "Big Five" insurance companies (Aetna, Cigna, Metropolitan, Prudential and Travelers) and related managed care companies -- which, taken together, now "cover" 90+ percent of those receiving care. Here a lucid and crisp summary review of what brought us to our present state, and how it happened (as related by Ellen Frank):

The early 1990s saw a wave of mergers and acquisitions among health insurers that left large regions of the country with only two or three competing health plans. Their superior bargaining power allowed insurers to negotiate sharp reductions in fees, which were passed on to employers in the form of lower premiums. In 1994 the average health-insurance premium /paid by employers/ fell for the first time in years; premiums increased at or below the inflation rate for the rest of the 1990s.

Hospitals, facing lower reimbursement rates, cut staff and beds for traditional inpatient care while expanding facilities for expensive services like outpatient surgery. Still, hospitals throughout the country suffered operating losses. Large urban hospitals in low-income areas were especially hard-hit.../some like that of Los Angeles, closing entirely/. For-profit hospital chains moved in quickly, buying up scores of non-profit community hospitals.

So, with patients and providers (doctors, labs, and hospitals) getting the dirty end of the stick, that leaves the HMOs, drug companies, and top insurance companies getting the sweet end -- their owners, their CEOs and their countless lobbyists, that is.

Business being business, another rising tendency is that of HMOs dropping Medicare patients, more than 2.5 million 1998 to the present. Plus, "Medicare patients can expect 'major changes -- that is, reductions of -- benefits, even if they are still enrolled: cutbacks in drug coverage /already cruelly inadequate/, and increases in premiums and co-payments." (ibid.)

So there we are. Or are we? Although there is a rising tide of anger, frustration, and worry among our people at the costs of medical care in the USA, with some emerging movement toward universal coverage, most still see the U.S. system, though costly, as the best.

The best is none too good: "According to a recent study of the Institute of Medicine, medical errors in hospitals kill up to 98,000 patients yearly, while injuring perhaps a million more." (Washington Post, Editorial, "America's medical scandal," 12-10-02). Such deaths and injuries are called "iatrogenic"; that is, caused by the docs themselves.

That was a few years ago. Now, as the USA's entire health care system becomes always more privatized and always more expensive to those needing it, those years are coming to look like paradise lost; and we ain't seen nothin' yet.


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[Mar 23, 2017] A "good start" at the expence of sick people for Collectly a new medical debt collection startuo -- they now collect twise larger share of debt then before. The founder is a former CEO of a debt collection agency and collected over $100 million before

Notable quotes:
"... our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime! ..."
Mar 23, 2017 | www.nakedcapitalism.com

"All 51 startups that debuted at Y Combinator W17 Demo Day 2" [ TechCrunch ] ( day one ). This is a good one:

Collectly helps doctors collect 2x's more debt than they have before. It's a business with $280 billion sent to debt but the debt collectors only collect on average up to 20%. The founder is a former CEO of a debt collection agency and collected over $100 million before

The acerbic Pinboard comments:
D Pinboard * Follow

@Pinboard

YC so far: surreptitious recording of phone calls, bus tickets for
the starving, debt collection, go live in a box, cow collars,
chatbots

11:41 PM-21 Mar 2017

He's not wrong. (And any time you encounter an online company with a cute name that's also an adverb, like collectly , run a mile, because it's a startup that wants to harm you. Kidding! I think .)

cocomaan , March 22, 2017 at 4:03 pm

Collectly is some really depressing stuff. Wow. More from their website.

3. Transparent collection
Our intelligent software automatically reaches out to customers that didn't pay in time, so you will never need to manually chase them again. And you can see every action on every case.

Totaly fair.

Totaly fair? I had to read it twice. Is that a typo? Or does it mean something?

Next up: our intelligent algorithm using state of the art innovative techniques of automation innovation disruption innovation disruption automatically sends orders to police and judges to prepare and serve pay or stay warrants, making sure your debtor goes to jail for their crime!

Edit: Weird, this went in the wrong place. Oh well.

[Mar 23, 2017] The difference between Obamacare and AHCA is 24 million uninsured people while the difference between single-payer and Obamacare is 28 million uninsured people

Mar 23, 2017 | economistsview.typepad.com
Peter K. : Reply Thursday, March 23, 2017 at 05:54 AM , March 23, 2017 at 05:54 AM
Reminds me of PGL, EMichael, "Anachronism" etc.

https://lbo-news.com/2017/03/22/never-demand/

Never Demand
by Doug Henwood
March 22, 2017

Matt Bruenig already wrote* about this (now deleted) tweet from Paul Waldman, which was a response to one from Bernie Sanders

Paul Waldman: Like saying "Never lose sight of the fact that our goal is to remodel the kitchen" when there are arsonists pouring gasoline on your porch."

Bernie Sanders: "Never lose sight of the fact that our ultimate goal is not just playing defense. Our goal is a Medicare-for-all, single payer system."

and before typing any more, I must confess to feeling guilty about writing a second blog post (god knows there are probably more) about a tweet. But, onwards.

As Bruenig writes, "The difference between Obamacare and AHCA is 24 million uninsured people while the difference between single-payer and Obamacare is 28 million uninsured people." Obamacare, with all its omissions and cost-shifting, isn't innocent of monstrousness.

There's a point about political strategy here worth drawing out here. Waldman, who self-identifies as "Washington Post blogger. Columnist for The Week. Senior Writer at the American Prospect.," was on the Cabalist, a secret listserv for liberal pundits which I strangely spent two or three years on. (I assume he still is, though I can't know now that I'm off the thing.) I was invited on, I suppose, for ideological diversity, but left as what most members probably saw as an annoying provocateur.

Waldman's tweet reflects a consensus on the list that one must never make demands or express ambitious political goals in the way Sanders' tweet does. All we can do it defend what we have, because the right holds all the cards. I never could convince them that this was a doomed strategy-that, principle aside, if you don't make big demands you can't win even small victories, or that without radicals pushing things in threatening ways their wimpy appeals to compromise will have no audience. To your modal Cabalister, to push for single-payer would be to "relitigate" (a favorite word of theirs, reflecting I suspect their preference for litigation over actual politics) Obamacare, and so expose it to repeal. That was their line a couple of years ago, when no one could have imagined President Trump. Now that it is under the threat of repeal, it's more urgent than ever to assume a defensive crouch.

You can see this sort of thinking behind the Democrats' responses to Trump. They're still stuck in the Hillary mode of treating him as an anomaly, something different from a "normal" Republican. They obsess about his alleged Russia ties, but offer nothing as a serious alternative to the Trump (or Ryan) agenda.

Obamacare has never been so popular now that it may go away. Millions of people have gotten something good out of it, as flawed as it is. Imagine how popular a program that offered everyone full coverage would be.

* https://medium.com/@MattBruenig/opponents-of-single-payer-are-moral-monsters-on-par-with-ahca-proponents-c6c152b18bd5#.2f52xubwb

JohnH -> Peter K.... , March 23, 2017 at 07:35 AM
Democrats play defense so much that occasionally they score on goals..handing victories to opponents because they could no effective offense of their own.

Imagine where Democrats could be if they deigned to talk to workers, actively pushed for higher minimum wages, and crafted a coherent economic message that spoke to "people who work hard and play by the rules."

Not going to happen: the corrupt, sclerotic Democratic leadership has grown comfy playing Washington General to Republicans' Harlem Globetrotter. They even refuse to sack a leadership who has lost most everything between the coasts.

Fortunately for them, we live in a duopoly, so there is always a place for the losing team.

RC AKA Darryl, Ron said in reply to JohnH... , March 23, 2017 at 08:19 AM
Yep.
im1dc -> JohnH... , March 23, 2017 at 08:57 AM
Dittos, and S. Sanders proved it last year. Why it is taking the current DEM leadership so long to put the lesson learned into action is beyond me and it angers me too.
RC AKA Darryl, Ron said in reply to Peter K.... , March 23, 2017 at 08:18 AM
Excellent article.
T : , March 23, 2017 at 06:12 AM
When the history is written, the Clinton Administration (and the Brad DeLongs in it) will be remembered for 4 things:

1) a massive increase in inequality carrying on the tradition began by Reagan;

2) incarcerating a large and increasing share of the black male population causing unfathomable damage to the black community;

3) passing a welfare reform package that was both cruel and unproductive to the least fortunate in our society;

4) negotiating and cheer-leading a Chinese trade deal that led to the loss of at least three million manufacturing jobs, primarily in the Midwest, and the destruction of community after community. And laying the seeds for those Democratic states to turn Republican.

Meanwhile Brad continues to let his "neoliberal freak flag fly."

painer -> T... , March 23, 2017 at 06:24 AM
Liberal consciences

Attend to this indictment

Peter K. -> T... , March 23, 2017 at 06:26 AM
So true. Also on macro policy he bent the knee to Greenspan/The Fed/the bond market, dumping his fiscal expansion campaign promise in exchange for deficit reduction.

Democrats have become all about deficit reduction and "the era of big government is over."

It is interesting to listen to David Beckworth's interview with Jason Furman who expresses the conventional thinking of Democrats.

Fiscal expansion is now good and desired within the context of the Zero Lower Bound and how unconventional monetary policy supposedly doesn't work.

But still they are okay with the Fed being paranoid about inflation, another legacy of the Clinton era.

Clinton did deliver a brief moment of a high-powered economy at the end of the 90s as Greenspan held off on raising rates.

But he also gave us the dot.com bubble with a push for deregulation, exemplified by repealing Glass-Steagall on behalf of the financial sector, the same people who would give us an epic financial crisis.

And Clinton was never big on union/organizing rights or anti-trust. He signed the Defense of Marriage Act etc etc etc.

But hey he was better than Republicans!

[Mar 23, 2017] Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Notable quotes:
"... Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. " ..."
Mar 23, 2017 | www.nakedcapitalism.com
djrichard , March 22, 2017 at 5:35 pm

Just a bit of a thought experiment, building on some thinking from a comment yesterday by jefemt

Paradoxically, we appear to be seeing a coalescence and consolidation of insurers, we will end up being delightfully exceptional, again- effectively being single-payer, private sector, paying a monopoly an add-on cost of 35-40% to a parasitic industry whose executives and employees do not contribute to the CARE equation.

Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE.

Conceivably, it wouldn't even have to live off appropriations from congress, assuming it was equally as extractive from the private sector as it is now (i.e. revenue model is the same). Talk about good living. Who knows, maybe they pocket their proceeds into some kind of surplus in Treasury dept.

But let's assume they had to give up on revenue models. [Afterall, it's easier to find partners in congress when you have an appropriations process that binds you to them.] Then they would be exposed. Somebody would get the bright idea that this agency doesn't need as much staffing since they are no longer revenue oriented. That indeed, they could have the same staffing profile as the agency responsible for medicare. Indeed they could be folded into medicare.

I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. "

Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.]

In contrast to other parts of the deep state that don't really have a revenue model. In which case, those parts need to be insourced by the Fed Gov.

human , March 22, 2017 at 7:46 pm

The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels.

Ernesto Lyon , March 23, 2017 at 12:09 am

Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface.

Guess who the Feds sent to get a handle on the cocaine smuggling?

See-eye-aye man George H.W. Bush. Coincidence?

[Mar 22, 2017] Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now? Because that is the genes of neoliberalism. A wolf cant stop hunting. This is a predatory ideology

Notable quotes:
"... Obamacare, President Donald Trump is fond of saying, is a "complete and total disaster" and must be replaced. Yet one of the most significant features of his party's proposed replacement has little to do with Obamacare. ..."
"... True, expanded eligibility for Medicaid is an important part of Obamacare. And the AHCA would reverse this expansion. But its much bigger change is to the Medicaid program as it existed long before Obamacare. Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now? ..."
"... Whatever the reason, it's a step in the wrong direction. Those who lose Medicaid coverage would still need care, and their fellow Americans would still have to pick up the tab. ..."
"... As things stand now with Medicaid, states pay doctors for providing care to enrollees, and the federal government reimburses the states up to 75 percent of that cost. When a state spends more than usual -- in the event of a hurricane or an opioid epidemic, for example -- the federal share keeps up. ..."
Mar 22, 2017 | economistsview.typepad.com
Anachronism : March 22, 2017 at 10:55 AM
https://www.bloomberg.com/view/articles/2017-03-22/republicans-want-to-repeal-medicaid-too

Republicans Want to Repeal Medicaid, Too

Obamacare, President Donald Trump is fond of saying, is a "complete and total disaster" and must be replaced. Yet one of the most significant features of his party's proposed replacement has little to do with Obamacare.

The American Health Care Act would drastically reshape Medicaid -- ending the federal government's long-running, open-ended commitment to help states pay for care for the poor. Instead, in 2020, Washington would make limited per capita contributions that would shrink as a share of costs with every passing year.

True, expanded eligibility for Medicaid is an important part of Obamacare. And the AHCA would reverse this expansion. But its much bigger change is to the Medicaid program as it existed long before Obamacare. Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now?

Part of the rationale is that the changes to Medicaid would save $880 billion over 10 years, allowing Congress to make further tax cuts later this year. (Trump telegraphed the strategy in a speech to supporters Monday.) At the same time, many Republicans have long disliked the program's open-ended promise of federal money.

Whatever the reason, it's a step in the wrong direction. Those who lose Medicaid coverage would still need care, and their fellow Americans would still have to pick up the tab.

As things stand now with Medicaid, states pay doctors for providing care to enrollees, and the federal government reimburses the states up to 75 percent of that cost. When a state spends more than usual -- in the event of a hurricane or an opioid epidemic, for example -- the federal share keeps up.

Under the AHCA, each state would instead be given a capped allowance, and that amount would rise each year with medical inflation. It would not account for any unforeseen expenses. Over time, as the rise in per-patient costs outstripped the rise in general medical inflation -- as the Congressional Budget Office assumes they will -- the federal share of funding would decline. Hundreds of billions in costs would be shifted from the federal government to the states. In response, states would need to either raise their own spending on Medicaid -- or more likely, offer fewer services to fewer people.

It is this last possibility that is most disturbing. Medicaid has been required to cover some groups of people -- mothers and children living in poverty, for example -- but not all. One of the consequences of the AHCA would be to discontinue coverage to many who just recently gained coverage under the expansion funded by Obamacare. If a state took the option, now included in the AHCA, to accept a Medicaid block grant rather than a per-capita allotment, it could set its own eligibility standards.

Sending large groups of people back to the private insurance market in a post-Obamacare world, with its increasingly unaffordable premiums and increasingly expensive out-of-pocket costs, would be not only inefficient but also unjust.

libezkova -> Anachronism ... , March 22, 2017 at 05:09 PM
"Medicaid is a popular and relatively efficient insurance program that has provided health care and peace of mind for millions of Americans for more than half a century. Why start taking it apart now?"

Because that is the genes of neoliberalism. A wolf can't stop hunting. This is a predatory ideology. And that creates the seeds of it own demise, despite being pretty resilient after 2008 crash.

[Mar 22, 2017] The Men Who Stole the World

Notable quotes:
"... History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century. ..."
"... Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit. ..."
Mar 22, 2017 | jessescrossroadscafe.blogspot.com
"The problem of the last three decades is not the 'vicissitudes of the marketplace,' but rather deliberate actions by the government to redistribute income from the rest of us to the one percent. This pattern of government action shows up in all areas of government policy."

Dean Baker

"When the modern corporation acquires power over markets, power in the community, power over the state and power over belief, it is a political instrument, different in degree but not in kind from the state itself. To hold otherwise - to deny the political character of the modern corporation - is not merely to avoid the reality.

It is to disguise the reality. The victims of that disguise are those we instruct in error."

John Kenneth Galbraith

And unfortunately the working class victims of that disguise are going to be receiving the consequences of their folly, and then some.

Secure in their monopolies and key positions with regard to reform and the law, the corporations are further acquiring access to the protections of the rights of individuals as well, it appears, at least according to Citizens United .

Maybe our leaders and their self-proclaimed technocrats will finally do the right thing. I personally doubt it, except that if they do it will probably be by accident.

More likely, the right thing will eventually come about the old-fashioned way- under the duress of a crisis, and the growing protests of the much neglected and long suffering.

History will look back at us with the same wonder that we look back on the mad excesses of certain nations founded in devotion to extreme, almost other-worldly, ideologies of the last century.

... ... ...

Apparently the slashing of health benefits for the unfortunate is not severe enough in the proposed Trump/Ryan plan. Our GOP house neo-liberals are enthusiastic to unleash the wonders of the cure-all deregulated market on the American public, again. Like a dog returns to its vomit.

Better if they start breaking up corporate health monopolies and embrace real reform at the sources of the soaring costs. The US pays far, far too much for drugs and healthcare, and deregulating the markets is not the solution. We do have the example of the rest of the developed world for what to do about this. It is called 'single payer.'

But players keep on playing. And politicians and their enablers in the professions will not see what their big money donors do not wish them to see. And that is one of their few bipartisan efforts.

Might one suggest that our political animals stop trying to do all the reforming and cost controls bottom up, while applying the stimulus top down? That approach they have been flogging to no avail for about thirty years is a recipe for a dying middle class.

Here is a short video from the Bernie Sanders WV town hall that shows The Face of American Desperation. By the way, the governor of West Virginia is a Democrat. He wasn't there.

...

[Mar 21, 2017] Trump healthcare plan means less in income taxes on the rich and more in sales taxes for the rest of us

Mar 21, 2017 | economistsview.typepad.com
Peter K. -> pgl... March 20, 2017 at 06:37 AM , 2017 at 06:37 AM
"It means less in income taxes on the rich and more in sales taxes for the rest of us."

Nah glibertarians are against the sales tax because they see how it has increased in Europe and led to bigger government. That's why they're opposing Paul Ryan's tax reform which includes progressive wage subsidies.

pgl -> Peter K.... , March 20, 2017 at 09:45 AM
You must not get Paul Ryan. He wants a smaller government paid for exclusively by sales taxes. His agenda is to eliminate all taxes on capital income. FYI - Europe still has rather high profits taxes. Ryan's latest would end that for the US.
ken melvin -> anne... , -1
Congress critters from red states are demanding that people must have a job bin order to qualify for medicaid. In red states, most jobs don't pay enough to afford health care.

Explained to an environmental class the other day how it was that before EPA people knowingly (and unknowingly) took hazardous jobs in order to make a living -- a trade off. This is where these guys are headed.

Peter K. -> anne... , March 20, 2017 at 09:01 AM
http://cepr.net/blogs/beat-the-press/paul-krugman-and-the-republican-corporate-income-tax-proposal

Paul Krugman and the Republican Corporate Income Tax Proposal

by Dean Baker

Published: 28 January 2017

The current corporate income tax is a massive cesspool. There are so many routes for avoidance that it is almost becoming voluntary. This matters not only because we don't get the revenue we should from the tax, but also because it has created a massive tax avoidance industry.

The tax avoidance industry is a big deal. This is an industry that contributes nothing to the economy. It involves people designing clever tricks to allow corporations to avoid paying their share of taxes.

The tax avoidance industry is also an important source of inequality since it is possible to get very rich designing clever ways to avoid taxes. My colleague Eileen Appelbaum (along with Rose Batt) show how the private equity industry is largely a tax avoidance industry in their recent book Private Equity at Work. Many of the very richest people in the country got their wealth as private equity fund partners.

In his movie, Capitalism: A Love Story, Michael Moore highlighted "dead peasant" insurance policies. This is when a major company like Walmart buys life insurance policies on tens of thousands of front line workers, like checkout clerks. Usually the insuree doesn't even know of the existence of the policy, but if they die, the company collects.

Moore emphasized the morbid nature of this game, but missed the real story. The point of these policies is to smooth profits, partly to manipulate share prices, but also for tax purposes. The real highlight of this story is that there is someone who likely got very rich by developing dead peasant insurance policies, rather than contributing anything productive to the economy.

I mention this as background to the corporate income tax discussion since to my view a major goal of corporate tax reform is to eliminate the enormous opportunities for gaming that currently exist. These opportunities are making some people very rich and are a complete waste from an economic standpoint.


For this reason, I am sympathetic to the plan the Republicans are debating. In its conception it would be enormous simplification relative to the current system. Of course, that is the conception, we will have to see the plan as it is drafted in legislation to reach any final judgement.

In this vein, I have been unhappy to see some of the attacks leveled by people for whom I have considerable respect, notably Paul Krugman. In a post yesterday, Krugman makes the case that the basic tax proposal would be a subsidy for domestic production and therefore inconsistent with free trade principles.

While I don't disagree with the logic, I question its importance. He contrasts the border adjustment with the Republican tax proposal with the border adjustment with a traditional value-added tax (VAT), pointing out that the latter doesn't give a domestic production subsidy in the same way. There are two important points left out of Krugman's discussion.

The first is the issue of size. VATs in our trading partners typically raise well over ten percent of GDP in revenue and sometimes more than 20 percent. By contrast, the corporate income tax has raised less than 1.7 percent of GDP in recent years. The Republicans are undoubtedly looking to reduce this amount further in their tax reform (hopefully they will not succeed), but the imposition of a tax equal to 15 percent of GDP matters much more for trade than a tax equal to 1.7 percent of GDP. (Suppose the dollar falls or rises by 1.7 percent in a week, as it often does. This has the same impact.)

The second issue is the point of reference. We don't currently have a VAT in the United States. We have various taxes that are assessed in the production process, including the income tax workers pay on their wages, that get passed on in the price of the product. If we snapped our fingers and replaced the income tax with a value added tax, we would then refund this tax on exported products. That would look like an export subsidy, relative to our current system. Similarly, we would slap the VAT on all items that are imported. That would look like an import tariff, relative to our current system.

Conventionally, economists urge us not to worry about this issue, since changes in currency values will even things out. This is probably true, at least over the long-run, if not immediately in a transition process. This is a situation where we should accept the economists' conventional wisdom on the net effect on trade, remembering that the amount at stake as an export subsidy or import tariff is just not that large in any case.

The Republican tax proposal, when it is actually put on the table, should be evaluated based on the extent to which it eliminates the waste associated with the tax avoidance industry and also for the amount of revenue it raises. Arguing for its rejection based on it being an unfair subsidy for domestic production is just silly.

There are plenty of very real reasons not to like the things Republicans are putting forward in the Trump administration. We don't have to invent fake ones.

Peter K. -> anne... , March 20, 2017 at 09:01 AM
http://cepr.net/blogs/beat-the-press/washington-post-pushed-fear-on-corporate-tax-reform

Washington Post Pushed Fear on Corporate Tax Reform
by Dean Baker
Published: 29 January 2017

The headline warned readers that the Republican's proposal for reforming the corporate income tax is coming for your toys, literally:

"Trump-era tax reform could come for your toys."
Okay, we get it. The Washington Post doesn't like the tax reform and is not content to keep its views to the opinion pages. (This article ran at the top of the Sunday business section.)

The basic story is almost Trumpian in its unreality. The tax reform includes a border adjustment tax on imports. This is similar (not identical) to what countries with value-added taxes do, which is almost every other wealthy country. The conventional wisdom among economists is that currencies adjust so that the net effect on the price of imports, including toys, is minimal.

While this piece notes this argument, it implies that consumers and retailers have great cause for concern over the tax. In this respect, it is worth pointing out that currencies fluctuate by large amounts all the time, in ways that are likely to have far more impact on the price of imported toys than this tax. The figure below shows the inflation-adjusted value of the dollar measured against the currencies of our major trading partners.

fredgraph10

Note that the dollar fell by more than 25 percent against the currencies of our major trading partners in the years between its peak in 2002 and its trough in 2008. This would have sent the price of imported toys up by far more than the new tax possibly could, even though it never prompted an article in the Post warning readers that a falling dollar was coming for their toys.

As a practical matter, a currency adjustment will take time and may not be complete, but in the technical language of economists, so what? If the price of imported toys rises by 3–4 percent as a result of the tax, what would be the big deal. This change is swamped by movements in currency values that never even get mentioned. (I discuss the tax reform proposal, which could get rid of the tax avoidance industry, at more length here.)

It is also worth pointing out that incredible hypocrisy and/or ignorance underlying these discussions. If the United States is to get back to something closer to balanced trade, as opposed to having a trade deficit of more than $500 billion (around 2.7 percent of GDP), it is likely to require a lower valued dollar and higher import prices.

We can count on news outlets like the Post pointing out that the higher import prices mean that lower income people will have to pay more for imported goods at Walmart. This is true, but they are also more likely to be able to get relatively good paying jobs in manufacturing. Also, the availability of these jobs is likely to put upward pressure on the wages of less-educated workers more generally. The net effect for these people is almost certain to be positive.

If this is hard to understand, suppose we remove the protectionist barriers that allow our doctors to earn twice as much as doctors in other wealthy countries. This would likely cause the pay of our doctors to be more in line with pay in Europe and Canada (@ $150,000 a year, as opposed to an average of more than $250,000 a year now). The doctors would all benefit because they and their families would now pay less for their health care, or at least this is how it would be covered using the Washington Post standard.

[Mar 21, 2017] Why No One Is Taking Robert Samuelson's Medicaid Deal Seriously

Mar 21, 2017 | economistsview.typepad.com
anne : March 20, 2017 at 05:50 AM , 2017 at 05:50 AM
http://cepr.net/blogs/beat-the-press/why-no-one-is-taking-robert-samuelson-s-medicaid-deal-seriously

March 20, 2017

Why No One Is Taking Robert Samuelson's Medicaid Deal Seriously

Robert Samuelson put forward what would ordinarily be a very reasonable proposal on Medicaid and Medicare in his column * today. He suggested that the federal government take over the portion of Medicaid that deals with low-income elderly and fold it into the Medicare program, while leaving states with full responsibility for dealing with the part of Medicaid that deals with low-income families below retirement age.

While he is right that this sort of consolidation could likely reduce costs and prevent seniors from falling between the cracks in the two systems, there is a basic problem with turning Medicaid over to the states. There are a number of states controlled by Republicans where there is little or no interest in providing health care for low income families.

This means that if Medicaid were turned completely over to the states, millions of low income families would lose access to health care. For this reason, people who want to see low income families get health care, which is the purpose of Medicaid, want to see the program remain partly under the federal government's control.

* https://www.washingtonpost.com/opinions/medicaid-is-out-of-control-heres-how-to-fix-it/2017/03/19/05167e9e-0b2e-11e7-a15f-a58d4a988474_story.html

-- Dean Baker

pgl -> anne... , March 20, 2017 at 06:04 AM
"There are a number of states controlled by Republicans where there is little or no interest in providing health care for low income families. This means that if Medicaid were turned completely over to the states, millions of low income families would lose access to health care."

Dean Baker is right to go after this idea from Robert (no relationship to Paul) Samuelson but two additional comments.

(1) This is really the Paul Ryan agenda.

(2) For states like mine that will take care of these low income families, this Ryan agenda does not mean less in taxes. It means less in income taxes on the rich and more in sales taxes for the rest of us. The ultimate Paul Ryan agenda.

Anachronism said in reply to pgl... , March 20, 2017 at 06:56 AM
There are 2 theories about how to argue with a republican. Neither one works.

What they care about is "lessez faire", which means low income families should die off from lack of healthcare. If they deserved healthcare, they should have been able to afford it themselves.

RC AKA Darryl, Ron said in reply to Anachronism ... , March 20, 2017 at 07:16 AM
If God had wanted poor people to have healthcare then he would have made them be born rich :<)
pgl -> Anachronism ... , March 20, 2017 at 09:43 AM
I might ask what those two theories are but I suspect you are right about neither one of them working.

[Mar 20, 2017] Reply

Mar 20, 2017 | onclick="TPConnect.blogside.reply('6a00d83451b33869e201b7c8e235d6970b'); return false;" href="javascript:void 0">
Monday, March 20, 2017 at 01:54 AM ken melvin said in reply to mulp... Let them eat ideology. Reply Monday, March 20, 2017 at 04:25 AM RC AKA Darryl, Ron said in reply to mulp... "...TANSTAAFL"

https://en.wikipedia.org/wiki/There_ain%27t_no_such_thing_as_a_free_lunch

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing. The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1] The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3] The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5] Campbell McConnell writes that the idea is "at the core of economics".


[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]
Reply Monday, March 20, 2017 at 04:59 AM ken melvin said in reply to mulp... She ate his lunch
http://crooksandliars.com/2017/03/joy-reid-destroys-lawmakers-medicaid-fear Reply Monday, March 20, 2017 at 05:08 AM pgl said in reply to ken melvin... "Appearing on Reid's Sunday morning program, Carter immediately got off to a rocky start after the MSNBC host asked how Georgia would be "better off" with nearly 500,000 people losing their Obamacare coverage."

Buddy Carter wasn't prepared. Joy Reid was. Thanks for the link. Reply Monday, March 20, 2017 at 05:44 AM Helicopter Appraisal Rules said in reply to mulp... kinds of medical treatments everyone expects insurance to pay for, like injuries from accidents, gunshots, child birth, premature birth neonatal care,
"

Insurance is a private matter unless subsidized. What inflation payers and taxpayers should never be forced to subsidize are childbirth and neonatal care. We shouldn't pay for what we have too much of already. Hell!

With global famine looming later this year and workers losing jobs to robotics, the last thing we need is more birth. Did Jean-Paul Sartre once quip, "Here is my definition of hell :

other people
"
?

No! He never learned to speak English. Or

did
he
?
Reply Monday, March 20, 2017 at 08:24 AM

[Mar 20, 2017] The Fake Freedom of American

Mar 20, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 19, 2017 at 06:07 AM , 2017 at 06:07 AM
'If you really want to free Americans and unburden
American employers, why not try, or at least seriously consider, some form of government-managed health care,
like almost every other capitalist democracy? There
are many ways of giving people choice and excellent
care under government management. Universal publicly
managed health coverage would even free America's corporations and businesses to streamline their
operations, releasing them from bureaucratic
obligations that ... look weirdly socialist.
Would this mean they would have to pay
more in taxes? Possibly.'

(Not 'Possibly'. Inevitably. So be it.)

The Fake Freedom of American
Health Care https://nyti.ms/2nDNgAm
NYT - ANU PARTANEN - MARCH 18, 2017

Last week the nonpartisan Congressional Budget Office estimated that the new Republican health plan would increase the number of uninsured Americans by 24 million people within a decade, mostly because changes in regulations, subsidies and Medicaid coverage would make insurance too expensive for them.

Republican leaders seem unfazed by this, perhaps because, in their minds, deciding not to have health care because it's too expensive is an exercise of individual free will. As Representative Jason Chaffetz, Republican of Utah, put it: "Americans have choices. And they've got to make a choice. And so maybe, rather than getting that new iPhone that they just love, and they want to go spend hundreds of dollars on that, maybe they should invest in their own health care."

There is an appealing logic to such thinking. The idea is that buying health care is like buying anything else. The United States is home to some of the world's best medical schools, doctors, research institutes and hospitals, and if you have the money for the coverage and procedures you want, you absolutely can get top-notch care. This approach might result in extreme inequalities and it might be expensive, but it definitely buys you the best medical treatment anywhere. Such is the cost of freedom. As House Speaker Paul Ryan put it in a tweet: "Freedom is the ability to buy what you want to fit what you need." Vice President Mike Pence picked up that baton: "Obamacare will be replaced with something that actually works - bringing freedom and individual responsibility back to American health care."

In practice, though, this Republican notion is an awfully peculiar kind of freedom. It requires most Americans to spend not just money, but also time and energy agonizing over the bewildering logistics of coverage and treatment - confusing plans, exorbitant premiums and deductibles, exclusive networks, mysterious tests, outrageous drug prices. And more often than not, individual choices are severely restricted by decisions made by employers, insurers, doctors, pharmaceutical companies and other private players. Those interest groups, not the consumer, decide which plans are available, what those plans cover, which doctors patients can see and how much it will cost.

And I haven't even mentioned the millions of Americans who don't earn enough to pay for insurance or a lifesaving treatment. If you can't afford it, not buying it is hardly a choice.

Eight years ago I moved to the United States from Finland, which like all the Nordic nations is a wealthy capitalist economy, despite the stereotypes you may have heard. And like all those countries, Finland has invested in a universal, taxpayer-funded and publicly managed health care system. Finns constantly debate the shortcomings of their system and are working to improve it, but in Finland I never worried about where my medical care came from or whether I could afford it. I paid my income taxes - which, again despite the stereotypes, were about the same as what I pay in federal, state and local income taxes in New York City - and if I needed to see a doctor, I had several options.

For minor medical matters, I could visit a private physician who was provided as a perk by my employer. Or I could call the public clinic closest to my home. If I saw the private doctor, my employer picked up the tab, with the help of public subsidies. If I went to the public clinic, it might cost me a small co-payment, usually around $20. Had I been pregnant, most care would have been free.

If I had wanted to, I also could have easily paid to see a private doctor on my own, again with the help of public subsidies. All of this works without anyone ever having to sign up for or buy health insurance unless he wants additional coverage. I never had to worry whether I was covered. All Finns are covered for all essential medical care automatically, regardless of employment or income.

Republicans are fond of criticizing this sort of European-style health care. President Trump has called Canada's national health care system "catastrophic." On CNN recently, Senator Ted Cruz gave multiple examples of how patients in countries with universal, government-managed health care get less care than Americans.

In Europe, he said, elderly people facing life-threatening diseases are often placed in palliative care and essentially told it's their time to go. According to the Republican orthodoxy, government always takes away not only people's freedom to choose their doctor, but also their doctor's ability to choose the correct care for patients. People are at the mercy of bureaucrats. Waiting times are long. Quality of care is dismal.

But are Republicans right about this? Practically every wealthy capitalist democracy in the world has decided that some form of government-managed universal health care is the most sensible and effective option. According to the latest report of the O.E.C.D. - an organization of mostly wealthy nations - the United States as a whole does not actually outshine other countries in the quality of care.

In fact, the United States has shorter life expectancy, higher infant mortality and fewer doctors per capita than most other developed countries. When it comes to outcomes in some illnesses, including cancer, the United States does have some of the best survival rates in the world - but that's barely ahead of, or even slightly behind, the equivalent survival rates in other developed countries. In breast cancer survival, for example, the United States comes in second, after Sweden. Third-best is Norway, then Finland. All three countries have universal, government-run health care systems.

For colorectal cancer, the five-year survival rate after diagnosis in the United States brings it to a not very impressive ninth place in the O.E.C.D. statistics. Ahead of the United States are South Korea, Israel, Australia, Sweden and Finland, all with some form of government-managed universal health care. And when it comes to cervical cancer, American women are at a significant disadvantage: The United States comes in only 22nd. Meanwhile, life expectancy at age 65 is higher in 24 other developed nations, including Canada, Britain and most European nations.

Americans might still assume that long waits for care are inevitable in a health care system run by the government. But that's not necessarily the case either. A report in 2014 by the Commonwealth Fund, a private foundation specializing in health care research, ranked the United States third in the world in access to specialists. That's a great achievement. But the Netherlands and Switzerland did better. When it comes to nonemergency and elective surgery, patients in several countries, including the Netherlands, Germany and Switzerland, all of which have universal, government-guided health care systems, have faster access than the United States.

It's not just American patients who endure endless bureaucratic hassles. American doctors were also significantly more likely to report as major problems the amount of time they spent on dealing with administrative burdens related to insurance and claims, as well as on getting patients medications or treatment because of restrictions imposed by insurance companies, compared with doctors in most of the other 10 countries studied - including Sweden and Britain.

Overall, Americans spend far more of their hard-earned money on health care than citizens of any other country, by a very wide margin. This means that it is in fact Americans who are getting a raw deal. Americans pay much more than people in other countries but do not get significantly better results.

The trouble with a free-market approach is that health care is an immensely complicated and expensive industry, in which the individual rarely has much actual market power. It is not like buying a consumer product, where choosing not to buy will not endanger one's life. It's also not like buying some other service tailored to individual demands, because for the most part we can't predict our future health care needs.

The point of universal coverage is to pool risk, for the maximum benefit of the individual when he or she needs care. And the point of having the government manage this complicated service is not to take freedom away from the individual. The point is the opposite: to give people more freedom. Arranging health care is an overwhelming task, and having a specialized entity do the negotiating, regulating and perhaps even much of the providing is just vastly more efficient than forcing everyone to go it alone.

What passes for an American health care system today certainly has not made me feel freer. Having to arrange so many aspects of care myself, while also having to navigate the ever-changing maze of plans, prices and the scarcity of appointments available with good doctors in my network, has thrown me, along with huge numbers of Americans, into a state of constant stress. And I haven't even been seriously sick or injured yet.

As a United States citizen now, I wish Americans could experience the freedom of knowing that the health care system will always be there for us regardless of our employment status. I wish we were free to assume that our doctors get paid a salary to look after our best interests, not to profit by generating billable tests and procedures. I want the freedom to know that the system will automatically take me and my family in, without my having to battle for care in my moment of weakness and need. That is real freedom.

So is the freedom of knowing that none of it will bankrupt us. That is the freedom I had back in Finland.

Here is my appeal to Republicans: If you really want to free Americans and unburden American employers, why not try, or at least seriously consider, some form of government-managed health care, like almost every other capitalist democracy? There are many ways of giving people choice and excellent care under government management. Universal publicly managed health coverage would even free America's corporations and businesses to streamline their operations, releasing them from bureaucratic obligations that to me, coming from Finland, I have to say look weirdly socialist. Would this mean they would have to pay more in taxes? Possibly.

Many countries require employers and employees to contribute to the health care system through payroll taxes, more than the United States does. But again, Americans are paying far more for health care than anyone else, and America's businesses are stuck managing this mess. It's true that in countries with universal health care the cost of hiring a new employee can be significant, especially for a small employer. Yet these countries still have plenty of thriving businesses, with lower administrative burdens. It can be done.

In wealthy capitalist democracies all around the world the government itself also has an essential kind of freedom. It's a freedom that enables the government to do work on behalf of the citizens who elect it, including negotiating the prices of health care with providers and pharmaceutical companies - a policy that has led to lower drug prices in those countries.

Americans today are paying vastly more in money, worry and hassle for the same, and sometimes worse, care than people in other wealthy capitalist democracies. Some Americans have coverage that serves them well, but judging by the current mood, the number of Americans who think the system needs to change is growing. No health care system is perfect. But in a nation that purports to champion freedom, the outdated disaster that is the United States health care system is taking that freedom away.

[Mar 17, 2017] The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

Mar 17, 2017 | economistsview.typepad.com
anne -> Fred C. Dobbs... March 16, 2017 at 06:41 AM , 2017 at 06:41 AM
The Affordable Care Act came nowhere close to universal healthcare insurance coverage:

https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Thousands without insurance for entire year)

2007 ( 44,088)
2008 ( 44,780)
2009 ( 48,985) Obama

2010 ( 49,951) (Affordable Care Act)
2011 ( 48,613)
2012 ( 47,951)
2013 ( 41,795)
2014 ( 32,968)

2015 ( 28,966)

anne -> Fred C. Dobbs... , March 16, 2017 at 07:26 AM
https://www.census.gov/content/dam/Census/library/publications/2016/demo/p60-257.pdf

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Percent without insurance for entire year)

2007 ( 14.7)
2008 ( 14.9)
2009 ( 16.1) Obama

2010 ( 16.3) (Affordable Care Act)
2011 ( 15.7)
2012 ( 15.4)
2013 ( 13.3)
2014 ( 10.4)

2015 ( 9.1)

[Mar 17, 2017] The difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year

Mar 17, 2017 | economistsview.typepad.com
anne : March 16, 2017 at 06:19 AM

, 2017 at 06:19 AM
http://cepr.net/blogs/beat-the-press/government-granted-patent-monopolies-cause-people-to-skip-cancer-treatments

March 16, 2017

Government Granted Patent Monopolies Cause People to Skip Cancer Treatments

National Public Radio had an interesting segment * on the difficulties that many families have paying for cancer treatments. The piece points out that even middle income families with good insurance may still face co-payments of tens of thousands of dollars a year.

One item not mentioned in this piece is that the reason the prices of new cancer drugs is high is that the government grants companies patent monopolies. This is done as a way to finance research. In almost all cases these drugs would be available for less than a thousand dollars ** for a year's treatment if the drugs were sold in a free market.

While it is necessary to pay for research, there are more modern and efficient mechanisms than patent monopolies (see "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer" *** ).

* http://www.npr.org/sections/health-shots/2017/03/15/520110742/as-drug-costs-soar-people-delay-or-skip-cancer-treatments

** http://www.thebodypro.com/content/78658/1000-fold-mark-up-for-drug-prices-in-high-income-c.html

*** http://deanbaker.net/images/stories/documents/Rigged.pdf

-- Dean Baker

anne -> anne... , March 16, 2017 at 06:20 AM
http://deanbaker.net/images/stories/documents/Rigged.pdf

October, 2016

Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer
By Dean Baker

The Old Technology and Inequality Scam: The Story of Patents and Copyrights

One of the amazing lines often repeated by people in policy debates is that, as a result of technology, we are seeing income redistributed from people who work for a living to the people who own the technology. While the redistribution part of the story may be mostly true, the problem is that the technology does not determine who "owns" the technology. The people who write the laws determine who owns the technology.

Specifically, patents and copyrights give their holders monopolies on technology or creative work for their duration. If we are concerned that money is going from ordinary workers to people who hold patents and copyrights, then one policy we may want to consider is shortening and weakening these monopolies. But policy has gone sharply in the opposite direction over the last four decades, as a wide variety of measures have been put into law that make these protections longer and stronger. Thus, the redistribution from people who work to people who own the technology should not be surprising - that was the purpose of the policy.

If stronger rules on patents and copyrights produced economic dividends in the form of more innovation and more creative output, then this upward redistribution might be justified. But the evidence doesn't indicate there has been any noticeable growth dividend associated with this upward redistribution. In fact, stronger patent protection seems to be associated with slower growth.

Before directly considering the case, it is worth thinking for a minute about what the world might look like if we had alternative mechanisms to patents and copyrights, so that the items now subject to these monopolies could be sold in a free market just like paper cups and shovels.

The biggest impact would be in prescription drugs. The breakthrough drugs for cancer, hepatitis C, and other diseases, which now sell for tens or hundreds of thousands of dollars annually, would instead sell for a few hundred dollars. No one would have to struggle to get their insurer to pay for drugs or scrape together the money from friends and family. Almost every drug would be well within an affordable price range for a middle-class family, and covering the cost for poorer families could be easily managed by governments and aid agencies.

The same would be the case with various medical tests and treatments. Doctors would not have to struggle with a decision about whether to prescribe an expensive scan, which might be the best way to detect a cancerous growth or other health issue, or to rely on cheaper but less reliable technology. In the absence of patent protection even the most cutting edge scans would be reasonably priced.

Health care is not the only area that would be transformed by a free market in technology and creative work. Imagine that all the textbooks needed by college students could be downloaded at no cost over the web and printed out for the price of the paper. Suppose that a vast amount of new books, recorded music, and movies was freely available on the web.

People or companies who create and innovate deserve to be compensated, but there is little reason to believe that the current system of patent and copyright monopolies is the best way to support their work. It's not surprising that the people who benefit from the current system are reluctant to have the efficiency of patents and copyrights become a topic for public debate, but those who are serious about inequality have no choice. These forms of property claims have been important drivers of inequality in the last four decades.

The explicit assumption behind the steps over the last four decades to increase the strength and duration of patent and copyright protection is that the higher prices resulting from increased protection will be more than offset by an increased incentive for innovation and creative work. Patent and copyright protection should be understood as being like very large tariffs. These protections can often the raise the price of protected items by several multiples of the free market price, making them comparable to tariffs of several hundred or even several thousand percent. The resulting economic distortions are comparable to what they would be if we imposed tariffs of this magnitude.

The justification for granting these monopoly protections is that the increased innovation and creative work that is produced as a result of these incentives exceeds the economic costs from patent and copyright monopolies. However, there is remarkably little evidence to support this assumption. While the cost of patent and copyright protection in higher prices is apparent, even if not well-measured, there is little evidence of a substantial payoff in the form of a more rapid pace of innovation or more and better creative work....

Tom aka Rusty said in reply to anne... , -1
I'm trying to imagine why anyone would write a 900 page textbook, plus add-ons (test bank, solutions manual) and then give it away.

I have refused to co-author several times because the work is agonizing, the revisions never ending, and only a few texts make anyone rich.

[Mar 16, 2017] Arrow said it decades ago, the market does not work for health care. The Brits have known it since WW II or before.

Mar 16, 2017 | economistsview.typepad.com
RGC -> anne... March 14, 2017 at 04:11 AM , 2017 at 04:11 AM
Western politicians and mainstream economists have the same game plan:


Given choice 1 and choice 2....

Republicans choose 1a Democrats choose 1b

Neoliberals choose 1a Neo classicals choose 1b

1a is "hard" laissez-faire

1b is "soft" laissez-faire

2 is democratic socialism

anne -> RGC... , March 14, 2017 at 05:10 AM
Clever, and worth developing as a complete argument.
ilsm -> anne... , March 14, 2017 at 05:19 AM
Arrow said it decades ago, the market does not work for health care. The Brits have known it since WW II or before.
anne -> ilsm... , March 14, 2017 at 07:04 AM
https://en.wikipedia.org/wiki/National_Health_Service

The National Health Service (NHS) is the name of the public health services of England, Scotland and Wales, and is commonly used to refer to those of Northern Ireland. They were established together as one of the major social reforms following the Second World War on the founding principles of being comprehensive, universal and free at the point of delivery. Today, each provides a comprehensive range of health services, the vast majority of which are free for people ordinarily resident in the United Kingdom.

Taken together, the four National Health Services in 2015-16 employed around 1.6 million people with a combined budget of £136.7 billion. UK residents are not charged for most medical treatment, with exceptions such as a fixed charge for prescriptions; dental treatment is administered differently, with standard charges for most procedures. For non-residents, the NHS is free at the time of use, for general practitioner (GP) and emergency treatment not including admission to hospital.

The NHS began on the 'Appointed Day' of 5 July 1948.

[Mar 16, 2017] Health Care and Market Based "Solutions"

Mar 16, 2017 | economistsview.typepad.com
anne : March 14, 2017 at 03:26 AM , 2017 at 03:26 AM
http://econospeak.blogspot.com/2017/03/health-care-and-market-based-solutions.htm

March 13, 2017

Health Care and Market Based "Solutions"

The opening of a critique of TrumpDoesn'tCare by John Osborne has this canard:

"The excerpts are interesting, not because there were stunning disclosures or revolutionary ideas, but to the contrary they reveal what many have been saying for some time: there is no plan that will enable the Republican Congress to effectively replace Obamacare by relying solely on conservative, market-based solutions...at least not without risking great disruption to an already skittish insurance market."

The canard is that conservatives have some "market based solution". This begs solution to what? I wonder if these conservatives have read the 1983 paper by John Moskop ?:

"This paper considers whether Rawls' theory of justice as fairness may be used to justify a human right to health care. Though Rawls himself does not discuss health care, other writers have applied Rawls' theory to the provision of health care. Ronald Green argues that contractors in the original position would establish a basic right to health care."

While Moskop does not entirely agree with Ronald Green, many of us see the health care debate as one of basic fairness – not just efficiency....

-- ProGrowthLiberal

pgl -> pgl... , March 14, 2017 at 04:24 AM
Check out the subtitle:

'A total of 54 million individuals would be uninsured in 2026 under the GOP plan, according to the White House analysis.'

So the TrumpCare proposal will double the number of uninsured. In relative terms, about 8% of the population would be without insurance. Under TrumpCare - make that 16%. We need an improvement of ObamaCare. This is the opposite.

JF -> pgl... , March 14, 2017 at 06:21 AM
Pgl, ok to talk about an insurance solution but can you also mention healthcare itself?

People care about their health when confronted with it, few care about insurance organizations. The discussion, as I think you'd agree, needs to be more about health and public-health (a societal level view, considering many years). It is not a good debate to just talk about insurance and insurance contracts/plans.

pgl -> JF... , March 14, 2017 at 07:01 AM
In my latest at Econospeak I did talk about ending the doctor cartel as well as the pharma cartel. You are right - the real reason we pay too much for health care are the economic rents reaped by the providers.
JF -> pgl... , March 14, 2017 at 07:32 AM
Alignments of incentives a la Arrow. Healthcare delivery system is not a place where ideal free markets can arise, as most know, it just is not possible from the nature of the service itself.

Now few markets ever attain the ideal, of course. This is one of the reasons why the republicans talk mostly about insurance, here market verbiage has more traction. But these are 'financial' insurance products, they are not healthcare. As we know, you only insure your finances if you have something financial at risk. Most young people and families, and many others are not looking to insure their finances, they do need healthcare, however.

Society's need is to have a rational healthcare delivery system. Subsidization of a financial insurance industry is no where close to being equivalent.

Know you know this. Would want journalists and analysts to know this and write accordingly.

pgl -> JF... , -1
"Society's need is to have a rational healthcare delivery system. Subsidization of a financial insurance industry is no where close to being equivalent."

Agreed. So much time on how to pay for it but almost no time on how health care is delivered. Both are important topics.

Anachronism : , March 14, 2017 at 05:03 AM
With apologies to Anne, the article simply won't copy paste. You'll have to read it.

The title is: No easy answers: why left wing economics is not the answer to right wing populism

http://www.vox.com/world/2017/3/13/14698812/bernie-trump-corbyn-left-wing-populism

anne -> Anachronism ... , March 14, 2017 at 05:17 AM
http://www.vox.com/world/2017/3/13/14698812/bernie-trump-corbyn-left-wing-populism

March 13, 2017

No easy answers: why left-wing economics is not the answer to right-wing populism
By Zack Beauchamp

On November 20, less than two weeks after Donald Trump's upset win, Bernie Sanders strode onto a stage at Boston's Berklee Performance Center to give the sold-out audience his thoughts on what had gone so disastrously wrong for the Democratic Party.

Sanders had a simple answer. Democrats, he said, needed to field candidates who would unapologetically promise that they would be willing "to stand up with the working class of this country and ... take on big-money interests."

Democrats, in other words, would only be able to defeat Trump and others like him if they adopted an anti-corporate, unabashedly left-wing policy agenda. The answer to Trump's right-wing populism, Sanders argued, was for the left to develop a populism of its own.

That's a belief widely shared among progressives around the world. A legion of commentators and politicians, most prominently in the United States but also in Europe, have argued that center-left parties must shift further to the left in order to fight off right-wing populists such as Trump and France's Marine Le Pen. Supporters of these leaders, they argue, are motivated by a sense of economic insecurity in an increasingly unequal world; promise them a stronger welfare state, one better equipped to address their fundamental needs, and they will flock to the left.

"[It's] a kind of liberal myth," Pippa Norris, a Harvard political scientist who studies populism in the United States and Europe, says of the Sanders analysis. "[Liberals] want to have a reason why people are supporting populist parties when their values are so clearly against progressive values in terms of misogyny, sexism, racism."

The problem is that a lot of data suggests that countries with more robust welfare states tend to have stronger far-right movements. Providing white voters with higher levels of economic security does not tamp down their anxieties about race and immigration - or, more precisely, it doesn't do it powerfully enough. For some, it frees them to worry less about what it's in their wallet and more about who may be moving into their neighborhoods or competing with them for jobs.

Take Britain's Labour Party, which swung to the populist left by electing Jeremy Corbyn, a socialist who has proposed renationalizing Britain's rail system, as its leader in 2015. The results have been disastrous: the Brexit vote in favor of leaving the European Union, plummeting poll numbers for both Corbyn and his party, and a British political scene that is shifting notably to the right on issues of immigration and multiculturalism....

anne -> Dan Kervick... , March 14, 2017 at 07:56 AM
https://www.weforum.org/agenda/2017/01/full-text-of-xi-jinping-keynote-at-the-world-economic-forum

January 17, 2017

Speech to Davos

Wrtten by Xi Jinping
President of the People's Republic of China

I'm delighted to come to beautiful Davos. Though just a small town in the Alps, Davos is an important window for taking the pulse of the global economy. People from around the world come here to exchange ideas and insights, which broaden their vision. This makes the WEF annual meeting a cost-effective brainstorming event, which I would call "Schwab economics".

"It was the best of times, it was the worst of times." These are the words used by the English writer Charles Dickens to describe the world after the Industrial Revolution. Today, we also live in a world of contradictions. On the one hand, with growing material wealth and advances in science and technology, human civilization has developed as never before. On the other hand, frequent regional conflicts, global challenges like terrorism and refugees, as well as poverty, unemployment and widening income gap have all added to the uncertainties of the world.

Many people feel bewildered and wonder: What has gone wrong with the world? ...

EMichael -> anne... , March 14, 2017 at 08:18 AM
Amazing he had the balls to say this:

"Countries, big or small, strong or weak, rich or poor, are all equal members of the international community. As such, they are entitled to participate in decision-making, enjoy rights and fulfill obligations on an equal basis."

Seriously?

pgl -> Dan Kervick... , March 14, 2017 at 08:11 AM
Well said. It should be about governance - not who wins a popularity contest.
Dan Kervick -> anne... , March 14, 2017 at 06:55 AM
I agree with Beauchamp that what we are seeing in the US and Europe is a broader wave against liberalism itself, not just a vote for some particular economic policy or other. But for writers like Beauchamp, it always seems to be just a coincidence that this great antiliberal wave coincides with the aftermath of the worst economic catastrophe since the Great Depression. Doesn't he wonder what causes upticks in xenophobia and racism, resistance to immigration, and similar behaviors? These things rise when people are unhappy about many other things in their lives. And that happens when a country is not thriving economically.

I suspect one source of western malaise is exasperation with liberalism - whether of the rightish, laissez faire capitalist variety or of leftish neoliberal capitalism + welfare state variety – is that contemporary liberalism takes an overly passive view toward future, deferring all of the major social outcomes to the inventions and innovations or capitalist entrepreneurs, and neglecting any strategic planning role for government.

In my lifetime, China as transformed itself from a land of impoverished peasants into a world economic powerhouse, doing it with a combination of capitalist and socialist mechanisms. Meanwhile, we in the US just drift along in the end-of-history shallows, waiting to see what new toy clever business-people will invent for us. We're destroying the planet and its biosphere, & yet the usual neoliberal response is "Maybe Gates or Musk will think of something."

"Tacking to the left" economically must be understood as more than expansion of the welfare state. It includes expansion of the government role in planning and setting the agenda or direction in the productive sphere, and also regulating firms and the distribution system at the root level, to assure a more equitable distribution of income. People must be guaranteed the possibility of stable and secure lifetime employment, and reliable retirement incomes, and protected from the economic devastation of personal healthcare emergencies. Meanwhile, we need to use government to formulate and execute long term economic plans.

People are bored and dismayed by the lack of purpose, leadership, direction and transformative ambition from our dysfunctional and complacent governments. They respond to "Make America Great Again" message because at least they detect some sense of energy and purpose behind that message. So yes, I sort of agree with Beauchamp to this extent: people are turning against liberalism itself, which seems decrepit, vacuously individualistic and adrift. So, the question is how to save what is good in liberalism, while moving on and forward from what is shallow & decadent in it. Do you want fascism? Or a reinvigorated, purposeful & powerful left with an ambitious plan for engineering a viable future?

JF -> Dan Kervick... , March 14, 2017 at 07:42 AM
Enjoy the writing and thought. Thanks.

The lessons to be taken from China, as you note above, is that they have reached the conclusion that things like pricing mechanisms and markets and even the enforceability of loan contracts, if desired, all work well to effect a societally useful economic system. This is what needs to be higlighted when trying to reach westerm thinkers, in my opinion.

The central and authoritarian control aspects are not good points to highlight - in China, in Russia, or in the US. These aspects offend me and many.

JF -> JF... , March 14, 2017 at 07:47 AM
But we do need thoughtful and intentional economic policies uniformly established via the public's law, if we can keep the Republican-form aspects that legitimize US governance; and we are losing this 'we the people' aspect to a radical faction who would implement their notion of central plans of benefit to their new aristocracy.
Dan Kervick -> JF... , March 14, 2017 at 01:03 PM
China didn't get decades of gigantic growth rates just by handing its economy over to markets and private contracts. They have had a national investment plan and long-term strategy spearheaded by a heavily-involved and assertive central government.

Yes I know many Americans are offended by the very idea of central planning, and have powerful, kneejerk reactions to all suggestions of that kind. Well, they can keep being offended and we keep drifting along with our old-fashioned ideas of radically decentralized liberal capitalism. We can keep letting our wonderful capitalist freedom cook the planet and decimate the biopshere, and segregate our anxious, increasingly angry population into winners and losers at each others's throats.

RC AKA Darryl, Ron -> Dan Kervick... , March 14, 2017 at 07:47 AM
Well said.

[Mar 16, 2017] Pence HIP aka Healthy Indiana Plan which means Medicaid expansions in IN is under threat from Trump administration of which Pense is a part

Mar 16, 2017 | economistsview.typepad.com
pgl : March 14, 2017 at 01:49 AM , 2017 at 01:49 AM
Here is a link to the CBO report:

https://www.cbo.gov/sites/default/files/115th-congress-2017-2018/costestimate/americanhealthcareact_0.pdf

Tom Price says it is not believable. I guess he does not want to admit that 24 million people will lose their insurance but I bet his colleagues will hype this:

"CBO and JCT estimate that enacting the legislation would reduce federal deficits by $337 billion over the 2017-2026 period."

That's only $34 billion per year and read on:

"The largest savings would come from reductions in outlays for Medicaid and from the elimination of the Affordable Care Act's (ACA's) subsidies for nongroup health insurance. The largest costs would come from repealing many of the changes the ACA made to the Internal Revenue Code-including an increase in the Hospital Insurance payroll tax rate for high-income taxpayers, a surtax on those taxpayers' net investment income, and annual fees imposed on health insurers-and from the establishment of a new tax credit for health insurance."

Hey it is easy to reduce the deficit if one abdicates responsibility for taking care of the truly needy. But hey – more tax cuts for the rich!

jonny bakho -> pgl... , March 14, 2017 at 06:11 AM
The reaction from Pence home state of Indiana:

"It's reality hitting home," Republican Senate leader Dave Long, of Fort Wayne, said earlier this month. "The issue of the working poor is real. It's not going to be easy."

More than 400,000 poor people in Indiana have health insurance after former Gov. Mike Pence, now the vice president, championed an expansion of Medicaid, which relies on the federal government for at least 90 percent of its funding.

Pence, who is being counted on by Trump to help sell the House plan, is now poised to help unwind one of his legacy achievements as governor if the bill is signed into law.

A Pence spokesman declined to comment.

Holcomb said he understands that there is a pressing need to rein in federal spending, but he said HIP 2.0, the program Pence implemented in Indiana, is working.

"I have not seen a more successful program," Holcomb said. "I don't want to overreact but I do think that HIP 2.0 is part of that answer in how our nation can address the issue of health care."

HIP = Healthy Indiana Plan = Medicaid expansions in IN under waiver
Holcomb is new governor

JF -> jonny bakho... , March 14, 2017 at 07:20 AM
Public financing, sure its successful. Happy for people there.

I assume that the reason why the proposed bill delays the Medicaid changes is so that the States that refused to sign up before get a chance to sign up for a few years.

This means that politicians who purposely sacrificed their population's health to make some ideological bow in order to undermine the successes of the ACA would get new public financing support, allowing them to claim this new success. Unctuous. Ugly.

I wonder how CBO scored this, did they recognize that new States would sign on to the Medicaid increased Fed Financing Supports for a few years, increasing the benchmark numbers for the block grants that then replace Medicaid in those States.

Again, I would be more than sanguine to see these States poorer populations better served, that would be success, at least for a few years. But the politics are radical, bald and unseemly.

And annual fiscal changes would be less then too, and wonder what CBO considered would happen.

JF -> JF... , March 14, 2017 at 09:19 AM
CBO gave no details but nited that State reactions to the bills provisions are uncertain.

If we presume all those nonparticipating states actually sign on to the ACA until the medicaid elements are changed in 2020, at which time they would do something to protect their budgets, the national budget savings would shrink. These are areas worth congressional hearing questions of CBO.

Apparently the bill proposes to grant special subsidies to the state who had not joined before. This rewards those zealots for screwing their own people, it is sad, but It is better to expand than screw them some more. Such bald, raw political engineering here.

Again, deserves congressional questions of CBO to explain their assumptions and to highlight this reward for what it is.

[Mar 14, 2017] Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems

Mar 14, 2017 | economistsview.typepad.com

Fred C. Dobbs : March 13, 2017 at 07:23 AM

Lousy Customer Service? A Better Way in Health Care
https://nyti.ms/2mBJxmw via @UpshotNYT
NYT - Austin Frakt - MARCH 13, 2017

You've all experienced it: There's a problem with your health care bill, or you have difficulty getting coverage for the care you need. Your doctor or hospital tells you to talk to your insurer. Your insurer tells you to talk to your doctor or hospital. You're stuck in an endless runaround.

A small patient advocacy industry has sprung up to help, but that help can cost several hundred dollars an hour. Is there a way to get the customer service we deserve?

Turns out, some kinds of health insurance plans provide better customer service than others. Among those that do are plans offered directly by hospitals or health systems, according to results from a recent study by me; Garret Johnson, now a medical student at Harvard; and Zoë Lyon, a research assistant at the Harvard T.H. Chan School of Public Health.

Our conclusions are based on analysis of Medicare Advantage plans - private insurance alternatives to traditional Medicare. Medicare Advantage plans are offered by major insurers like UnitedHealthcare, Humana, Aetna, BlueCross BlueShield affiliates and others. But nearly one-quarter of the plans are issued by hospitals or health systems. These provider-offered plans are more likely found in dense, urban areas in the Northeast and the West.

The government collects data on health care quality from surveys and medical claims, then aggregates them into ratings of plans. These are publicly reported in units of stars: Five stars represents the highest quality, and one the lowest. Our study, published this month in the health policy journal Health Affairs, found that provider-offered plans have higher quality ratings.

(Provider-Offered Medicare Advantage Plans:
Recent Growth And Care Quality
http://content.healthaffairs.org/content/36/3/539.abstract )

Plans offered by insurers have average ratings of just over 3.5 stars for both nondrug and drug service. An average provider-offered plan has quality ratings that are about one-third of a star higher for both, after adjusting for factors that could confound the comparison, like socioeconomic status and the types and number of doctors where plans are offered.

Our study dug deeper to examine the kinds of quality enhancements available in provider-offered plans. Some aspects of quality are clinically focused. For instance, measures of preventive screening - like that for colorectal cancer - or management of chronic conditions assess the quality of care delivered by doctors and hospitals in a plan's networks. Provider-offered plans perform somewhat better than insurer-offered plans in such areas.

Other aspects of quality pertain to customer service. In measures of complaints, responsiveness to customers and the enrollees' overall experiences, provider-offered plans really shine. In each area of customer service we examined, provider-offered plans are rated one-half star higher than insurer-offered ones. (This is a big difference. For comparison, over half of plans are within one star of each other in overall quality.)

These results make some sense. When a customer has an issue - like a problem with a hospital bill - the easiest thing for a health plan to do is pass it off to the hospital. Likewise, the hospital's easiest course of action is to blame the health plan. The patient, stuck in the middle, is not likely to rate his plan (or hospital) highly for customer service in this case.

However, when the plan and hospital are one and the same, neither can pass the buck to the other. Problems may be resolved faster; they may be less likely to develop in the first place. This could lead to the higher customer satisfaction reflected in the quality ratings.

If the higher ratings are enough to interest you in trying a provider-offered plan, how would you find one? Unfortunately, there's no readily accessible source to inform consumers (or researchers) about this feature of plans. Sometimes the plan's name gives away the relationship. The UPMC Health Plan practically has the health system that offers it right in the name - UPMC stands for University of Pittsburgh Medical Center. In other cases, consumers can identify the relationship on plans' or health systems' websites. For example, the Vital Traditions plan website identifies as its parent company the largest nonprofit hospital system in Texas, Baylor Scott & White.

But in many cases, it's not so easy to figure out. In fact, this is why there has been so little analysis of provider versus insurer plans. For our study, we had to scroll through hundreds of websites, news articles and documents to build a research data set on provider-offered plans from 2011 to 2015. Because of the work involved, there are very few studies on the subject. Another, published in Health Service Research by me, Roger Feldman of the University of Minnesota and Steven Pizer of Northeastern University, found a similar quality relationship when examining 2009 data.

That earlier study also found that provider-offered Medicare Advantage plans charge higher premiums. But a recent study of marketplace plans found that provider-offered ones are not necessarily the most expensive. For some, a higher premium may outweigh the benefits of greater quality, but for others it may not.

From our study, we can't be certain that provider sponsorship of plans causes higher quality. It could be that higher-quality providers are the ones that choose to offer plans. Nevertheless, such tight integration between plans and providers is at least a signal of higher quality, even if it doesn't cause it.

Recent trends suggest more health systems are offering plans in other health care markets for the working-age population, not just in Medicare Advantage. Not all markets may be hospitable to provider-offered plans, however. Some systems that did offer plans are pulling back. According to The Wall Street Journal, Catholic Health Initiatives, which runs over 100 hospitals across 18 states, is divesting itself of some of its health insurance plans. After struggles with profitability, Tenet Healthcare and several other health systems have said they will do the same. ...

Big hospital operator retreats from health-insurance foray
http://www.wsj.com/articles/big-hospital-operator-retreats-from-health-insurance-foray-1481814003
via @WSJ - December 15

[Mar 14, 2017] It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph,

Notable quotes:
"... It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph, A National Health System for America, practically on the eve of Bush's inauguration: ..."
"... The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed. ..."
"... In 1991 Mark Pauly, of the University of Pennsylvania, elaborated on the concept, in a widely-read article in the journal Health Affairs. The individual mandate became the basis for a Congressional Republican proposal introduced in 1993 as an alternative to Hillary Clinton's anticipated proposal of a single-payer national health service. The scheme was subsequently endorsed (subscription required) by Newt Gingrich. ..."
Mar 14, 2017 | economistsview.typepad.com
Peter K. : March 13, 2017 at 05:46 AM

Fred Dobbs corrected me by saying Romenycare started in Massachusetts, not a Republican think tank. Not according to David Warsh in today's links.

"How did a Republican program introduced on the eve of the George H.W. Bush administration wind up in the crosshairs of the Republican Congress under House Speaker Paul Ryan (R-Wis.) twenty-five years later? Here, at the beginning of the attempt to repeal Obamacare, let's take a quick trip down memory lane.

It was in 1989 that economist Stuart Butler proposed an individual mandate in a Heritage Foundation monograph, A National Health System for America, practically on the eve of Bush's inauguration:

The requirement to obtain basic insurance would have to be enforced. The easiest way to monitor compliance might be for households to furnish proof of insurance when they file their tax returns. If a family were to cancel its insurance, the insurer would be required to notify the government. If the family did not enroll in another plan before the first insurance coverage lapsed and did not provide evidence of financial problems, a fine might be imposed.

That autumn, in Assuring Affordable Health Care for All Americans, a conference talk, Butler explained why the provision of health care is unlike almost all other markets:

If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance. If we find that he has spent his money on other things rather than insurance, we may be angry but we will not deny him services – even if that means more prudent citizens may wind up paying the tab.

In 1991 Mark Pauly, of the University of Pennsylvania, elaborated on the concept, in a widely-read article in the journal Health Affairs. The individual mandate became the basis for a Congressional Republican proposal introduced in 1993 as an alternative to Hillary Clinton's anticipated proposal of a single-payer national health service. The scheme was subsequently endorsed (subscription required) by Newt Gingrich.

..."

http://www.economicprincipals.com/issues/2017.03.12/1980.html

Up above in comments, PGL is getting all strident about Paul Ryan watering down what is essentially a Republican water-downed alternative to Hillarycare.

"He is gloating that we have more "choices" as he takes away any possible means for actually paying for our health care. This in a nutshell is the entire GOP approach. We are free to die."

The comedians are having a fun time pointing out how Trump won't put his name on the replacement plan even though he loves putting his name on things.

Peter K. -> Peter K.... , March 13, 2017 at 05:51 AM
Was Hillarycare a single-payer?

https://en.wikipedia.org/wiki/Clinton_health_care_plan_of_1993

"To achieve this, the Clinton health plan required each US citizen and permanent resident alien to become enrolled in a qualified health plan on his or her own or through programs mandated to be offered by businesses with more than 5,000 full-time employees. Subsidies were to be provided to those too poor to afford coverage, including complete subsidies for those below a set income level. Users would choose plans offered by regional health alliances to be established by each state. These alliances would purchase insurance coverage for the state's residents and could set fees for doctors who charge per procedure.[5][6] The act provided funding to be sent to the states for the administration of the plan, beginning at $14 billion in 1993 and reaching $38 billion in 2003."

im1dc -> EMichael... , March 13, 2017 at 08:44 AM
Short Sweet Bernie Sanders Takedown of the Ryan Repeal and Replace Health Care Plan

http://www.politicususa.com/2017/03/12/bernie-sanders-demolishes-paul-ryans-obamacare-replacement-incredible-82-seconds.html

"Bernie Sanders Demolishes Paul Ryan's Obamacare Replacement In An Incredible 82 Seconds"

By Jason Easley...Mar 12th, 2017

"Sen. Bernie Sanders needed just 82 seconds to completely demolish Speaker of the House Paul Ryan's Obamacare replacement on Face The Nation.

The full interview with Sen. Sanders on CBS's Face The Nation:

Face The Nation video

Sen. Sanders was asked if the Ryan Obamacare replacement can get 51 votes in the Senate, and he answered, "I hope not. It is an absolute disaster. It is a disgrace, and by the way, this really has nothing to do with healthcare. What this has everything to do with is a massive shift of wealth from working people and middle-income people to the richest people in this country. It is a 275 billion dollar tax break for the top two percent. Millionaires will get about $50,000 a year in tax breaks, while at the same time 5-10 million people are going to lose their health insurance, premiums are going to soar. The AARP says that if you are 64 years of age and you're making about 25,000 a year, you're going pay up to $7,000 more for you're health insurance. They're going to defund Planned Parenthood. Deny over 2 million the right to choose they healthcare that they need. They're going to decimate Medicaid, which is why the American Medical Association, the AMA, and the American Hospital Association oppose it, in addition to the AARP. This is a disgrace, and by the way, they are so cowardly that they want to go forward before the CBO gives an estimate of what it will cost, and how many people will lose their insurance."...

im1dc : , March 13, 2017 at 09:30 AM
Anyone mention Single Payer? No? Why not...

"Republican lawmakers think the biggest problem with health insurance is that too many people have it"

http://www.marketwatch.com/story/ryancare-doesnt-fix-health-care-but-here-are-some-ideas-that-would-2017-03-10

"Ryancare doesn't fix health care, but here are some ideas that would"

By Rex Nutting, Columnist...Mar 13, 2017...7:53 a.m. ET

"Congressional Republicans are moving forward with a bill to repeal and replace the Affordable Care Act, but the proposed bill doesn't do very much to improve on the flaws in Obamacare. The Republican plan doesn't solve any of our health-care problems, because it wasn't designed to.

Instead, it tries (and fails) to solve a political problem.

What are the main complaints about Obamacare? That, even with subsidies, health care is too costly, with rising premiums and high out-of-pocket costs. That, in some areas, there aren't enough choices for health insurance, and there aren't enough choices about doctors or other medical-care providers. That there's a mandate to purchase insurance, even if you're healthy.

Paul Ryan's replacement bill doesn't address any of those concerns. Instead, it would drive costs up for almost everyone except the very healthy and the very rich, and would hit those in their 50s and 60s particularly hard. It would phase out expanded Medicaid coverage, so millions of working-class Americans would lose their insurance completely. It doesn't guarantee that you'll have more choices, and it maintains a mandate to buy insurance.

Unfortunately, the bill's penalty for not buying continuous insurance coverage would create such perverse incentives that it would likely result in even fewer healthy people buying health insurance, which would in turn lead to higher premiums for sick people as the insurance pool becomes smaller and sicker, culminating in the very "death spiral" that supposedly killed Obamacare.

So what is the Republican bill all about? It's an attempt to square the circle politically. Republicans have an intractable problem: People really like having health insurance and the care that goes with it, but Republican lawmakers think the biggest problem with health insurance is that too many people have it.

As Mike Konczal writes: "Conservatives talk compassion, but they really believe that the problem with health care is too much coverage, too little risk for individuals and too much taxation."

Or as my colleague Caroline Baum writes: "Republicans are getting a crash course on what they already knew, or should have known: once an entitlement, always an entitlement." In other words, Republicans should go back to the principle that no one should get anything they can't afford. There's no free lunch, and no free health care.

As you can see, there is no way to square this. People want affordable health care, and Republicans don't want to give it to them. So of course the bill is a mess, pleasing no one except those who foolishly think that the people wouldn't notice that the Republicans had replaced Obamacare with something much worse.

The problems of health care

So how should we improve our health-care system? The first step is to identify what's wrong with it. Several things:

...Everyone should be insured, with the costs fairly divided among all of us. Make it so.

...We could control some costs by shifting the way we reimburse doctors and hospitals.

...We should make sure that health-care providers don't benefit financially from the treatments they prescribe.

...Introducing more competition would drive down prices.

...let's take away the patents for drugs and medical equipment and establish alternative means of encouraging research, innovation and invention

...Finally, we need more transparency about prices, as well as about the risks and benefits of the treatments recommended for us. Prices ought to be posted on the wall of every waiting room and admittance office."...

[Mar 14, 2017] No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist.

Mar 14, 2017 | economistsview.typepad.com
Noni Mausa : March 13, 2017 at 04:13 PM

What the wealthy right wing has decided in the past 40 years is that they don't need citizens. At least, not as many citizens as are actually citizens. What they are comfortable with is a large population of free range people, like the longhorn cattle of the old west, who care for themselves as best they can, and are convenient to be used when the "ranchers" want them.

Of course, this is their approach to foreign workers, also, but for the purpose of maintaining a domestic society within which the domestic rich can comfortably live, only native born Americans really suit.

With the development of high productivity production, farming, and hands-off war technology the need for a large number of citizens is reduced. The wealthy can sit in their towers and arrange the world as suits them, and use the rest of the world as a "farm team" to supply skills and labour as needed.

Proof of this is the fact that they talk about the economy's need for certain skills, training, services and so on, but never about the inherent value of citizens independent of their utility to someone else.

No wonder the unemployed increasingly kill themselves, or others. The whole economy tells them, indirectly but unmistakably, that their human value does not exist. ken melvin : , March 13, 2017 at 04:48 PM

Can someone get me from $300 billion tax cut for the rich to getting the markets work for health care?
ken melvin : , March 13, 2017 at 04:54 PM
It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do. Insurance policies they don't pay out, the ones Ryan is referring to, are as good as any for scoring.
libezkova : , March 13, 2017 at 07:09 PM
"It isn't about 'markets', never is. It is about extraction of as much profit as possible using whatever means necessary. This is what the CEOs of insurance companies get payed to do."

What surprises me most in this discussion is how Obamacare suddenly changed from a dismal and expensive failure enriching private insurers to a "good deal".

Lesseevilism in action ;-)

ilsm : , March 13, 2017 at 01:41 PM
When the PPACA band-aid is pulled off the US health care mess the gusher will be blamed on "the Russians running the White House".

Cuba does better than the US despite being economically sanctioned for 55 years. Distribution of artificially scarce health care resources is utterly broken. This failed market is financed by a mix of 'for profit' insurance and medicare (which sublets a big part to 'for profit' insurance).

Coverage!!! PPACA added taxpayers' money to finance a bigger failed market. It did nothing to address the market fail!

Single payer would not address the market failure. Single payer would put the government financing most of the failed market.

Democrats have put band-aids on severe bleeds since Truman made the cold war more important than Americans.

At least we know what Trump stands for!

jeff fisher said in reply to ilsm... , March 13, 2017 at 01:58 PM
Cuba is the shining example of how doing the first 20% of healthcare well for everyone gets you 80% of the benefit cheap.

The US is the shining example of how refusing to do the first 20% of healthcare well for everyone only gets you 80% of the benefit no matter how much you spend.

jonny bakho : , March 13, 2017 at 12:09 PM
Mark's very nice argument does nothing to address The Official Trump Counter Argument:

[Shorter version: Obamacare is doomed, going to blow up. Any replacement is therefore better than Obamacare; Facts seldom win arguments against beliefs]

"During a listening session on healthcare at the White House on Monday, President Donald Trump said Republicans "are putting themselves in a very bad position by repealing Obamacare."

Trump said that his administration is "committed to repealing and replacing" Obamacare and that the House Obamacare replacement will lead to more choice at a lower cost. He further stated, "[T]he press is making Obamacare look so good all, of a sudden. I'm watching the news. It looks so good. They're showing these reports about this one gets so much, and this one gets so much. First of all, it covers very few people, and it's imploding. And '17 will be the worst year. And I said it once; I'll say it again: because Obama's gone."

He continued, "And the Republicans, frankly, are putting themselves in a very bad position - I tell this to Tom Price all the time - by repealing Obamacare. Because people aren't gonna see the truly devastating effects of Obamacare. They're not gonna see the devastation. In '17 and '18 and '19, it'll be gone by then. It'll - whether we do it or not, it'll be imploded off the map."

He added, "So, the press is making it look so wonderful, so that if we end it, everyone's going to say, 'Oh, remember how great Obamacare used to be? Remember how wonderful it used to be? It was so great.' It's a little bit like President Obama. When he left, people liked him. When he was here, people didn't like him so much. That's the way life goes. That's human nature."

Trump further stated that while letting Obamacare collapse on its own was the best thing to do politically, it wasn't the right thing to do for the country.

http://www.breitbart.com/video/2017/03/13/trump-republicans-putting-bad-position-repealing-obamacare/

[Mar 10, 2017] Get private insurers out of the game, they are taking 20 percent of everyone's money, for no value-added

Mar 10, 2017 | economistsview.typepad.com
Lee A. Arnold -> jonny bakho... March 10, 2017 at 03:59 AM Obama and the Dems can avert the blame by saying,

"Get private insurers out of the game, they are taking 20% of everyone's money, for no value-added. Create a public option that will knock the price down, and will lead us to a single payer, like 'Medicare for All'. Healthcare can't work as a totally free market, it has to work like Medicare. Don't blame the Democrats, blame the Republicans for obstructing smart economics. ACA tried to bring everybody into the system, to reveal our true costs as a nation."

This shouldn't be hard, people!! jonny bakho -> Lee A. Arnold ... , March 10, 2017 at 04:37 AM

People do NOT like dealing with insurance period. A program that is automatic enroll / file to opt out would require less effort and be more appealing. Programs that force people to do things (Read health care legalese) will create a lot more grumbling than programs that auto enroll. It should be as simple as signing up for Medicare. The GOP could buy good will by keeping most of ObamaCare and changing the process. However, the primary GOP goal is to eliminate the taxes on the wealthy that pay for Obamacare subsidies. It is not to do something for their uninsured voters
Lee A. Arnold -> jonny bakho... , March 10, 2017 at 04:51 AM
Totally agree in regards to healthcare, (and we should get rid of the Medicare donut-hole too). Note that part of Obamacare's taxation covers the shortfall in Medicare, so that repealing Obamacare puts Medicare back into jeopardy. Probably one reason that the GOP is trying to avoid a CBO score for as long as possible. Medicare goes on the chopping-block next, make no mistake about it.
Lee A. Arnold -> Lee A. Arnold ... , March 10, 2017 at 05:07 AM
If you have watched a senior try to deal with the Medicare donut-hole, you realize the enormous and cruel burden it places upon some of them. A county-level bureaucrat advised me that this travesty was included to make some people get sick and die faster, so that they don't burden the Medicare system. Old people can get the idea that they have no right to live, because the money ain't there; they don't want to be a burden.
Benedict Arnold -> Lee A. Arnold ... , -1

county-level bureaucrat advised me that this travesty was included to make some people get sick and die faster, so that they
"
~~Lee A. Arnold said~

This is even worse!

"
Senator Michael Enzi and Michigan Representative Fred Upton advocated the extension from October into November especially to allow children to go trick-or-treating in more daylight.[13]

Under Section 110 of the Act, the U.S. Department of Energy was required to study the impact of the 2007 DST extension no later than nine months after the change took effect. The report, released in October 2008, reported a nationwide electricity savings of 0.03% for the year of 2007.[14]

An October 2008 study conducted by the University of California at Santa Barbara for the National Bureau of Economic Research found that the 2006 DST adoption in Indiana increased energy consumption in Indiana by an average of 1%. Although energy consumption for lighting dropped as a result of the DST adoption, consumption for heating and cooling increased by 2 to 4%.
"

From this can you easily visualize what a bunch of clowns and jokers we have in Congress? Look!

Railroads, ships, and planes need a consistent system of time that is the same in all parts of the World, the kind of time that does not confuse the human mind. Sure!

computers can be properly reprogrammed to compensate for the stupidity of Congress, but humans using the computers and programming the computers have been confused enough already. We need to revert back to Greenwich Mean Time that has been slightly tweaked by atomic clock but essentially the same in all countries simultaneously. Look!

There is nothing wrong with having lunch at 7:00 in Washington; nothing wrong with having midnight at 19:00 in DC. Hell!

That's even better! At least you know where you are on the planet just from knowing when folks have sun-transit. Sure!

Folks can move trick-or-treat to a different schedule or move school-bus to a different time whenever they like. Sure! Folks can change from one month to the next when to open the glof-course, but don't try to change the entire system of conventional time just to suit your golfing foursome!

Fore
!

pgl -> Lee A. Arnold ... , March 10, 2017 at 05:43 AM
"they are taking 20% of everyone's money, for no value-added. Create a public option that will knock the price down". Exactly.

Their gross margin have risen above 20%. We are talking about operating expenses near 15% of premium revenue which is about twice what this should be. Profits margins are near 6% of premium revenue which translates into ROAs near 25%. And reasonable analysis would suggest that the cost of capital is less than 8% so profit margins closer to 2% would be generous.

Of course - we know why. An oligopoly structure means no real competition. But that is what Paul Ryan wants as he is bought and paid for by the health insurance oligopolists. Remember that when they talk about "free market principles". All talk - no reality.

Lee A. Arnold -> pgl... , March 10, 2017 at 05:55 AM
I thought that ACA restricted the insurers to a "medical loss ratio" (MLR) no lower than 80%, i.e. no more than 20% for themselves.
Anachronism -> Lee A. Arnold ... , March 10, 2017 at 06:00 AM
It does. Don't know about anyone else in this blog, but I'm self employed and buy my own insurance, so I am directly affected by ACA.

Every August, I get a check from Blue Cross for the excess charged (that "no more than 20% for themselves). This year is was just a hair under $2K.

pgl -> Anachronism ... , March 10, 2017 at 06:36 AM
This gives me a thought about the usual Republican babble as to how price controls create shortages (their free market spin of late). Let's suppose my back of the envelope guess of what a competitive gross margin should be is right - that it would be 10% but for the oligopoly structure. With the oligopoly and no ceiling - let's say they are getting a 25% gross margin off of us not on ACA. Then the ACA ceiling is actually a movement towards competition both lowering prices and increasing quantity provided. Standard economics for a market infested with monopoly power.

This says there are two ways to move the market more efficient - either enforce competition (public option) or impose a lower ceiling. So ACA did not go far enough with this 20% ceiling. It should be cut in half.

Anachronism -> pgl... , March 10, 2017 at 06:57 AM
Maybe non-serious republicans think the health insurance market is a free-market situation, but I don't see how. It is rife with imperfect knowledge about the marketplace and failures in pricing.

Without knowing if your back-of-the-envelope is correct, I'd guess the difference between the 10% margin and the actual 20% is a political quid pro quo (I give you the extra 10% and you support the legislation).

What I can say is that I know Medicare operates with a 3 1/2% overhead margin, so moving to a public option should definitely reduce premiums.

pgl -> Lee A. Arnold ... , March 10, 2017 at 06:20 AM
You may be right but ACA covers only a subset of the population. I'm thinking about the overall financials for these companies. Maybe this is why they don't like ACA. They prefer setting this absurdly high gross margin even higher. It could be and should be less than 10%.
EMichael -> pgl... , March 10, 2017 at 06:52 AM
The ACA mandates a MLR of 85% for employer provided insurance.
anne -> Lee A. Arnold ... , March 10, 2017 at 07:32 AM
"Get private insurers out of the game, they are taking 20% of everyone's money, for no value-added...."

Where is this quote taken from? I assume the 20% figure refers to the Medical Loss ratio, * but I do not understand how low that ratio could be under any insurance system.

* https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Medical-Loss-Ratio.html

The Affordable Care Act requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement, also known as the Medical Loss Ratio (MLR). It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards. The Affordable Care Act requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the rate review provisions imposing tighter limits on health insurance rate increases.

Lee A. Arnold -> anne... , March 10, 2017 at 08:31 AM
Anne: "I do not understand how low that ratio could be under any insurance system"

I think that Social Security and Medicare only spend around 2%.

anne -> Lee A. Arnold ... , March 10, 2017 at 08:39 AM
"I do not understand how low that Medical Loss ratio could be under any insurance system"

I think that Social Security and Medicare only spend around 2%.

[ This is what I was after and is especially important. What we need then is to document the administrative cost of Medicare and Social Security. ]

EMichael -> Lee A. Arnold ... , March 10, 2017 at 08:48 AM
A little higher than that, but obviously lower. At the same time, SS does not count except that it makes Medicare Admin costs lower.

Also, admin costs will be lower when you are talking about the simple fact that once people are on Medicare there are no changes(or not many) that has to be dealt with. In the private marketplace there are constant changes(births, policy changes, etc), and these make for higher admin costs.

Not to say these costs are not too high, but there will be higher admin costs for those under 65.

Lee A. Arnold -> EMichael... , March 10, 2017 at 09:40 AM
EMichael: "there will be higher admin costs for those under 65."

Put everybody into one big public risk pool, & the incidence of disease, the treatment costs, and the actuarial tables ought to be pretty steady and predictable.

EMichael -> Lee A. Arnold ... , March 10, 2017 at 09:46 AM
Of course they would. I said the same thing.

Just saying they will not be as low as Medicare, and that the insurance companies do not increase costs by 20%.

Lee A. Arnold -> EMichael... , March 10, 2017 at 10:25 AM
I am not sure I understand you. In a universal public healthcare system, why would administrative costs be different than for Medicare?
anne -> Lee A. Arnold ... , March 10, 2017 at 08:49 AM
http://www.pnhp.org/sites/default/files/Medicare_admin_costs_JHPPL.pdf

February 15, 2013

How to Think Clearly about Medicare Administrative Costs: Data Sources and Measurement
By Kip Sullivan

Abstract

The Centers for Medicare and Medicaid Services (CMS) annually publishes two measures of Medicare's administrative expenditures. One of these appears in the reports of the Medicare Boards of Trustees and the other in the National Health Expenditure Accounts (NHEA). The latest trustees' report indicates Medicare's administrative expenditures are 1 percent of total Medicare spending, while the latest NHEA indicates the figure is 6 percent. The debate about Medicare's administrative expenditures, which emerged several years ago, reflects widespread confusion about these data. Critics of Medicare argue that the official reports on Medicare's overhead ignore or hide numerous types of administrative spending, such as the cost of collecting taxes and Part B premiums. Defenders of Medicare claim the official statistics are accurate. But participants on both sides of this debate fail to cite the official documents and do not analyze CMS's methodology. This article examines controversy over the methodology CMS uses to calculate the trustees' and NHEA's measures and the sources of confusion and ignorance about them. It concludes with a discussion of how the two measures should be used.

anne -> anne... , March 10, 2017 at 09:03 AM
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

December 6, 2016

Historical

The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. The data are presented by type of service, sources of funding, and type of sponsor.

anne -> anne... , March 10, 2017 at 09:09 AM
http://www.pnhp.org/sites/default/files/Medicare_admin_costs_JHPPL.pdf

February 15, 2013

Medicare Administrative Expenses as Percent of Total Expenditures

( Medicare Trustees) ( National Health Expenditure Accounts)

2000 ( 2.0) ( 3.8)
2001 ( 1.6) ( 3.5) Bush
2002 ( 1.8) ( 3.3)
2003 ( 1.7) ( 3.1)
2004 ( 1.9) ( 3.6)

2005 ( 1.8) ( 4.0)
2006 ( 1.5) ( 5.3)
2007 ( 1.5) ( 5.6)
2008 ( 1.4) ( 5.3)
2009 ( 1.3) ( 5.7) Obama

2010 ( 1.3) ( 5.9)
2011 ( 1.4)

-- Kip Sullivan

Lee A. Arnold -> anne... , March 10, 2017 at 09:45 AM
Considering the jump in administrative expenses in the National Health Expenditure Accounts after 2004, we ought to investigate whether this was caused by the passage of privatized Medicare Part D in 2003.
pgl -> anne... , March 10, 2017 at 09:34 AM
Even at 6%, this is far lower than what the private insurers pay.
pgl -> anne... , March 10, 2017 at 09:32 AM
Aetna's 10K reports its health care costs relative to its health care premiums. That is the main part of its gross profit margin and indeed it is as high as he says. And I still stand by my contention that this margin could be cut in half.
anne -> pgl... , March 10, 2017 at 09:49 AM
Supposing I understand the research, administration costs for Medicare ranged between 1.3% and 5.9% of total Medicare spending between 2000 and 2010. Medical Loss ratios for insurers under the Affordable Care Act have been set between 80% and 85%. Here then we would seem to have boundaries within which to argue.
New Deal democrat -> jonny bakho... , March 10, 2017 at 04:49 AM
Yes, agreed. Just to flesh out your point a little ...

The GOP really wants to repeal Obamacare in full and "replace" it with "save money for when you get sick." Oh, and tax cuts for the rich as always.

But they can't do that outright now that 20 million people have coverage under Obamacare, and it is really helping them.

So in "phase 1" of their plan, they kick away the funding, for which they only need 50 votes (+the VP) in the Senate.

"Phase 2" deals with the coverage. It is really crappy. They can accomplish this by nuking the filibuster, *OR* they can tell Dems that if they don't go along, they will get blamed for the death spiral of the existing law (now that funding is gone). Since the GOP plan is also designed to go into a death spiral, the Dems probably will hold the line.

But either way, there is a death spiral. The GOP wurlitzer will be easier to crank up with blaming the Dems when they don't go along. And since it will block grant Medicaid and cause the Medicare trust fund to be exhausted in 2024, it tees up the next round of gutting the civil state.

reason -> New Deal democrat... , March 10, 2017 at 05:12 AM
This is the Republican plan - but it is a disaster for Trump. The problem is of course that he is too stupid to realize it.
reason -> jonny bakho... , March 10, 2017 at 05:09 AM
placate (not place) - for those who are having trouble reading jonny bakho here.

[Mar 10, 2017] All roads politically lead to a single-payer (perhaps accompanied by a secondary market for add-on coverage for the rhinestone-encrusted lifestyle) however long and bumpy the road will be.

Mar 10, 2017 | economistsview.typepad.com
jonny bakho : March 10, 2017 at 04:30 AM

, 2017 at 04:30 AM
Kevin Drum understands:
Republicans knew exactly what problem they were trying to solve. Their preference has always been to repeal Obamacare and do nothing in its place, but they don't have the votes to overcome a Democratic filibuster, so they can't do that. They also realize that the optics of baldly ripping away health coverage from 20 million people would be mildly troublesome.

So their goal was simple: do what they could to destroy Obamacare and take away as much health coverage as they could, without making it look like they weren't offering a replacement. The result is a plan that offers the trappings of health care-subsidies, pre-existing conditions, etc.-but which is all but useless to the people who actually need it. It's too stingy for poor people, and mostly unnecessary for middle-class folks who already get health insurance from their employers. It will cost very little because virtually nobody will use it.

The part they apparently didn't realize is that keeping the pre-existing conditions clause-which is both popular and impossible to repeal-while tearing down the rest of Obamacare is likely to destroy the individual insurance market. At least, I assume they didn't realize that, since this would be bad news even by Republican standards. Maybe they're just counting on their repeal bill failing in the Senate, so nothing bad will happen and they can get back to complaining about Obamacare.

http://www.motherjones.com/kevin-drum/2017/03/republican-health-care-bill-carefully-crafted-solve-specific-problem

Lee A. Arnold : , March 10, 2017 at 04:46 AM
It's odd that the GOP didn't understand this, because they have had enough time to figure it out. All roads politically lead to a single-payer (perhaps accompanied by a secondary market for add-on coverage for the rhinestone-encrusted lifestyle) however long and bumpy the road will be. So either they are 1. intellectually incompetent (always a good bet) or 2. they are short-term punters who understand the limited attention-span of the U.S. voter, or 3. they believe that free-market capitalism is a religious emotion that salves all wounds if only it can be impressed far enough into the psyche.
pgl -> Lee A. Arnold ... , March 10, 2017 at 05:45 AM
"they have had enough time to figure it out".

The latest GOP spin is that they have been talking about their plan for over 7 years. Really? Is that why they kept their plan a secret until a few days ago?

kthomas -> pgl... , March 10, 2017 at 08:23 AM
There was never any plan. Ryan is a charlatan.
pgl -> kthomas... , March 10, 2017 at 09:34 AM
Yep.
George H. Blackford : , March 10, 2017 at 05:38 AM
Democrats ran away from Obamacare in 2010, 2012, and 2014. Then Hillary wasted her time ridiculing Trump without offering a solution to the rising cost of healthcare except more of the same.

The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions.

Democrats make no more sense in this regard than the Republicans do. Why should anyone listen to Democrats in this situation when the Democrats have nothing to offer but more of the same?

pgl -> George H. Blackford ... , March 10, 2017 at 05:48 AM
Back in 1993 Mrs. Clinton was supposed to come up with some awesome health care reform. Maybe her team did but they never really got the message out clearly. In the meantime the Republicans savaged the air waves and nothing got done. ACA may have been Romney's plan but at least Obama got it past. And of course even Mitt Romney has spent the last 7 years attacking this former Republican plan. The new plan is really awful but the current Republicans are pushing it through as if it were written by God.
George H. Blackford -> pgl... , March 10, 2017 at 05:51 AM
QED
Anachronism said in reply to pgl... , March 10, 2017 at 06:03 AM
They're pushing it thru because they want it passed before the CBO can score it. They're afraid of the results.

The Brookings Institute scored it and estimated 7 million reduced from direct purchasing of healthcare, another 7 million off of Medicaid roles, and costs roughly $800 billion over 10 years.

pgl -> Anachronism ... , March 10, 2017 at 06:22 AM
I was hoping some independent and credible group would score this awful thing. I bet Paul Ryan decries Brookings as "librul".
Anachronism said in reply to pgl... , March 10, 2017 at 06:59 AM
Anyone who disagrees with them is not credible.
pgl -> Anachronism ... , March 10, 2017 at 09:35 AM
We have a consensus. As kthomas wrote:

"Ryan is a charlatan."

Ed Brown -> pgl... , March 10, 2017 at 07:54 AM
Thinking back to Mrs. Clinton's activities in 1993 on this issue: imagine if Melania Trump was currently working to architect something significant, such as trade policy. It would be odd, no? She was not elected.

The Clinton's have consistently exhibited a certain level of arrogance and entitlement which has not been helpful to the political left over the years.

Oh well, spilled milk I guess.

EMichael -> Ed Brown... , March 10, 2017 at 08:06 AM
Liberals are the worst team mates in the world.

Yeah, having HRC work on healthcare was surely an example of "arrogance and entitlement".

geez

https://learnodo-newtonic.com/eleanor-roosevelt-accomplishments

Pinkybum -> Ed Brown... , March 10, 2017 at 08:39 AM
"imagine if Melania Trump was currently working to architect something significant, such as trade policy. It would be odd, no? She was not elected."

Hahahaha! Plenty of people who are not elected work on policy.

EMichael -> Pinkybum... , March 10, 2017 at 09:09 AM
Nelson was the only Dem Senator that held his vote to end debate in order to get something. He was "paid off" and dropped his filibuster.

Lieberman, along with every Rep senator, stopped the public option.

Best part of the whole sorry process was the work of Pelosi, who took away Nelson's kickback through reconciliation. Something she could not do to Lieberman.

sanjait -> Pinkybum... , March 10, 2017 at 10:08 AM
"Hahahaha! Plenty of people who are not elected work on policy."

Yes. It was such a strange criticism.

The worst thing about Hillary Clinton is that somehow she is a magnet for this kind of faux serious critic.

It's especially odd considering that we are talking about an effort to expand healthcare access, and doubly especially odd considering the instrumental role HC played in getting SCHIP passed after "Hillarycare" crashed.

yuan -> Ed Brown... , March 10, 2017 at 09:19 AM
hopefully more like the dustbin of history...
pgl -> Ed Brown... , March 10, 2017 at 09:36 AM
Melania Trump may not be the sharpest pencil in the box but I bet she could do a better job than Peter Navarro.
jonny bakho said in reply to George H. Blackford ... , March 10, 2017 at 06:41 AM
"Hillary wasted her time ridiculing Trump without offering a solution to the rising cost of healthcare except more of the same."

This strikes me as revisionist history. The AntiObamacare voters were not persuadable. They believed and still believe Trump's lies about creating a better program.

Obamacare has been bending health care costs.

The solution to Health care costs requires reform of the medical care delivery system. There is zero public support for that

George H. Blackford -> jonny bakho... , March 10, 2017 at 08:15 AM
There is zero public support for that because Democrats, except for Sanders, refuse to make it an issue in a campaign and explain it to the American people. It was Democrats who rejected Sanders and nominated more of the same Hillary.
yuan -> George H. Blackford ... , March 10, 2017 at 09:24 AM
"There is zero public support for that because Democrats, except for Sanders"

this is not accurate, imo. a more accurate statement would be that triangulation of the democratic party (clinton and obama) into conservative territory has created a repubicanesque punish-the-poors voting block.

EMichael -> George H. Blackford ... , March 10, 2017 at 06:57 AM
I'll ignore the straw man you place firmly in your first sentence and just ask how you can say,

"Democrats make no more sense in this regard than the Republicans do."

What it means is that you think the ACA is as good as this GOP plan.

Seriously?

I am also more than a little tired of supposed liberals repeating constantly the "dems did not want the public option" meme. Beyond tiring, and self defeating.

Liberals make the worst team mates in the world.

Peter K. -> EMichael... , March 10, 2017 at 07:01 AM
They didn't want it. Obama didn't fight for it. Lieberman blocked it.

You can always count on EMichael to defend the Democrats no matter what the accusation.

Why is that?

Whose payroll is he on?

sanjait -> Peter K.... , March 10, 2017 at 10:09 AM
Peter unwittingly illustrates EMichael's point...
George H. Blackford -> EMichael... , March 10, 2017 at 08:32 AM
EMichael, What it means is exactly what I said:

The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions.

Democrats make no more sense in this regard than the Republicans do. Why should anyone listen to Democrats in this situation when the Democrats have nothing to offer but more of the same?

The obvious answer to that rhetorical question is that there is no reason anyone should listen to Democrats given their refusal to offer a solution to the problem of the rising cost of healthcare, and the result of this is Trump.

I think it is a bit much to blame voters for the failures of the Democrats to come up with sensible programs.

EMichael -> George H. Blackford ... , March 10, 2017 at 08:42 AM
Good is not the enemy of perfect.

In the US, there are only two choices.

The Dems tried to get a public option (which would certainly result in single payer)into law. Not one single GOP senator was even in favor of allowing the public option to get to the floor. Only one Rep House member voted for the public option.

And someone you think they are the same.

Wonder why Sanders did not try to run for the Rep nomination?

George H. Blackford -> EMichael... , March 10, 2017 at 09:06 AM
You've got it exactly right, and the Democrats refused to make it a campaign issue to bring it to the electorate and fight for it.

Neither Republicans nor Democrats make any sense on this issue since neither are willing to fight for anything that makes sense.

To my mind, what that means is that trying to defend either one against the other is nonsense.

EMichael -> George H. Blackford ... , March 10, 2017 at 09:13 AM
I don't know, maybe it is me.

Seems to me that defending a program that has saved more than 100,000 American lives makes sense.

Seem to me that defending a program that has given more than 20 million Americans health insurance makes sense.

Not perfect. But then again there are only two choices.

George H. Blackford -> EMichael... , March 10, 2017 at 09:24 AM
The moral of the story is that both the Democrats and the Republicans have proved to be so incompetent that we ended up with Trump!

It seems to me that it is a serious mistake to ignore this fact and to try to blame the mess we are in on someone else.

The fault, dear Brutus, is not in our stars But in ourselves, that we are underlings.

EMichael -> George H. Blackford ... , March 10, 2017 at 09:37 AM
Please.

Don't move that goal post on me.

I do not ignore the fact that Democrats have not been successful in their admin efforts on many levels.

Some of that is incompetence. Some of that is Rep opposition. Both can be cured.

But neither can be cured by thinking they are all the same.

Bernie Sanders knows that. Why can't everyone figure that out?

George H. Blackford -> EMichael... , March 10, 2017 at 10:07 AM
Facts Liberal elites refuse to face:

a) In the 70s, a Dem congress began deregulating the financial system with the help of a Dem president.

b) In the 80s, a Dem congress continued deregulation and cut taxes on the rich, increased taxes on the not so rich, cut SS benefits and essential government programs, and abandoned the unions.

c) In the 90s, a Dem president reappointed Greenspan to the Fed, further deregulated and cut essential programs, and signed draconian crime, welfare, and student loan bills into law.

d) In 07, the Dems took back the congress and did nothing to hold accountable those who had led us into a war under false pretenses, turned us into a nation of torturers, and politicized the Justice Department as the concentration of income rose until the economy blew up in the fall of 08.

e) In 09 the Dems took complete control of the federal government and ignored students and homeowners as they bailed out the banks, passed a Heritage Foundation healthcare plan championed by the insurance and drug companies as incomes and wages plummeted.

The working and middle classes were decimated throughout this process, and, somehow, it's the voters' fault we ended up with a throw the bums out Trump instead of a more of the same Hillary? I don't think so!

Liberal elites are in a state of denial. It's time to wake up and face reality:
http://www.rweconomics.com/htm/Ch_1.htm
http://www.rweconomics.com/Deficit.htm
http://www.rweconomics.com/Sanders1.htm


pgl -> George H. Blackford ... , March 10, 2017 at 09:40 AM
Harris Wofford was a nobody in 1992 until he decided to take on the health care issue. And he shocked the world by beating one of the stars in the GOP machine. We should have had a real health care bill in 1993 but we failed. Obama sort of succeeded by dusting off the Republican plan. We need the next Harris Wofford.
Pinkybum -> George H. Blackford ... , March 10, 2017 at 08:43 AM
"The obvious solution for rising healthcare costs is either a public option or extending Medicare to younger and younger people, but Democrats, other than Sanders, refuse to offer or defend these solutions."

Medicare for all was not offered because politically it was a non-starter. The public option was offered and once the Republicans (and Democrats who might as well be Republicans) realized what it meant (out-competing insurance companies) they opposed it.

EMichael -> Pinkybum... , March 10, 2017 at 09:14 AM
oops, put this in the wrong place.

Nelson was the only Dem Senator that held his vote to end debate in order to get something. He was "paid off" and dropped his filibuster.

Lieberman, along with every Rep senator, stopped the public option.

Best part of the whole sorry process was the work of Pelosi, who took away Nelson's kickback through reconciliation. Something she could not do to Lieberman.

yuan -> Pinkybum... , March 10, 2017 at 09:32 AM
"and Democrats who might as well be Republicans"

people who try to equate these class traitors to all democrats are carrying their water.


[[House Speaker Nancy Pelosi (D-CA) pledged at the time that the House bill would include a public option.15 Indeed, a public option offered through a private insurance exchange was included in all three versions of the bill passed by House committees in the summer of 2009 (House Ways and Means and House Education and Labor on 17 July 2009; House Energy and Commerce on 31 July 2009), as well as in the bill passed by the full House of Representatives on 7 November 2009 (the Affordable Health Care for America Act, HR 3962). A public option was also included in the bill passed by the Senate Health, Education, Labor, and Pensions Committee on 15 July 2009 (the Affordable Health Choices Act, S 1679).

Senate Democrats were engaged in a highly contentious debate throughout the fall of 2009, and the political life of the public option changed almost daily. The debate reached a critical impasse in November 2009, when Sen. Joseph Lieberman (I-CT), who usually caucuses with the Democrats, threatened to filibuster the Senate bill if it included a public option.

Sen. Charles Schumer (D-NY) and Sen. Jay Rockefeller (D-WV) made last-minute attempts to introduce amendments to include a public option as the bill was about to be voted on by the Senate Finance Committee. Those failed, and there was no public option in either the bill that emerged from that committee or the bill that passed the full Senate on 24 December 2009]]

http://content.healthaffairs.org/content/29/6/1117.full

George H. Blackford -> yuan... , March 10, 2017 at 09:41 AM
My question is, why was this allowed to die there?

Why wasn't it raised as a campaign issue in the 2010, 2012, and 2014 elections, explained to the public, and fought for by the Democrats?

yuan -> George H. Blackford ... , March 10, 2017 at 09:47 AM
i think obama's conservatism played a huge role.
EMichael -> George H. Blackford ... , March 10, 2017 at 09:53 AM
It wasn't allowed to die there. It did die there.

Fairly easy to see that the election of a black man brought the GOP together in a way that nothing else could.

Dems took a beating in the mid terms, not because of the lack of a public option, but because of a black man in the white house. They could not run on further health care reform, cause that was not possible.

One thing.

Congress controls legislation. And to spit into the wind is stupid.

George H. Blackford -> EMichael... , March 10, 2017 at 10:11 AM
It died because the Democrats ran away from it in the 2010 election.
pgl -> Pinkybum... , March 10, 2017 at 09:43 AM
The Republicans have no ideas but they are very good at shutting down the best ideas for policy. Of course when people think of health care like they think about buying groceries getting past the GOP BS re market solutions needs louder and crispy messaging.
Jerry Brown : , March 10, 2017 at 06:46 AM
Part of me hopes the Republicans enact their dumb plan. It is not a good plan, not even as good as Obamacare which isn't all that great itself. But at least they will be on record for voting for it. Almost as soon as it goes into effect, it will be very obvious (even to many Republicans) that it needs to be fixed. At that point I am sure Democrats would be willing to help fix it. And if they don't fix it, their plan will crash, and then maybe we can enact real Health Care for Americans rather than subsidized premiums for insurance companies.

This plan is bad, and enacting it will be harmful to many Americans in the short term- but enacting it at least will affirm that even Republicans accept a role for government in the provision of health care.

Anachronism said in reply to Jerry Brown... , March 10, 2017 at 07:02 AM
You're correct that most people don't understand the abstract. They have to see it implemented in order to be able to say "Gee, this is horrible".

But when that happens, you now are inflicting a lot of pain on a lot of people who don't deserve it.

I like Will Rogers quote: "Some people can figure things out for themselves. Others learn by reading. The rest of the world needs to pee on the electric fence".

Jerry Brown said in reply to Anachronism ... , March 10, 2017 at 07:17 AM
Yes, it will inflict a lot of unnecessary pain on people, including me. And that is very unfortunate and should be considered criminal or at least sociopathic. And it should not be necessary. But I think that is what we will get out of this Congress and this President.

And then we may be able to fix it or even better scrap it for a Medicare for all type plan.

pgl -> Jerry Brown... , March 10, 2017 at 09:44 AM
It is a bad plan but given that we have been at this since Nixon, maybe the pain of this awful idea will finally wake people up. BTW - as bad a President as Nixon was, at least he wanted health care reform.
Fred C. Dobbs : , March 10, 2017 at 06:51 AM
(So there.)

How a Republican Obamacare replacement plan could
leave rural areas farther behind, from @fivefifths: https://www.theatlantic.com/politics/archive/2017/02/the-gop-plan-to-create-health-coverage-deserts/517839/
The Atlantic - Vann R. Newkirk II - Feb 28, 2017

The devil's always in the details, but if the details of a new 100-page leaked draft of a House Republican plan to repeal Obamacare are too dense to parse, here's a brief snapshot: Millions of people in rural areas where it's already hardest to find doctors might no longer be able to afford health insurance in a few years.

The basics of that plan, which was unveiled by House Speaker Paul Ryan two weeks ago, and the rough shape of which has the support of new health secretary Tom Price and the Trump administration, are known. The plan removes the individual and employer mandates to purchase and provide insurance, respectively, and it would also repeal most of the taxes that fund Obamacare. It would roll back funding for the Affordable Care Act's Medicaid expansion and dramatically restructure the Medicaid program's funding. Further, the plan would replace the Affordable Care Act's cost-sharing subsidies and premium tax credits with an age-rated tax credit, all while keeping Obamacare's popular pre-existing conditions ban.

With the leaked draft legislation released by Politico last week, there are more details as to exactly how House Republicans and the Trump administration plan to repeal Obamacare and usher in a replacement. The draft specifies that Obamacare's Medicaid expansion for low-income able-bodied adults won't be completely eliminated, but the eligibility and funding will be rolled back after 2020. The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation.

Although the draft plan repeals the tax-based individual mandate, it re-establishes a kind of mandate through its incentive to maintain continuous health-insurance coverage. For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don't enroll in coverage as soon as they age out of their parents' plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals' pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage.

After reforming Medicaid, repealing the taxes and mandates of Obamacare and establishing continuous-coverage requirements, the last major reform of this preliminary scheme is to replace the cost-sharing reductions and premium tax credit subsidies of Obamacare's exchanges with a refundable tax credit. Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. So while older people with more health needs receive more than "young invincibles," lower-income people who tend to have more pressing health needs would have even less ability to take care of those needs given their existing ability to pay.

The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ...

The tax-credit structure in the Republican draft plan might be even more damaging than the Medicaid changes to those underserved and rural areas. The existing Obamacare tax credits are not only adjusted by family income, but also by the actual cost of health-care plans in a given market. That geographic adjustment is one of the most important parts of the basic logic of Obamacare, since health-care costs vary quite a bit from place to place.

In the most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ...

Fred C. Dobbs said in reply to Fred C. Dobbs... , March 10, 2017 at 06:55 AM
A tax-credit plan that doesn't account for the actual cost of a person's health insurance might reasonably be expected to create areas where coverage is simply unaffordable, and not just in Alaska. Research indicates that health-insurance premiums are higher for rural counties and states, particularly towards the interior and western frontier of the country-prime Trump country. Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers.

That disparity between costs and access for rural residents creates a conundrum for Republicans. By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out. These patients already suffer the effects of "health-care deserts" as rural hospital systems collapse and access to basic specialty services like maternal care wane. In addition to those health care and service deserts in rural areas, Republicans would be contributing to brand-new "coverage deserts."

The result might be a national health-insurance system that does relatively well for so-called "coastal elites" with decent access to physicians and robust state public-health infrastructure, but rather badly for the denizens of Middle America that Trump and the GOP place at the center of their rhetoric. As more and more Republican congressmen in those places face hostile town halls about Obamacare and a real fear of losing coverage from constituents, this new policy outline doesn't seem likely to alleviate those fears.

sanjait -> Fred C. Dobbs... , March 10, 2017 at 10:14 AM
Didn't read past the heading ... but yes, rural residents would be screwed by the GOP's bill.

Rural residents are more likely to be receiving subsidies under the expanded Medicaid and exchanges.

Perhaps worse,*rural hospitals* are always hanging on by a thread, and when more of their patients are uninsured that tips the balance toward insolvency for them. The American Health Carnage Act would result in significantly reduced access to healthcare for rural residents, because geography.

Fred C. Dobbs : , March 10, 2017 at 07:35 AM
BLUEXIT

A Modest Proposal For Separating Blue States From Red

The New Republic - KEVIN BAKER - March 9, 2017

https://newrepublic.com/article/140948/bluexit-blue-states-exit-trump-red-america

Dear Red-State Trump Voter,

Let's face it, guys: We're done.

For more than 80 years now, we-the residents of what some people like to call Blue America, but which I prefer to think of as the United States of We Pay Our Own Damn Way-have shelled out far more in federal tax monies than we took in. We have funded massive infrastructure projects in your rural counties, subsidized your schools and your power plants and your nursing homes, sent you entire industries, and simultaneously absorbed the most destitute, unskilled, and oppressed portions of your populations, white and black alike.

All of which, it turns out, only left you more bitter, white, and alt-right than ever.

Some folks here in self-supporting America like to believe that there must be a way to bring you back to your senses and to restore rational government, if not liberal ideals, sometime in the foreseeable future. Everyone seems to have an answer for how to do this. Every day another earnest little homily finds its way to me over my internet transom: "Think locally, act globally," or "Make art and fight the power," or the old Joe Hill standby-"Don't mourn. Organize."

To which I say: Don't organize. Pack.

Not literally, of course. Not even the good people of Canada should have to stomach a mass migration of moping American liberals mumbling, "Live locally make art." What I mean is that it's time for blue states and cities to effectively abandon the American national enterprise, as it is currently constituted. Call it the New Federalism. Or Virtual Secession. Or Conscious Uncoupling-though that's already been used. Or maybe Bluexit.

Truth is, you red states just haven't been pulling your weight. Not for, well, forever. Red states are nearly twice as dependent on the federal government as blue states. Of the twelve states that received the least federal aid in return for each tax dollar they contribute to the U.S. Treasury, ten of them voted for Hillary Clinton-and the other two were Michigan and Wisconsin, your newest recruits. By the same count, 20 of the 26 states most dependent on federal aid went to Trump.

Take Mississippi (please!), famous for being 49th or 50th in just about everything that matters. When it comes to sucking at the federal teat, the Magnolia State is the undisputed champ. More than 40 percent of Mississippi's state revenue comes from federal funding; one-third of its GDP comes from federal spending; for every dollar it pays out in federal taxes, it takes in $4.70 in federal aid; one in five residents are on food stamps-all national highs. You people-your phrase, not mine-liked to bash Obama for turning America into what you derisively referred to as "Food Stamp Nation." In reality, it's more like Food Stamp Red America-something your Trump-loving congressmen will discover if and when they fulfill their vow to gut the program.

Trump's characterization of "American carnage" in our urban centers aside, cities now generate the vast majority of America's wealth-the cities, that is, where blue folks live. It's true that Hillary Clinton carried just 487 counties in 2016. It's also true that those 487 counties generate almost two-thirds of the nation's economic activity. ...

Fred C. Dobbs said in reply to Fred C. Dobbs... , March 10, 2017 at 07:39 AM
Except for California (a big
exception), Red states are
where most of our food
comes from, yes?

Hmmm.

yuan -> Fred C. Dobbs... , March 10, 2017 at 09:34 AM
i guess you have never visited oregon and washington.
Fred C. Dobbs said in reply to yuan... , March 10, 2017 at 09:59 AM
Actually, I have, if briefly.
The home of Harry & David.

They may have to keep us alive.

New Deal democrat said in reply to Fred C. Dobbs... , March 10, 2017 at 08:13 AM
The Constitution does allow Interstate Compacts, and it is high time the blue states banded together to offer social insurance via that route.

It would also be fun to talk up an "Interstate Balanced Budget Amendment" enacting Baker's proposition, just for the shits and giggles of watching the red states squirm.

llisa2u2 : , March 10, 2017 at 09:25 AM
"But the answer, of course, is that they were all lying, all along - and they still are. On this, at least, Republican unity remains impressively intact."

What a shame that there really is no integrity in this "replace" process.

MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. What options will the American Citizen have to consider for coverage and at what price? Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up!

How about comparisons as to costs for coverage for what medical services that citizens pay in England, Canada, Germany, France, Switzerland, Norway, Denmark, Sweden, Spain?
How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services....

The Dems and Repubs and everybody else needs to cut the BS!
Quit talking about nothing! Put some real cut and dry facts out to LaLaLand....

llisa2u2 : , March 10, 2017 at 09:32 AM
Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens.
Sanjait : , March 10, 2017 at 09:36 AM
The GOP plan makes perfect sense when you realize it was designed with talking points in mind, rather than impact.

They replaced the mandate with "responsibility", replaced coverage standards with "choice", put in block grants because "states rights" and "flexibility," and delayed the onset of spending cuts because "stability."

It was a strategy, just not an effective one. few people right now are buying their talking points, so it just looks like a "WTF?" situation.

DrDick -> Sanjait... , March 10, 2017 at 10:50 AM
Governance by talking point.
DeDude : , March 10, 2017 at 09:38 AM
How about allowing everybody to buy into Medicare, Medicaid, VA or congresses own health insurance plan - with subsidies to those who cannot afford it. Those programs are the most cost-effective in all of US. If the private sector want to provide something more cost effective it would be welcome to do so in a direct competition. What could be more market based and efficient than that?
RC AKA Darryl, Ron said in reply to DeDude... , March 10, 2017 at 10:22 AM
The VA healthcare plan is about the same as the Republican plan. If you can afford to live in or travel to Bethesda MD then you may live. Otherwise, costs are controlled by a mortality expectation that is shorter than wait time.
im1dc : , March 10, 2017 at 09:43 AM
PK: "the modern G.O.P. always wants to comfort the comfortable and afflict the afflicted; so the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't."

Absolutely loved reading this expose of the GOP in D.C.

yuan -> im1dc... , March 10, 2017 at 09:49 AM
it's an accurate description, imo. funny how the so called "liberal media" can't find the courage to use similarly honest language.
im1dc : , March 10, 2017 at 10:11 AM
Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare.

IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs.

Fred C. Dobbs said in reply to im1dc... , March 10, 2017 at 11:01 AM
Indeed. Folks who feel that
have worked hard in their
lives believe they are entitled,
and those who haven't - for
whatever reasons - are not.

Which takes little account of
those who have been severely
disadvantaged over many years.

Fred C. Dobbs : , March 10, 2017 at 10:57 AM
It has been noted that many of those
who voted for Mr Trump are opposed
to providing medical benefits for
those they regard as 'freeloaders'.

Also, those in the Red states seem
to be opposed to basing benefit amounts
in favor of those Blue staters who have
extra-expensive medical care.

Clearly, the Ryan-Trump plan deals with both issues.

And will further jeopardize healthcare in
a lot of GOP-supporting areas, ironically.

(I'd bet something is going to be
done to fix that anomaly.)

[Mar 10, 2017] Funny how the so called liberal media cant find the courage to use similarly honest language: the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't.

Notable quotes:
"... the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't." ..."
"... Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare. IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs. ..."
"... Envy as a sister of competition story ;-) ..."
"... As someone said the other day on the intertubes, this is an upper class tax cut funded by eliminating healthcare for the poor. ..."
Mar 10, 2017 | economistsview.typepad.com
im1dc : March 10, 2017 at 09:43 AM
PK: "the modern G.O.P. always wants to comfort the comfortable and afflict the afflicted; so the bill ends up throwing away the taxes on the rich that help pay for subsidies, and redirects the subsidies themselves away from those who need them to those who don't."

Absolutely loved reading this expose of the GOP in D.C.

yuan -> im1dc... , March 10, 2017 at 09:49 AM
it's an accurate description, imo. funny how the so called "liberal media" can't find the courage to use similarly honest language.
im1dc : ,
Something I have noticed in my neighborhood in Deep Red Tennessee is that Trump Supporters really want Obamacare repealed and not replaced BUT almost to a person these are people who have either Federal or State funded Health Insurance or Medicare. IOW, they got theirs and expect everyone else to get theirs from the Tooth Fairy like they think they got theirs.
libezkova -> im1dc... , March 10, 2017 at 01:52 PM
Envy as a sister of competition story ;-)
Fred C. Dobbs -> im1dc... , March 10, 2017 at 11:01 AM
Indeed. Folks who feel that
have worked hard in their
lives believe they are entitled,
and those who haven't - for
whatever reasons - are not.

Which takes little account of
those who have been severely
disadvantaged over many years.

DrDick : , March 10, 2017 at 11:34 AM
As someone said the other day on the intertubes, this is an upper class tax cut funded by eliminating healthcare for the poor.

[Mar 10, 2017] All this neoliberals cries about deficiencies of Trumpcare plan are just crocodile tears

Notable quotes:
"... my falling out with the Democratic Party goes back to at least 1968, with concerns even earlier when I was still a school kid. ..."
"... Power corrupts is one of the immutable laws of economics. Democracy is not a good spectator sport. ..."
Mar 10, 2017 | economistsview.typepad.com
libezkova -> ilsm... March 10, 2017 at 05:01 PM
I like the guys who first created meth epidemic in the US and now shed crocodile tears about deficiencies of Obamacare replacement.

RC AKA Darryl, Ron : March 10, 2017 at 03:08 PM , 2017 at 03:08 PM

Why did Republicans propose a "sick joke of a health plan"?

[I am guessing that is a rhetorical question. Just saying that the Republican Party is a sick joke of a political party is both too easy and too obvious.]

libezkova -> RC AKA Darryl, Ron... March 10, 2017 at 05:23 PM , 2017 at 05:23 PM
The problem is not that "the Republican Party is a sick joke of a political party". That's given. Just look at McCain and friends.

The problem is that the Democratic Party became the same sick joke. Even slightly sicker in some respects as they more rely on betrayal of voters and bait and switch tactics pursuing the same neoliberal policies.

Republicans were neoliberal party, the party of big business for a long time. They gave us Reagan and Bush II. But Democrats became the party of Wall Street relatively recently during Clinton presidency.

Get people decent jobs and healthcare plan issues might be more solvable. Institute higher minimal wage as a start. Tax neoliberal "masters of the universe" (and especially the strata of Wall Street speculators and Buffet wannabees ) at Eisenhower rates and put those money into national health insurance fund for everybody, providing for "catastrophic insurance" for a start.

Destroy at least a part of sick, criminal links between medical insurance and for profit hospitals using RICO statute. They are really a new type of mafia. All those useless stent surgeries are not that different from shooting people on the street.

But redistribution policies are a taboo under neoliberalism, so DemoRats will just complain about Trumpcare and than support Republicans in enacting it. The same story as before. Vichy DemoRats will always remain Vichy DemoRats.

If you have no money for both apartment and food like many Wal-Mart workers (living on foodstamps) I doubt that you can pay for health insurance either. So for really poor folks Obamacare was a sick joke. It really was. Obama sold himself to medical-industrial complex which is no less vicious and greedy the military industrial complex.

So all this neoliberals cries about deficiencies of Trumpcare plan are just crocodile tears.

RC AKA Darryl, Ron -> libezkova... March 10, 2017 at 05:32 PM , 2017 at 05:32 PM
That was a bit harsh but there is more than a grain of truth in it. It is late now and I don't have the time now to go into a more measured accounting of how we got from the New Deal to here, but my falling out with the Democratic Party goes back to at least 1968, with concerns even earlier when I was still a school kid.

Power corrupts is one of the immutable laws of economics. Democracy is not a good spectator sport.

[Mar 10, 2017] How a Republican Obamacare replacement plan could leave rural areas farther behind

Notable quotes:
"... Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. ..."
"... The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ... ..."
"... he most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ... ..."
"... Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers. ..."
Mar 10, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 10, 2017 at 06:51 AM , 2017 at 06:51 AM
(So there.)

How a Republican Obamacare replacement plan could leave rural areas farther behind, from @fivefifths: https://www.theatlantic.com/politics/archive/2017/02/the-gop-plan-to-create-health-coverage-deserts/517839/
The Atlantic - Vann R. Newkirk II - Feb 28, 2017

The devil's always in the details, but if the details of a new 100-page leaked draft of a House Republican plan to repeal Obamacare are too dense to parse, here's a brief snapshot: Millions of people in rural areas where it's already hardest to find doctors might no longer be able to afford health insurance in a few years.

The basics of that plan, which was unveiled by House Speaker Paul Ryan two weeks ago, and the rough shape of which has the support of new health secretary Tom Price and the Trump administration, are known. The plan removes the individual and employer mandates to purchase and provide insurance, respectively, and it would also repeal most of the taxes that fund Obamacare. It would roll back funding for the Affordable Care Act's Medicaid expansion and dramatically restructure the Medicaid program's funding. Further, the plan would replace the Affordable Care Act's cost-sharing subsidies and premium tax credits with an age-rated tax credit, all while keeping Obamacare's popular pre-existing conditions ban.

With the leaked draft legislation released by Politico last week, there are more details as to exactly how House Republicans and the Trump administration plan to repeal Obamacare and usher in a replacement. The draft specifies that Obamacare's Medicaid expansion for low-income able-bodied adults won't be completely eliminated, but the eligibility and funding will be rolled back after 2020. The draft also contains a provision changing federal funding for Medicaid in 2020 onward from an open-ended obligation to a system where the per-person spending every year is capped based on spending levels in 2019 and increased annually to correspond with medical inflation.

Although the draft plan repeals the tax-based individual mandate, it re-establishes a kind of mandate through its incentive to maintain continuous health-insurance coverage. For people not covered by employers or public insurance who have to purchase insurance on individual, small group, or exchange markets, this proposal would allow insurers to charge up to 30 percent more in premiums to people who go without coverage at any point for more than two months, and also for young adults who don't enroll in coverage as soon as they age out of their parents' plans, a surcharge that would not be remitted as taxes to sustain the system, but would be paid as profits to insurers. The effects of this potential measure on individuals' pockets are potentially limited by a reduction of federal oversight over what can be considered health-insurance coverage, which would allow people to avoid penalties by purchasing barebones coverage.

After reforming Medicaid, repealing the taxes and mandates of Obamacare and establishing continuous-coverage requirements, the last major reform of this preliminary scheme is to replace the cost-sharing reductions and premium tax credit subsidies of Obamacare's exchanges with a refundable tax credit. Unlike the Obamacare tax credit, which is adjusted by income, age, and the average price of insurance in a person's market, this new credit would only take age into account, starting with $2,000 per year up to age 30 and capping at $4,000 for people over 60. So while older people with more health needs receive more than "young invincibles," lower-income people who tend to have more pressing health needs would have even less ability to take care of those needs given their existing ability to pay.

The result of all these provisions would almost certainly be a system that benefits people who already have wealth and health and penalizes others, but there would also be very strong geographic effects. For one, pegging Medicaid spending to a base year would reduce states' ability to ramp up health-care spending because of disasters or emerging health problems, and these problems already exert the most pressures on states and areas with infrastructure that is ill-equipped to combat them. Rural residents already rely much more heavily on public insurance than do city-dwellers, so any reductions of funding and funding flexibility will have a larger effect on the health issues they face. ...

The tax-credit structure in the Republican draft plan might be even more damaging than the Medicaid changes to those underserved and rural areas. The existing Obamacare tax credits are not only adjusted by family income, but also by the actual cost of health-care plans in a given market. That geographic adjustment is one of the most important parts of the basic logic of Obamacare, since health-care costs vary quite a bit from place to place.

In the most extreme example, Alaskans in the Obamacare exchanges currently receive tax credits at rates double the average for the rest of the country, a number that reflects the scarcity of coverage in Alaska and the demands of covering a frontier population. The Republican proposal might knock all 16,000 of these Alaskans out of insurance markets. ...

Fred C. Dobbs -> Fred C. Dobbs... , March 10, 2017 at 06:55 AM
A tax-credit plan that doesn't account for the actual cost of a person's health insurance might reasonably be expected to create areas where coverage is simply unaffordable, and not just in Alaska. Research indicates that health-insurance premiums are higher for rural counties and states, particularly towards the interior and western frontier of the country-prime Trump country. Those costs increase even as rural residents have less access to basic health care and worse overall health status than their metropolitan peers.

That disparity between costs and access for rural residents creates a conundrum for Republicans. By reducing state Medicaid financial flexibility, reducing oversight over minimum insurance requirements, instilling continuous coverage requirements, and removing regional costs offsets, their Obamacare replacement would in essence put health insurance even further out of reach for sicker, rural patients who need it more and then penalize them for being left out. These patients already suffer the effects of "health-care deserts" as rural hospital systems collapse and access to basic specialty services like maternal care wane. In addition to those health care and service deserts in rural areas, Republicans would be contributing to brand-new "coverage deserts."

The result might be a national health-insurance system that does relatively well for so-called "coastal elites" with decent access to physicians and robust state public-health infrastructure, but rather badly for the denizens of Middle America that Trump and the GOP place at the center of their rhetoric. As more and more Republican congressmen in those places face hostile town halls about Obamacare and a real fear of losing coverage from constituents, this new policy outline doesn't seem likely to alleviate those fears.

[Mar 10, 2017] Neoliberals replaced the mandate with responsibility , replaced coverage standards with muckk worce choice , put in block grants because of states rights and flexibility, and delayed the onset of spending cuts because stability.

Notable quotes:
"... But the answer, of course, is that they were all lying, all along - and they still are. ..."
"... MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. ..."
"... Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up! ..."
"... How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services.... ..."
"... The Dems and Repubs and everybody else needs to cut the BS! Quit talking about nothing! Put some real cut and dry facts out to LaLaLand.... ..."
"... Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens. ..."
Mar 10, 2017 | economistsview.typepad.com

sanjait : March 10, 2017 at 09:36 AM , 2017 at 09:36 AM

The GOP plan makes perfect sense when you realize it was designed with talking points in mind, rather than impact.

They replaced the mandate with "responsibility", replaced coverage standards with "choice", put in block grants because "states rights" and "flexibility," and delayed the onset of spending cuts because "stability."

It was a strategy, just not an effective one. few people right now are buying their talking points, so it just looks like a "WTF?" situation.

llisa2u2 : March 10, 2017 at 09:25 AM , 2017 at 09:25 AM
"But the answer, of course, is that they were all lying, all along - and they still are. On this, at least, Republican unity remains impressively intact."

What a shame that there really is no integrity in this "replace" process.

MSM, CSPAN discussions and townhall meetings need to address and compare specific medical scenario examples as to "What will be the real costs to the American Citizen".. What options will the American Citizen have to consider for coverage and at what price?

Discussions have been so superficial, and just rehashing trite to simplistic process, and primarily Ryan's Powerpoint presentation. Probably the only real take-away from his presentation is the fact that he spoke with his shirt-sleeves rolled up!

How about comparisons as to costs for coverage for what medical services that citizens pay in England, Canada, Germany, France, Switzerland, Norway, Denmark, Sweden, Spain?

How much does a specific drug cost in those countries versus in the US? There is absolutely no addressing the reality of annual costs to the American Citizen and what he/she is paying for. Presently my superficial takeaway is I presume that the majority of citizens will be paying annually $6,000 just for the right to say they have paid for the right to have access to any kind of medical insurance, then there will be various options for any kind of real coverage for specific procedures and services....

The Dems and Repubs and everybody else needs to cut the BS! Quit talking about nothing! Put some real cut and dry facts out to LaLaLand....

llisa2u2 : March 10, 2017 at 09:32 AM , 2017 at 09:32 AM
Every member of Congress, retiree of Congress, President, and past president, every Federal and State employee needs to be under exactly the same coverage options, with no exceptions to entitled separate "exclusive" coverage as governmental employees, as all other American citizens.

[Mar 10, 2017] This is not an act of mercy. It is an act of malice

Mar 10, 2017 | economistsview.typepad.com
Fred C. Dobbs : March 09, 2017 at 01:49 PM , 2017 at 01:49 PM
Ryan defends health care bill amid fierce protest
http://www.bostonglobe.com/news/politics/2017/03/08/house-committees-convene-over-controversial-health-care-law/6LfoZ7S1GBh5cEO4EhV7KJ/story.html?event=event25
via @BostonGlobe - March 8

WASHINGTON (AP) - Speaker Paul Ryan staunchly defended the House Republican health care plan Wednesday as the only alternative to the current Obama-era law, as he confronted forceful opposition from conservatives, medical professionals and others.

''This is the choice we face. Are we going to stay with Obamacare ... or are we going to do what we said we would do,'' Ryan said at a Capitol Hill news conference after a private GOP meeting in which he tried to rally support.

Shortly after Ryan's comments, two committees - Ways and Means and Energy and Commerce - kicked off what are expected to be marathon sessions to finalize the legislation that would scrap major parts of Barack Obama's health overhaul while also fundamentally restructuring Medicaid for low-income people.

Democrats resorted to delaying tactics. At Energy and Commerce, the clerk was forced to start reading the legislation word for word after Rep. Ben Lujan, D-N.M., objected to routinely dispensing with such a reading. At Ways and Means, Republicans voted down a motion by Rep. Lloyd Doggett, D-Texas, to delay deliberations so lawmakers could have more time to study the bill.

Ryan cast the task for the GOP as fulfilling seven years of promises to ''repeal and replace'' with a ''conservative wish list'' scaling back the role of government in health care, cutting money for Planned Parenthood and overhauling mandatory programs.

''Most importantly, we get Washington out of the business of being a nanny state,'' he said.

President Donald Trump and Vice President Mike Pence back the House plan, and Ryan is confidently predicting it will win passage. Behind closed doors on Wednesday, Ryan pointedly told fellow lawmakers that the president is all-in and suggested they should fall in line. ...

Joe Kennedy III attacks GOP health plan for its 'malice'
http://www.bostonglobe.com/metro/2017/03/08/kennedy-rips-gop-health-plan/IWpUdBxaIrjA50ooQ1z43J/story.html?event=event25
via @BostonGlobe - Joshua Miller - March 8, 2017

US Representative Joe Kennedy III ripped into the House GOP's plan to repeal the Affordable Care Act Wednesday in a surprisingly pointed jibe at Speaker Paul Ryan.

Ryan said Tuesday that Republicans are "doing an act of mercy" by repealing the law known as Obamacare and replacing it with something else.

Kennedy, shall we say, does not share that assessment.

"I was struck last night by a comment that I heard made by Speaker Ryan, where he called this repeal bill 'an act of mercy.' With all due respect to our speaker, he and I must have read different Scripture," Kennedy said as the House Energy and Commerce Committee dove into the details of the GOP effort.

"The one I read calls on us to feed the hungry, to clothe the naked, to shelter the homeless, and to comfort the sick.

"It reminds us that we are judged not by how we treat the powerful, but by how we care for the least among us," said the Brookline Democrat and scion of the most famous Massachusetts political dynasty.

"There is no mercy in a system that makes health care a luxury. There is no mercy in a country that turns their back on those most in need of protection: the elderly, the poor, the sick, and the suffering. There is no mercy in a cold shoulder to the mentally ill," he said, appearing to read from notes.

"This is not an act of mercy. It is an act of malice," he said. ...

Senator Warren says GOP health care plan is 'fundamentally cruel'
http://www.bostonglobe.com/metro/2017/03/09/senator-warren-says-gop-health-care-plan-fundamentally-cruel/UOwTdHl3KFloausjuGQK0H/story.html?event=event25
via @BostonGlobe - March 9

BOSTON (AP) - Sen. Elizabeth Warren says the health care bill rolled out by Republicans is ''fundamentally cruel'' and will end up benefiting the wealthy at the expense of middle and working class families.

The Massachusetts Democrat said Wednesday that Republicans seem more interested in bragging about getting rid of ''Obamacare'' than helping people stay healthy.

Warren says the GOP plan will ''work great for those at the top and just kick dirt in the faces of everybody else.'' ...


anne : , March 09, 2017 at 01:54 PM
http://www.oecd.org/health/health-systems/oecd-health-statistics-2014-frequently-requested-data.htm

November, 2016

Organisation for Economic Co-operation and Development Health Data

Total health care spending per person, 2014 *

United States ( 9451)
OCED average ( 3814)

Australia ( 4420)
Austria ( 5016)
Belgium ( 4611)
Canada ( 4608)
Chile ( 1728)
Czech Republic ( 2464)
Denmark ( 4943)
Finland ( 3984)
France ( 4407)
Germany ( 5267)
Greece ( 2245)
Hungary ( 1845)
Iceland ( 4012)
Ireland ( 5131)
Israel ( 2533)
Italy ( 3272)
Japan ( 4150)
Korea ( 2488)
Luxembourg ( 7765)
Mexico ( 1052)
Netherlands ( 5343)
New Zealand ( 3590)
Norway ( 6567)
Poland ( 1677)
Portugal ( 2631)
Slovak Republic ( 2064)
Spain ( 3153)
Sweden ( 5228)
Switzerland ( 6935)
Turkey ( 1064)
United Kingdom ( 4003)

* Data are expressed in US dollars adjusted for purchasing power parities (PPPs), which provide a means of comparing spending between countries on a common base. PPPs are the rates of currency conversion that equalise the cost of a given "basket" of goods and services in different countries.

anne -> anne... , March 09, 2017 at 02:04 PM
Correcting date for data:

http://www.oecd.org/health/health-systems/oecd-health-statistics-2014-frequently-requested-data.htm

November, 2016

Organisation for Economic Co-operation and Development Health Data

Total health care spending per person, 2015 *

[Mar 09, 2017] The case for Single Payer just go stronger

Mar 09, 2017 | economistsview.typepad.com
im1dc : March 09, 2017 at 02:25 PM , 2017 at 02:25 PM
The case for Single Payer just go stronger

http://www.huffingtonpost.com/entry/insurance-companies-medicare-for-all_us_58c1b1fae4b054a0ea690dc8

"Insurance Companies Just Accidentally Made The Case For Medicare For All"

'It's all about the overhead and profit'

By Daniel Marans...03/09/2017...03:51 pm ET...Updated 23 minutes ago

"America's Health Insurance Plans, the trade group for commercial health insurance companies, published an infographic this month breaking down how the industry spends every dollar it receives in premiums.

The group apparently crafted the visual aid to defend rising premiums its member companies are charging customers.

But the chart also inadvertently helps explain why commercial health insurance is a bad deal.

The graphic shows that about 80 percent of every premium dollar goes toward medical expenses ― prescription drugs, doctor visits, hospitalization and other services. Approximately 18 percent goes to administrative costs, and some 3 percent is profit. (The total is more than 100 percent because of rounding. America's Health Insurance Plans explains how it gathered the figures for its infographic here... https://ahip.org/health-care-dollar/

Graphic 'Premium Dollar Breakdown'

By contrast, Medicare, the largest U.S. public insurer, paid just 1.5 percent of its budget to administer traditional insurance plans for seniors and workers with severe disabilities in 2015, according to official data. The rest of Medicare's budget went to paying doctors, hospitals, drug companies and other health care providers.

When you account for administrative costs of Medicare's private plans, which cover some one-third of Medicare beneficiaries, Medicare's overhead approaches 6.4 percent of its budget.

The comparison shows that expanding Medicare to cover the entire population ― or adopting a single-payer health insurance system ― would significantly reduce health care costs by eliminating a whole lot of expenses that aren't related to medical care. That's in part because Medicare does not have to advertise its services, make a profit for investors, or reward its executives with multi-million-dollar compensation packages, as private insurers do.

If the Republican health care replacement law takes effect, it could encourage companies to jack up executive pay even higher. The legislation would raise limits on how much executive compensation a company can deduct from taxes.

Some critics claim the Medicare figures are misleading, because the government insurance program benefits from Social Security Administration and Internal Revenue Service help in collecting the taxes it needs to fund its operations.

In fact, Medicare reimburses the other federal agencies for their services, according to Paul Van de Water, a senior fellow at the liberal Center on Budget & Policy Priorities.

"The notion that there are all these federal costs that are not accounted for is absolutely positively false," Van de Water said.

There are risks and tradeoffs of a single-payer system, like the possibility that insurance coverage will provide fewer benefits than the private insurance market, according to Austin Frakt, a health economist for the Department of Veterans Affairs with academic posts at Boston University and Harvard.

And there are other systems for bringing down costs, like all-payer rate setting, which allows multiple insurers to negotiate provider prices as a single unit, Frakt added.

But "if you look just at cost control, you almost can't do better than single payer," Frakt said.

Thanks, America's Health Insurance Plans!"

[Mar 09, 2017] The roak from Obama care to Trumpcare is full or traps

Mar 09, 2017 | economistsview.typepad.com
anne : March 09, 2017 at 02:18 PM , 2017 at 02:18 PM
http://www.pnhp.org/news/2017/march/pnhp-on-gops-re-branded-and-far-meaner-version-of-aca

March 8, 2017

Physicians for a National Health Program on GOP's re-branded and far meaner version of ACA

The 'American Health Care Act' perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich

Proposed as a replacement of the Affordable Care Act (ACA), the AHCA would maintain its basic structure. The bill would:

• Continue to channel billions of taxpayer dollars through wasteful private insurers;

• Sharply reduce the ACA's subsidies (or "tax credits") available to lower-income persons, particularly older adults, to purchase coverage;

• End the ACA's cost-sharing subsidies for copayments and deductibles, increasing the cost of care for those with chronic medical conditions;

• Replace the ACA's "individual mandate" penalty on the uninsured with a 30 percent surcharge on insurance premiums for those who experienced a lapse in insurance coverage;

• Slash federal funding for the Medicaid expansion beginning in 2020, and move towards a "per capita" cap on Medicaid spending that would squeeze state Medicaid budgets and push millions of enrollees out of the program;

• Increase the tax-favored status of Health Savings Accounts, which mostly benefit people in high income brackets;

• Reduce taxes on pharmaceutical, medical device and health insurance companies;

• Offer tax reductions totaling $274.6 billion over 10 years to the wealthiest 2 percent of Americans.

These and other provisions would take the nation in the wrong direction. Even with the ACA in place, 29 million remained uninsured in 2015; the ACHA would only push that number higher. And today, even many Americans with coverage face bankrupting medical bills for copayments, deductibles and uncovered services. By lowering the standards of private insurance plans and ending cost sharing subsidies, the ACHA would only intensify the problem of "underinsurance."

The ACHA would replace the ACA with a worse, more regressive version of the original bill. This is not what Americans want or need. PNHP instead urges Congress to replace the ACA with a single-payer national health care program. Unlike the ACA or the ACHA, single-payer, Medicare for All reform could effectively control costs while creating a right to high-quality healthcare for everyone in America.

anne -> anne... , March 09, 2017 at 02:25 PM
Clarifying:

http://www.pnhp.org/news/2017/march/pnhp-on-gops-re-branded-and-far-meaner-version-of-aca

March 8, 2017

The 'American Health Care Act' perpetuates the basic structure of the Affordable Care Act, including the subsidization of the private health insurance industry, while cutting benefits to the poor and middle class, and giving hundreds of billions in tax breaks to the rich
By Physicians for a National Health Program

libezkova -> anne... , March 09, 2017 at 05:37 PM
"• Sharply reduce the ACA's subsidies (or "tax credits") available to lower-income persons, particularly older adults, to purchase coverage;"

That's a shame. Over 50 and unemployed is hard enough for most Americans to be hit with additional health insurance charges.

[Mar 07, 2017] Republicans Look to Top 50 Million Uninsured

Mar 07, 2017 | economistsview.typepad.com
anne : March 07, 2017 at 11:10 AM , 2017 at 11:10 AM
http://cepr.net/blogs/beat-the-press/republicans-look-to-top-50-million-uninsured

March 7, 2017

Republicans Look to Top 50 Million Uninsured

In the years before the Affordable Care Act (ACA) the uninsured population peaked at just over 50 million people. It fell sharply when the main provisions of the ACA took effect, falling to less than 28 million in recent quarters. However, in its effort to make America great again, the Republicans expect to raise the number of uninsured back above 50 million. Serious analysis of their plan shows that they have a good shot at meeting this goal.

While the Republicans are in principle keeping some of the provisions of the ACA that were responsible for lowering the number of uninsured, this effect will be temporary. In most cases the situation for most people not covered by their employers will be the same or worse than before the ACA took effect.

For example, the plan leaves in place the expansion of Medicaid through 2020. This should be long enough so that most currently serving Republican governors will not have to deal with the effect of the elimination of this provision. After 2020 people benefiting from the expansion will be allowed to remain on Medicaid, but new people will not be added. Since people tend to shift on and off Medicaid (something rarely understood by reporters who cover the ACA), after two or three years the vast majority of the people who benefited from the expansion will no longer be getting Medicaid. By 2025 the impact of the expansion on the number of the uninsured will be trivial.

The plan also allows insurers to charge people with pre-existing conditions higher rates, if they allow their insurance to lapse. While the provision allowing people to avoid being penalized for pre-existing conditions, if they maintain continuous coverage, may appear to provide protection, in reality this is not likely to be the case. Before the ACA workers were allowed to keep employer based coverage for a substantial period of time after they left their employer under COBRA. * The take up rate under this law was always low, primarily because most workers could not afford to keep their coverage once they left their jobs. This is likely to be the case when the Republican plan takes effect as well.

The Republican plan does provide modest subsidies to people for buying insurance, but the impact of these subsidies will be swamped by the rise in health care costs. The subsidies would be $2000 a year for those under 30 and $4,000 a year for those over age 60. According to the Center for Medicare and Medicaid Services the average cost of health care per person was $9,100 in 2013. Per person costs are projected to rise to $15,800 by 2025.

The Republicans will be further helped in their plans to raise the uninsured population back above 50 million with their proposals for segmenting the market by encouraging healthy people to buy low cost catastrophic health care plans. The Republicans propose to raise caps on health savings accounts, which will give healthy people a strong incentive to buy plans with very high deductibles. As a result, plans that have lower deductibles will have a less healthy population and therefore be very expensive. This should make it more difficult for people with health conditions to afford insurance.

On net, it seems likely the Republican proposal will succeed in raising the number of uninsured above the pre-ACA level. Since this seems the likely outcome, it is reasonable to assume that it is the intention of the Republican designers of the bill.

* https://en.wikipedia.org/wiki/Consolidated_Omnibus_Budget_Reconciliation_Act_of_1985

-- Dean Baker

[Mar 07, 2017] The Republican plan appears to be a poorly considered rush job, not unlike the original ACA. It solves none of the problems created by the ACA and creates new problems of its own

Notable quotes:
"... The point is that 65-70% of the people want a single-payer. It is time to start making that into an electoral reality, and the way to do that is to start beating that drum now. The free market will never work for universal healthcare. God knows whether the Democrats have enough political brains to follow Bernie on this, however. ..."
Mar 07, 2017 | economistsview.typepad.com
mrrunangun : March 07, 2017 at 06:26 PM

, 2017 at 06:26 PM
The Republican plan appears to be a poorly considered rush job, not unlike the original ACA. It solves none of the problems created by the ACA and creates new problems of its own. Perhaps there are enough sensible people left in the Congress to do away with this nonsense, but I doubt that there are enough people there with a sufficient sense of public purpose to work together to improve on the precarious existing system resulting from the ACA.
libezkova -> mrrunangun... , March 07, 2017 at 07:58 PM
A very good insight ! Thank you !
Sporkfed : , March 07, 2017 at 04:36 PM
Increasing the demand for healthcare by providing insurance through a third party will
not contain healthcare costs, nor in the long run, provide quality, affordable, healthcare for the majority of the intended recipients. The monopolies that exist in American medicine must be
eliminated to reduce costs, all other "tweaks" are just bandaids. Single payer may be the best
solution to an intractable problem.
sanjait : , March 07, 2017 at 12:48 PM
Dems need to stand firm and be clear on their messaging, and they will win this debate and stop the GOP from passing a bill.

The GOP bill slashes Medicaid and the support that working families get for exchange insurance, all to finance big tax cuts for the rich. Those are the main things it accomplishes, and Americans are rapidly becoming aware of this reality.

Fred C. Dobbs : , March 07, 2017 at 12:12 PM
The polarization in the US is
such that while Dems & progressives
have accepted that 'universal
healthcare' is a basic right,
GOPsters & conservatives take
the other side. Except when they
too have become enlightened,
partially & somewhat, it seems.

House Republicans Unveil Plan to Replace Health Law https://nyti.ms/2myipXZ

... On Monday, four Republican senators - Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska - signed a letter saying a House draft that they had reviewed did not adequately protect people in states like theirs that have expanded Medicaid under the Affordable Care Act.

Three conservative Republicans in the Senate - Mike Lee of Utah, Rand Paul of Kentucky and Ted Cruz of Texas - had already expressed reservations about the House's approach. ...

See also:

4 GOP senators demand to keep Obamacare
Medicaid expansion http://politi.co/2lVflBP

Four Republican senators from states that expanded Medicaid under Obamacare say they can't support a draft House repeal bill because it won't protect people enrolled in the health entitlement - a move that could doom the legislation's prospects.

"We are concerned that any poorly implemented or poorly timed change in the current funding structure in Medicaid could result in a reduction in access to life-saving health care services," Sens. Rob Portman of Ohio, Shelley Moore Capito of West Virginia, Cory Gardner of Colorado and Lisa Murkowski of Alaska wrote in a letter to Majority Leader Mitch McConnell. "The February 10th draft proposal from the House does not meet the test of stability for individuals currently enrolled in the program and we will not support a plan that does not include stability for Medicaid expansion populations or flexibility for states." ...

Lee A. Arnold -> sanjait... , March 07, 2017 at 01:26 PM
Sanjait: "Going 'single payer' in response is like throwing a Hail Mary pass"

Wrong analogy really, because a single-payer isn't legislatively possible at this moment. Kevin Drum has this right, as almost always. Beyond that, the GOP will never go for a single-payer; this is NOT the point. The point is that 65-70% of the people want a single-payer. It is time to start making that into an electoral reality, and the way to do that is to start beating that drum now. The free market will never work for universal healthcare. God knows whether the Democrats have enough political brains to follow Bernie on this, however.

[Mar 07, 2017] Americans' Challenges with Health Care Costs

Notable quotes:
"... Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items. ..."
"... Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine. ..."
Mar 07, 2017 | economistsview.typepad.com
anne : March 06, 2017 at 11:40 AM , 2017 at 11:40 AM
http://kff.org/health-costs/poll-finding/data-note-americans-challenges-with-health-care-costs/

March 2, 2017

Americans' Challenges with Health Care Costs
By Bianca DiJulio, Ashley Kirzinger, Bryan Wu, and Mollyann Brodie

As lawmakers debate the future of the country's health care system and outline plans to repeal and replace the Affordable Care Act, much of the current debate surrounds how to change or eliminate the health insurance marketplaces developed under the ACA where individuals eligible for financial assistance could compare plans and purchase insurance. While this is an important source of coverage for some, the vast majority of Americans with insurance have coverage from other sources, such as an employer, Medicaid or Medicare, and the public's top priority for lawmakers is reducing what Americans pay for health care. Two recent Kaiser Health Tracking Polls take stock of the public's current experience with and worries about health care costs, including their ability to afford premiums and deductibles. For the most part, the majority of the public does not have difficulty paying for care, but significant minorities do, and even more worry about their ability to afford care in the future. Some of the key findings include:

Four in ten (43 percent) adults with health insurance say they have difficulty affording their deductible, and roughly a third say they have trouble affording their premiums and other cost sharing; all shares have increased since 2015.

Three in ten (29 percent) Americans report problems paying medical bills, and these problems come with real consequences for some. For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items.

Challenges affording care also result in some Americans saying they have delayed or skipped care due to costs in the past year, including 27 percent who say they have put off or postponed getting health care they needed, 23 percent who say they have skipped a recommended medical test or treatment, and 21 percent who say they have not filled a prescription for a medicine.

Even for those who may not have had difficulty affording care or paying medical bills, there is still a widespread worry about being able to afford needed health care services, with half of the public expressing worry about this.

Health care-related worries and problems paying for care are particularly prevalent among the uninsured, individuals with lower incomes, and those in poorer health; but women and members of racial minority groups are also more likely than their peers to report these issues....

Peter K. -> anne... , March 06, 2017 at 11:48 AM
"For example, among those reporting problems paying medical bills, seven in ten (73 percent) report cutting back spending on food, clothing, or basic household items."

That's what the neoliberals like our dear trolls kthomas and PGL want.

They're in the pocket of the lobbyists.

[Mar 07, 2017] Uncertainty and the Welfare Economics of Medical Care

Mar 07, 2017 | economistsview.typepad.com
anne -> anne... March 06, 2017 at 05:11 PM , 2017 at 05:11 PM
https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

December, 1963

Uncertainty and the Welfare Economics of Medical Care
By KENNETH J. ARROW

I. Introduction: Scope and Method

This paper is an exploratory and tentative study of the specific differentia of medical care as the object of normative economics. It is contended here, on the basis of comparison of obvious characteristics of the medical-care industry with the norms of welfare economics, that the special economic problems of medical care can be explained as adaptations to the existence of uncertainty in the incidence of disease and in the efficacy of treatment.

It should be noted that the subject is the medical-care industry, not health. The causal factors in health are many, and the provision of medical care is only one. Particularly at low levels of income, other commodities such as nutrition, shelter, clothing, and sanitation may be much more significant. It is the complex of services that center about the physician, private and group practice, hospitals, and public health, which I propose to discuss.

The focus of discussion will be on the way the operation of the medical-care industry and the efficacy with which it satisfies the needs of society differ from a norm, if at all. The "norm" that the economist usually uses for the purposes of such comparisons is the operation of a competitive model, that is, the flows of services that would be offered and purchased and the prices that would be paid for them if each individual in the market offered or purchased services at the going prices as if his decisions had no influence over them, and the going prices were such that the amounts of services which were available equalled the total amounts which other individuals were willing to purchase, with no imposed restrictions on supply or demand.

The interest in the competitive model stems partly from its presumed descriptive power and partly from its implications for economic efficiency. In particular, we can state the following well-known proposition (First Optimality Theorem)....

a

[Mar 07, 2017] Notes on US healthdoesntcare

Mar 07, 2017 | economistsview.typepad.com
libezkova : March 06, 2017 at 08:41 PM

The problems with US Healthdoesn'tcare started around 1980.

What we observe now (completely broken and corrupt to the core system) is the result of long term term slow deterioration.

Now the US Healthdoesn'tcare in many cases represent the completely opposite practice to healthcare -- health racket.

And they even created their specialized firms that help to extract maximum dollars for private providers.

An interesting example of how pervert the USA healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically are always "out of network" and after providing services (often non-essential and equal to the ride to ER, but mostly unavoidable as soon as 911 service or traffic police is involved, especially for those who are in this situation for the first time ) they bill an outrageous amount to lemmings who do not know how to fight the system.

Average private ambulance bill is probably around $5K in the USA. And that if this was just a ride to ER.

If you have insurance it will pay around the same as Medicare and your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states (CA, partially NY), but still is legal in most other states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/). And look who is at the helm of this wonder of neoliberal health industry (pretty profitable -- currently bills over 120 million in revenue annually taking in probably lion share of that) -- James J. Loures, President & CEO

James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region.

Is not neoliberalism wonderful social system ?

So when somebody is taking about destruction of the US health care system by Trump one needs to understand that there is not much left to destruct. Most of the heavy lifting was done by previous administrations.

Including Obama with his coward method of betrayal of his voters and serving medical industrial complex.

Trump is bad, but to claim that because of that Obama was good is silly. He was just a perfect example of neoliberal "bait and switch" politician.

B.T. :
, March 06, 2017 at 07:51 PM
So it's like the ACA?

Or it's terrible?

Make up your minds neoliberals. Since you didn't want single payer.

libezkova -> B.T.... , March 06, 2017 at 09:12 PM
It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ( http://khn.org/morning-breakout/health-care-billing-errors/ )

"thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones."

Private medical industry and insurance are symbiotic in their desire to milk patients out of their money in the most efficient way possible.

And while those "death panel" decisions are very difficult indeed, fraud is rampant and they are very successful in over-billing patients.

This symbiosis is very similar in nature to what we observe with body shops and car insurance.

[Mar 06, 2017] Something about the meaning of life under neoliberalism

Notable quotes:
"... Probably the most telling example on neoliberal transformation is transformation of healthcare. ..."
"... Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing. ..."
"... Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles. ..."
"... In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests). ..."
"... James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. ..."
Mar 03, 2017 | economistsview.typepad.com
libezkova : March 03, 2017 at 03:51 PM
Something about the "meaning of life" under neoliberalism

Probably the most telling example on neoliberal transformation is transformation of healthcare.

http://onlinelibrary.wiley.com/doi/10.1111/maq.12161/full

== quote ==

Several anthropologists have written about how "market ideology and corporate structures are shaping medicine and health care delivery" (Horton et al. 2014; Lamphere 2005; Rylko-Bauer and Farmer 2002:476).

Mulligan's research shows how "market values come to displace competing notions of what is "good" or "right" in health care" (Mulligan 2010:308–309). She argues that quality in health care is not only a technical matter for evaluating the performance of systems, but, more importantly, it is a particular epistemology, a specific way of knowing.

The information that is produced in technical public health policy terms, and, I would add, in technical legal terms, is "a knowledge-making practice that creates information about the health care system and for managing the system in new ways" (Mulligan 2010:309).

Managing for-profit health care systems successfully requires innovative mechanisms of population control (Abadía-Barrero et al. 2011), including people's acceptance of market principles.

In this historical context, what is crucial is the understanding of the relationship between techniques of governance and the production of social inequality (i.e., an ideological domination reflected in people's support for political practices that are antithetical to their interests).

According to Fassin (2009), Foucault's undeveloped concept of a Politics of Life can illuminate how in regulating populations and normalizing societies, moral ideas about the meaning of life and about how life is valued are enforced.

An understanding of moral definitions of human life must take into account how history becomes embodied, which then illuminates the political tensions that support differential values by which life is organized, represented, and responded to, for example through public policy (Fassin 2007).

== end of quote ==

See also

https://www.youtube.com/watch?v=TsoZeg6CDRY

An interesting example of how pervert the healthcare system became in the USA under neoliberalism is proliferation of private ambulance services which are technically always "out of network" and after providing services (often non-essential) bill outrageous amount to lemmings who do not know how to fight the system. Average private ambulance bill is probably around $5K in the USA. If you have insurance your bill will be around ~$3.5K

This so called differential billing in now outlawed in a couple of states, but still is legal in most states.

This industry also creates specialized collector agencies that deal almost exclusively with collecting ambulance bills like Revenue Guard - Ambulance Billing & Financial Management ( https://www.revenue-guard.com/)

== quote ==

Revenue Guard Executive Team

James J. Loures, President & CEO
James began his career as a broker on Wall Street. In 1984 he left the financial world and founded MultiCare, which grew to be a largest private EMS operation in the Northeast operating 140 ambulances in the New Jersey, New York, and Philadelphia region. After merging MultiCare with the publicly traded Rural-Metro in 2001, James then founded Revenue-Guard in 2004. The company has grown to be a premier provider of EMS revenue cycle and management services in the hospital marketplace, and currently bills over 120 million in revenue annually for their clients. James studied economics at Rutgers University .

Steven J. Loures, Co-Founder and Chief Operations Officer
Steven Loures has 30 years of experience in the Emergency Medical Services / Mobile Health Services field and is considered an expert in revenue cycle, compliance and improving ambulance service operating margins. His real-world revenue cycle knowledge combined with 20 years of managing ambulance operations uniquely differentiates himself with a comprehensive industry perspective. His leadership has provided client confidence to initiate targeted change knowing his proven track record. He is the point of contact for all new and existing clients.

Prior to his current role Steven was the New Jersey Division General Manager of Rural Metro Ambulance. Rural Metro is a large nationwide provider of Emergency Medical Services. He was responsible for oversight of 350 employees, 6 operating locations in three states including New Jersey, Pennsylvania and New York City. Additionally, Steven's responsibilities included all budgets, revenue cycle management, billing compliance, and Sarbanes Oxley financial controls.

Prior to Rural Metro Steven was a Commercial Lear Jet Pilot. The operation provided nationwide long distance critical care air ambulance services. Steven graduated from Embry-Riddle Aeronautical University, Daytona Beach Florida with his Federal Aviation Administration Commercial, Multi-Engine, and Instrument ratings. Early in his career path Steven was a certified NJ paramedic at age 21 and one of the youngest certified paramedics in New Jersey.

Stephanie Dall, Vice President of Finance
Stephanie joined Revenue-Guard in 2005 and is responsible for Finance, Administration, Compliance and client reporting. She has 20 years experience in finance and administration with Rural-Metro Inc. the leading EMS provider in the nation. Stephanie develops budgets and establish performance metrics for Revenue-Guard. Stephanie has a bachelors degree in accounting from Rutgers University.

Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale, Arizona. She handles all system customizations, ePCR integration and client support services. Jen studied at Pace University in New York City.

[Mar 03, 2017] U.S. Medical Coding System

Notable quotes:
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
Mar 03, 2017 | www.nakedcapitalism.com
From my review of Akerlof and Shiller's Phishing for Phools , November 25, 2015 :

As businesspeople choose what line of business to undertake - as well as where they expand, or contract, their existing business - they (like customers approaching checkout) pick off the best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are quickly taken off the table, leading to a situation where such opportunities are hard to find. This principle, with the concept of equilibrium it entails, lies at the heart of economics.

The principle also applies to phishing for phools. That means that if we have some weakness or other - some way in which we can be phished for fools for more than the usual profit - in the phishing equilibrium someone will take advantage of it . Among all those business persons figuratively arriving at the checkout counter, looking around, and deciding where to spend their investment dollars, some will look to see if there are unusual profits from phishing us for phools. And if they see such an opportunity for profit, that will (again figuratively) be the "checkout lane" they choose.

And economies will have a "phishing equilibrium," in which every chance for profit more than the ordinary will be taken up.

We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or, in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall see, plenty of "opportunities for unusual profits" exist in medical coding.

... ... ...

Here is the medical coding process, from the coders perspective, as described by MB-Guide, a site for aspiring medical coders :

Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid.

Hmm. "Their" benefit. Here are the guidelines:

I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. The Denver Post gives a horrific example:

Miscoding Fictions, frauds found to abound in medical bills

A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.

Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy.

Finally, there's "upcoding," and if you are reminded of "upselling" you are exactly right. The Center for Public Integrity :

But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.

The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.

Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system :

"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today's complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. "Until the fraud is detected in these bills the cost of health care is just going to increase. It's not accidental. We've been fighting these overcharges they continue to happen and we continue to get them removed from bills." These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That "mysterious code" is (now) ICD-10, and it's the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post :

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts.

Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors.

It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse." Others say that errors occur largely because of "the complexity of deciphering bills and claims weighted down by complex codes."

Even if the "trade group" is talking it's book, it's still quite a book . NBC :

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

Neoliberal "Consumer"-Driven Solutions

My guts have started to gripe, so I won't go into detail about how you too, the citizen , can learn medical billing codes if you want to dispute your bill. See this cheery post from NerdWallet on "How to Read Your Medical Bill :

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Your medical bill is going to be chock-full of codes and words you may not understand, so the first step is gathering resources that will translate them into plain English.

Ivy , March 2, 2017 at 2:29 pm

One useful adjunct to the coding discussion concerns other billing details such as meds. There is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix) or $26 for a single Tylenol, then something is not right. Of course, that does not include any allocation for nurses, pharmacy or other potential costs, since those are rolled into other line items to decipher. When hospital billing reps are asked about the reasonability and basis of their charges, they spout the canned line about being in line with their local competitors.

Why not have some program with mutual insurance companies, removing in theory some of the profit that is driving the typical health care insurers?

TheBellTolling , March 2, 2017 at 2:31 pm

Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image).

ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims.

_________________________________

Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has conditions that will cost more) each member is and give insurers more or less money based on the average risk scores of their members. Since it relies on coding this system is also subject to gaming.

In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability to use some adjustment factors to MA payments to address the issue but I don't really know how effective it is.

In ACA this is done relative to all the other insurers in the individual/small group market(so all the money is changing hands between the insurers). More established plans generally do better since they have more data on members from before ACA to make sure they get coded in addition to resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and newer plans like co-ops.
_____________

[Mar 03, 2017] How to Read Your Medical Bill

Notable quotes:
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
NerdWallet
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in names and addresses result in huge billing complications. Before you move on, make sure your name, address, insurance information and dates of care are correct on the top of the bill.

header

When you receive inpatient or outpatient care, the first statement you'll receive is most likely a summary bill. Often, but not always, health care providers will send only a summary of charges with a final charge at the end. The body of the bill has a few generic categories and no codes, looking something like this:

summarybill

That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this:

detailed

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Next, know what the codes are for

Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's more than one type of code that may be listed on your bill.

svccode

HCPCS Level I, or CPT Codes, are universal, used by all providers in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed as service codes.

svccode2

HCPCS Level II Codes identify supplies or products used during your visit. These codes often start with a letter, rather than a number, but are also referred to as service codes.

[Feb 27, 2017] Why Markets Can't Cure Healthcare

Feb 27, 2017 | economistsview.typepad.com
anne -> anne... February 26, 2017 at 02:07 PM , 2017 at 02:07 PM
http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/

July 25, 2009

Why Markets Can't Cure Healthcare
By Paul Krugman

Judging both from comments on this blog and from some of my mail, a significant number of Americans believe that the answer to our health care problems - indeed, the only answer - is to rely on the free market. Quite a few seem to believe that this view reflects the lessons of economic theory.

Not so. One of the most influential economic papers of the postwar era was Kenneth Arrow's "Uncertainty and the Welfare Economics of Health Care," * which demonstrated - decisively, I and many others believe - that health care can't be marketed like bread or TVs. Let me offer my own version of Arrow's argument.

There are two strongly distinctive aspects of health care. One is that you don't know when or whether you'll need care - but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor's office; and very, very few people can afford to pay major medical costs out of pocket.

This tells you right away that health care can't be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can't just trust insurance companies either - they're not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers' point of view - they actually refer to it as "medical costs." This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there's a widespread sense that our fellow citizens should get the care we need - not everyone agrees, but most do - this means that private insurance basically spends a lot of money on socially destructive activities.

The second thing about health care is that it's complicated, and you can't rely on experience or comparison shopping. ("I hear they've got a real deal on stents over at St. Mary's!") That's why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don't trust them - they're profit-making institutions, and your treatment is their cost.

Between those two factors, health care just doesn't work as a standard market story.

All of this doesn't necessarily mean that socialized medicine, or even single-payer, is the only way to go. There are a number of successful healthcare systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn't work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

* https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

anne -> anne... , February 26, 2017 at 02:44 PM
Correcting again and continuing:

Though Krugman always praises the work of Arrow on healthcare markets, Krugman never seems much been influenced by the work.

Though praising Arrow on healthcare markets, Krugman seemingly has spent no time on or possibly has dismissed research affirming Arrow and has not supported the sorts of healthcare insurance systems that would follow from accepting the work of Arrow:

https://promarket.org/there-is-regulatory-capture-but-it-is-by-no-means-complete/
/
March 15, 2016

"There Is Regulatory Capture, But It Is By No Means Complete"
By Asher Schechter

Kenneth J. Arrow, one of the most influential economists of the 20th century, reflects on the benefits of a single payer health care system, the role of government and regulatory capture.

Mr. Bill : , February 26, 2017 at 03:32 PM
So Anne, what your saying is that "health care" is a monopolistic industry that makes more money by restricting care and charging more ? Allowing people that can't afford to live, too die?

Well. yes, I agree with your presumed hypothesis, and I admire your boldness for stepping out in front of this moving freight train, risking your beloved tenure.

To me ? Thanks for asking.

I think that the 3 % administrative costs of the existing single payer system are more pareto optimal than the 25 % that the monopolists' extract. What do I know. This is America. Dumb is not an option.

anne : , February 26, 2017 at 06:33 PM
Turning again to Kenneth Arrow and healthcare markets, assuming that Arrow was correct for all these years, and subsequent research repeatedly has confirmed Arrow, then a typical American market-based healthcare insurance system is going to prove unworkable. Why then has the work of Arrow which is at least superficially so broadly praised by economists not been more influential in forming policy?
libezkova -> anne... , February 26, 2017 at 07:12 PM
"It is difficult to get a man to understand something, when his salary depends on his not understanding it."

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

[Feb 26, 2017] Clowbacks to benefits manager is "It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get

Feb 26, 2017 | economistsview.typepad.com
im1dc : February 24, 2017 at 05:26 PM , 2017 at 05:26 PM
Real World Economics

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

https://www.bloomberg.com/news/articles/2017-02-24/sworn-to-secrecy-drugstores-stay-silent-as-customers-overpay

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

by Jared S Hopkins...February 24, 2017...9:52 AM EST

> Gag clauses stop pharmacists from pointing out a cheaper way

> Cigna, UnitedHealth and Humana face at least 16 lawsuits

"Eric Pusey has to bite his tongue when customers at his pharmacy cough up co-payments far higher than the cost of their low-cost generic drugs, thinking their insurance is getting them a good deal.

Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask.

"Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."

Graphic

Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks.

"It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get enough."

The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively."
Racketeering Accusations

Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws.

"Pharmacies should always charge our members the lowest amount outlined under their plan when filling prescriptions," UnitedHealthcare spokesman Matthew Wiggin said in a statement. "We believe these lawsuits are without merit and will vigorously defend ourselves."

Mark Mathis, a Humana spokesman, declined to comment. Matt Asensio, a Cigna spokesman, said the company doesn't comment on litigation.

"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the Pharmaceutical Care Management Association, said in a statement.

Read more: Escalating U.S. drug prices -- a QuickTake explainer

Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals.

The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price.

"There's this whole industry that most people don't know about," said Connecticut lawyer Craig Raabe, who represents people accusing the companies of defrauding them. "The customers see that they go in, they are paying a $10 co-pay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 co-pay."

On Feb. 10, a customer at an Ohio pharmacy paid a $15 co-pay for 15 milligrams of generic stomach medicine pantoprazole that the pharmacist bought for $2.05, according to receipts obtained by Bloomberg. The pharmacist was repaid $7.22, giving him a profit of $5.17. The remaining $7.78 went back to the benefits manager.
Opaque Market

Clawbacks are possible because benefit managers take advantage of an opaque market, said Hayes, the Illinois consultant. Only they know who pays what.

In interviews, some pharmacists estimate clawbacks happen in 10 percent of their transactions. A survey by the more than 22,000-member National Community Pharmacists Association found 83 percent of 640 independent pharmacists had at least 10 a month.

"I've got three drugstores, so I see a lot of it," David Spence, a Houston pharmacist, said in an interview. "We look at it as theft -- another way for the PBMs to steal."

Lawsuits began in October in multiple states, and some have since been consolidated. Most cite an investigation by New Orleans television station Fox 8, which featured interviews with Louisiana pharmacists whose faces and voices were obscured.
Tight Restrictions

Many plans require pharmacies to collect payment when prescriptions are filled and prohibit them from waiving or reducing the amount. They can't even tell their customers about the clawbacks, according to the suits. Contracts obtained by Bloomberg prohibit pharmacists from publicly criticizing benefit managers or suggesting customers obtain the medication cheaper by paying out of pocket.

Pharmacists who contract with OptumRx in 2017 could be terminated for "actions detrimental to the provider network," doing anything that "disparages" it or trying to "steer" customers to other coverage or discounted plans, according to an agreement obtained by Bloomberg.

"They're usually take-it-or-leave-it contracts," said Mel Brodsky, who just retired as chief executive officer of Pennsylvania's Keystone Pharmacy Purchasing Alliance, which buys drugs on behalf of independent pharmacies.

OptumRx is among the three largest benefit managers that combine to process 80 percent of the prescriptions in the U.S. The other two, Express Scripts Holding Co. and CVS Caremark, haven't been accused of clawbacks. CVS doesn't use them, it said in a statement. Express Scripts is so opposed that it explains the practice on its website and promises customers will pay the lowest price available.
Potential Death Blow

Pharmacies fear getting removed from reimbursement networks, a potential death blow in smaller communities. But some pharmacists jump at opportunities to inform customers who question their co-pay amounts.

"Most don't understand," said Spence, who owns two pharmacies in Houston. "If their co-pay is high, then they care."

States are responding. Last year, Louisiana began allowing pharmacists to tell customers how to get the cheapest price for drugs, trumping contract gag clauses. In 2015, Arkansas prohibited benefit managers and pharmacies from charging customers more than the pharmacy will be paid.

"The consumers don't know what's going on," said Steve Nelson, a pharmacist in Okeechobee, Florida. "We try to educate them with regards to what goes into a prescription, OK? You've got to kind of tip-toe around things."

ilsm -> im1dc... , February 24, 2017 at 07:08 PM
pharma to USG

like drug cartel in Mexico

except no briefcases

im1dc -> ilsm... , February 24, 2017 at 07:47 PM
That's a valid observation.

[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Feb 01, 2017] The dangers of repeal of obamacare

Feb 01, 2017 | economistsview.typepad.com
EMichael : January 31, 2017 at 05:34 AM
Meanwhile, have you noticed this from Drum?

"I've written before about the possibility that repealing bits and parts of Obamacare-which is all Republicans can do-will destroy the individual insurance market. Not just the Obamacare exchanges, but the entire market. Insurers would still be required to insure everyone who applies for coverage, but there would be no subsidies and no mandate. The result would be a flood of super-expensive patients like me, and virtually no healthy people to balance out the pool. If that happens, insurers will simply exit the individual market rather than take huge losses

Here's the only reaction I could find from the insurance industry:

"At a time when the individual market faces challenges, we need as many people as possible to participate - so that costs go down for everyone," said Kristine Grow, spokeswoman for America's Health Insurance Plans.

This wasn't even a reaction to Obamacare repeal, either. It was a reaction to the Trump administration's childish attempt at sabotaging signups for 2017. Basically, the insurance industry has been curiously quiet about the whole thing.

Why? They know the stakes better than anyone. Recent premium hikes hold out the promise that after years of losses, their Obamacare business will finally turn profitable this year or next. But a ham-handed repeal effort does just the opposite. The individual market would become massively unprofitable, and insurers would have to decide whether to ride it out for a year or two, or simply abandon the individual market altogether. These are really lousy alternatives."

http://www.motherjones.com/kevin-drum/2017/01/insurance-industry-curiously-quiet-about-obamacare-repeal

I think I know the reason for the insurance company's silence. They want to go back to the old way. Sure, if the ACA stays in place as it is, they are OK and will profit once they find the proper premium levels. But with what the Reps have already done to the ACA they doubt the program can move forward, especially now.

But even if the Reps just let it stand(which they won't), the insurance companies have figure out that they would be far better off with the old private markets of high deductibles, pre existing condition bans, recissions and cancelling of policies once the holder gets sick.

Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies.

So they stay silent(in public anyway) cause no matter what happens they make out, and this way it seems like they are just following orders and working to "help" the public.

Peter K. -> EMichael... , January 31, 2017 at 05:44 AM
Don't people argue that if we go back to the old way, that the entire system will collapse and we'll get single payer eventually after many painful years?

Trump and that clown Stephen Moore keep talking about competition across state lines but I don't see that happening.

DeDude -> EMichael... , January 31, 2017 at 06:38 AM
ObamaCare required a lot of things, including that they didn't use more than 20% of the premiums on profits. They couldn't just be a scam collecting premiums and kicking people off their plans if/when they got sick. In the old model it was a lot easier to make fat profits out of the asymmetrical knowledge between them and the marks.
EMichael -> DeDude... , January 31, 2017 at 06:54 AM
If the insurance companies thought that medical loss ratios would make it into the bill, they would never have allowed Lieberman to break the filibuster.

Meanwhile, over at Angry Bear, Run has a great post.

http://angrybearblog.com/2017/01/38918.html

I am not sure whether the House is the only one that can change their rules to avoid a CBO analysis. Trying to find out.

DeDude -> EMichael... , January 31, 2017 at 07:22 AM
Yes banning the CBO from scoring repeal and revealing that it is a big budget buster - was a classic GOP trick (keep the people uninformed before you screw them). I agree that it is a little surprising that democrats have not yet gotten the big guns our and pointed out how MediCare will go bankrupt when ACA is repealed. There must be some tactical calculation there. They probably want that perfect storm of scared seniors to call their Senators at a specific time when it will be most likely to tip over the wagon.
DeDude -> DeDude... , January 31, 2017 at 07:26 AM
The GOP repeal of ACA will bankrupt MediCare and Paul Ryan doesn't want you to know about it !!!!!!!!!!!!!!!

Write your Senators and write your representative demanding that they reveal all the details of their nefarious plans.

pgl -> DeDude... , January 31, 2017 at 08:30 AM
"more than 20% of the premiums on profits"

Gross or operating? Operating profit margins are only 8% (4 times greater than a competitive return). Gross margins include the bloated operating expenses. Think X-inefficiency.

pgl -> EMichael... , January 31, 2017 at 08:29 AM
"Combine that with losing medical loss ratios on both private and employer provided insurance and it would be a bonanza for health insurance companies."

One minus the medical loss ratio is the gross profit margin for these oligopolists. This margin should be less than 10% for reasons I have noted before. But wait - they now exceed 20%. What one gets when one allows unfettered monopoly power.

EMichael -> pgl... , January 31, 2017 at 08:45 AM
No, they do not exceed 20%. That is the max in the private market, 15% in the employer market.
DeDude -> EMichael... , January 31, 2017 at 09:13 AM
I should have been a little more precise. "The 80/20 rule requires insurance companies to rebate any excess premium charged if they spend less than 80% of premiums on medical care and efforts to improve the quality of care"

https://www.cms.gov/CCIIO/Resources/Files/Downloads/mlr-report-02-15-2013.pdf

So it includes everything including administration.

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 21, 2017] Assessing Obama healthcare track record

Jan 21, 2017 | www.jacobinmag.com
Over his two terms, Barack Obama signed a number of major health-care bills into law, most significantly the Affordable Care Act of 2010 (ACA), though also more recently the 21st Century Cures Act of 2016. Though the GOP's coming assault on health care is likely to be heartless - and though resistance to it must be resolute - we would be better served by a sober assessment of Obama's health-care legacy than by triumphalist acclaim of such laws.

The ACA, passed without any Republican votes, has had a significant impact on health-care access: mainly through the expansion of Medicaid together with the subsidization of private health insurance, it achieved a partial reduction in the number of the uninsured, from 48.6 million in 2010 to 28.4 million in early 2016 (still an enormous number!), according to National Health Interview Survey estimates . Other provisions of the law, like those eliminating co-payments for some preventive care or banning preexisting condition discrimination, benefited many more.

Yet those who trumpet such gains while scratching their heads at the law's relative unpopularity are missing the crux of the problem: despite President Obama's reforms, the health-care system continues to fail much of the nation.

One example: in Canada, physicians and hospitals are free when you use them. In the United States, co-payments and deductibles for such care (which average $7,474 for a family marketplace silver plan) often rations medical care by economic status. Studies have shown that those with inadequate insurance avoid going to the ER even when they need it, delay care when in the throes of a heart attack , and face financial strain and sometimes bankruptcy when sickness strikes. Such injustices preceded the ACA, but because the law failed to fix them, it is blamed - fairly or unfairly - for their persistence.

More recently, Obama signed the 21st Century Cures Act into law, which among other things incrementally reduced the rigor of the Food and Drug Administration's drug approval process. These provisions were tantamount to a generous handout to the pharmaceutical industry, which had lobbied heavily for the bill. Not surprisingly, it also did precisely nothing about sky-high drug costs .

This is a decidedly mixed legacy. The gains of the ACA are evident: indeed, for some of those who gained coverage, it was lifesaving. Its shortcomings, however, are equally evident: some twenty-eight million uninsured, persistently high cost-sharing, inequalities in access, uncontrolled drug prices, and so forth.

Of course, Republican designs, whether repeal and/or modification, will only make things worse. When that happens, we should dub the resultant fiasco GOP-Care, and blast it for all its injustices. However, it should also be clear that "Let's go back to 2016" will not be a winning campaign slogan for Democrats in coming elections: people want - and deserve - real change.

To defeat GOP-Care, we will need a more powerful weapon than Obamacare. For this reason, the time to push for universal single-payer health care is right now

-Adam Gaffney

[Jan 18, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 18, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 16, 2017] The Biggest Changes Obamacare Made, and Those That May Disappear

Jan 16, 2017 | economistsview.typepad.com
Fred C. Dobbs : January 15, 2017 at 08:37 AM , 2017 at 08:37 AM
The Biggest Changes Obamacare Made, and Those That
May Disappear https://nyti.ms/2itydsr via @UpshotNYT
NYT - Margot Sanger-Katz - January 13, 2017

It looks like the beginning of the end for Obamacare as we know it.

After years of vowing to repeal the Affordable Care Act, as it is formally known, Republican lawmakers in both chambers of Congress have now passed a bill that will make it easier to gut the law.

Because they are using a special budget process, Republicans won't be able to repeal all provisions of the health law. But it seems like a good time to look at the major changes Obamacare brought to health care, which of those changes may now disappear, and what might replace them.

An important note: We still don't know the details of a repeal bill, and passage is not guaranteed. But Republicans passed a similar package in 2015, vetoed by President Obama, that provides a rough template. Republicans have also said they hope to make further changes through additional legislation. We'll provide updates when new legislative language arrives, expected in several weeks.

1) Obamacare insured millions through new insurance markets.

The health law reduced the number of uninsured Americans by an estimated 20 million people from 2010 to 2016. One of the primary ways it did so was by creating online markets where people who didn't get insurance through work or the government could shop for a health plan from a private insurer. The law offered subsidies for Americans with lower incomes to help pay their premiums and deductibles.

What would happen? The Republican bill is expected to eliminate the subsidies. This would make insurance unaffordable for millions of Americans and sharply reduce the number who buy their own health coverage.

With many fewer people buying coverage, the insurance markets are likely to become increasingly unstable. Many insurers will stop offering policies, and the remaining customers are likely to be sicker than current Obamacare buyers, a reality that will drive up the cost of insurance for everyone who buys it, and force more people out of the markets. The Urban Institute estimates that the change would cause a total of 22.5 million people to lose their health insurance.

What might replace it? Separate legislation may include some new form of subsidy to help people afford insurance. Plans from House Speaker Paul Ryan and the budget committee chairman Tom Price, President-elect Donald J. Trump's pick to lead the Department of Health and Human Services, would both offer a flat tax credit to help buy insurance that varies by age. A proposal from the House Republican Study Committee would give all Americans a standard tax deduction to buy insurance.

2) Obamacare insured millions more by expanding Medicaid.

The health law provided federal funds for states to offer Medicaid coverage to anyone earning less than about $16,000 for a single person or $33,000 for a family of four. Not every state chose to expand, but most did.

What would happen? The Republican plan is expected to eliminate federal funding for the expansion. An estimated 12.9 million people would lose Medicaid coverage, according to the Urban Institute's projections.

What might replace it? Republican leaders have discussed reforming the remaining Medicaid program to give states more autonomy and to reduce future federal investment.

3) Obamacare established consumer protections for health insurance.

One of the law's signature features prevents insurance companies from denying coverage or charging a higher price to someone with a pre-existing health problem. The law included a host of other protections for all health plans: a ban on setting a lifetime limit on how much an insurer has to pay to cover someone; a requirement that insurers offer a minimum package of benefits; a guarantee that preventive health services be covered without a co-payment; a cap on insurance company profits; and limits on how much more insurers can charge older people than younger people. The law also required insurance plans to allow adult children to stay on their parents' policies until age 26.

What would happen? These rules can't be changed using the special budget process, so they would stay in place for now. But eliminating some of the other provisions, like the subsidies, and leaving the insurance rules could create turmoil in the insurance markets, since sick customers would have a much stronger incentive to stay covered when premiums rise. .

What might replace it? Mr. Trump has said that he'd like to keep the law's policies on pre-existing conditions and family coverage for young adults, but Senate Republicans recently voted against nonbinding resolutions to preserve those measures, suggesting they may be less committed. Some of the other provisions would probably be on the table if there were new legislation. Republicans in Congress would probably eliminate rules that require a minimum package of benefits for all insurance plans and allow states to determine what insurers would have to include. Mr. Trump has said he'd like to encourage the sale of insurance across state lines, a policy likely to make coverage more skimpy but less expensive for many customers. Republicans would also like to expand tax incentives for people to save money for health expenses.

Many of the Republican proposals would also establish so-called high-risk pools, which would provide subsidized insurance options for people with chronic health problems who wouldn't be able to buy insurance without rules forcing insurers to sell them coverage.

4) Obamacare required individuals to have health insurance and companies to offer it to their workers.

To ensure that enough healthy people entered insurance markets, the law included mandates to encourage broader coverage. Large employers that failed to offer affordable coverage, or individuals who failed to obtain insurance, could be charged a tax penalty.

What would happen? The bill is expected to eliminate the mandates. Some experts think that eliminating the individual mandate, in particular, could destabilize insurance markets by reducing incentives for healthy people to buy coverage. The mandate had less of an impact on the employers, which had already been offering coverage.

What might replace it? Some Republican plans would allow insurers to charge much higher rates to customers who allow their coverage to lapse than to those who renew their policies every year. Such a system might provide a different financial incentive for healthy people to stay insured.

5) Obamacare raised taxes related to high incomes, prescription drugs, medical devices and health insurance.

To help pay for the law's coverage expansion, it raised taxes on several players in the health industry and on high-income earners.

What would happen? The G.O.P. package may roll back those tax increases, though there is some disagreement among Republican lawmakers about the deficit impact of such changes.

What might replace it? Republicans have not discussed raising new taxes to replace those in the Affordable Care Act. But some of their plans would limit the tax benefits offered to people who get their health insurance through work. That change would increase tax revenues, but would increase the cost of health insurance for many people who get it through work.

6) Obamacare made major reforms to Medicare payments.

The law cut the annual pay raises Medicare gives hospitals and reduced the fees Medicare pays private insurance companies. It created new incentives for hospitals and doctors to improve quality. It also set up a special office to run experiments in how Medicare pays doctors and hospitals for health care services. Those experiments are now widespread and have begun changing the way medicine is practiced in some places.

What would happen? The new legislation is expected to leave these changes alone, even though many have come under criticism by Republicans in Congress over the years, including from Mr. Price, an orthopedic surgeon. Many of the experiments could be reshaped or eliminated through regulation or through a future budget process.

What might replace it? Republicans in Congress have long talked about even more ambitious changes to Medicare, intended to move more beneficiaries into private insurance coverage. Mr. Trump has said that he does not want to make major changes to Medicare, so it is unclear if such a proposal would move forward.

7) Obamacare made many smaller changes that will probably last.

Obamacare had a range of policies meant to improve health and health care, including requirements that drug companies report payments made to physicians, a provision written by the Iowa senator Chuck Grassley, a Republican; a requirement that chain restaurants publish calorie counts on their menus; and a rule that large employers must provide a space for women to express breast milk.

What would happen? When Republicans talk about repealing Obamacare, they tend to focus on the parts of the law that expanded insurance coverage and regulated health insurance products, not these ancillary parts. That means that portions of the Affordable Care Act that people don't associate with the word "Obamacare" are likely to endure.

Fred C. Dobbs -> Fred C. Dobbs... , January 15, 2017 at 08:42 AM
Perhaps the most horrendous loss
(to Big Healthcare) will be if ~20M
people lose coverage, even if it is
high-deductible 'catastrophic' coverage,
hospitals will lose billions in insurance
reimbursements for 'free care', which had
*much* to do with why/how Massachusetts
got the ball rolling in the first place.
im1dc -> Fred C. Dobbs... , January 15, 2017 at 11:32 AM
Every time I read an article about the Republicans 'Repeal of Obamacare' I remind myself that Trump has not said he would sign Repeal only.

Rather, he repeatedly has said and recently reiterated that he wants Repeal to coincide with Replace, hours, days, not weeks, months, or years.

That sets up an Executive Branch vs Legislative Branch conflict.

One of the party's pledges will have to give to the others, either Trump or the Speaker Ryan House Republican majority and or the Majority Leader McConnell's Republican majority Senate.

Today I'm guessing Trump gets his wish.

But that leads me to ask what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised, repeatedly.

If it is exciting to watch a train wreck then it is exciting to watch this budding and self-inflicted catastrophe develop in Republican controlled D.C., although I would rather not.

DeDude -> im1dc... , January 15, 2017 at 12:49 PM
"what are the Republicans going to substitute for PACA/Obamacare that is 'cheaper and provides more and better health care' that Donald Trump promised"

Yes my guess is that TrumpCare will not be bigger and better. More likely it will be small - like his hands

DeDude -> Fred C. Dobbs... , January 15, 2017 at 01:02 PM
She missed the biggest and most important part. ACA reduced the size of the doughnut hole in Medicare part D. Indeed ObamaCare was going to make the doughnut hole go completely away by 2020. So if we go back to the old Bush part D there will suddenly be a $4000 gap of no coverage for prescription drugs for our seniors. What are the GOPsters going to do about that?
Fred C. Dobbs -> DeDude... , January 15, 2017 at 01:19 PM
Get rich(er), I'd guess.

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.

[Jan 15, 2017] The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States

Jan 15, 2017 | economistsview.typepad.com
JohnH -> anne... , January 14, 2017 at 08:00 AM
The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States.
'
This is only the beginning of Democrats' appeasement of Trump and Republicans...it will be stunning to watch how much damage Republicans can do during Trump's first 90 days with only a slim majority in the Senate. During the first 90 days under Obama, who had a true electoral mandate and big majorities in both houses, Democrats basically sat on their hands, blaming Republicans for their unwillingness to do much for the American people.
Observer -> anne... , January 14, 2017 at 08:50 AM
So if we matched Canada, we'd see a 30% decrease, of a segment which comprises 10% of health care spending, or 3% overall decrease.

"PwC's Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate."

So reaching Canadian spending levels would counter ~ 6 months of health care cost increases. Reaching OECD levels buys you another couple of months.

Put another way, reaching OECD levels for drug spending closes 10% of the US-OECD spending gap.

Not nothing, but "fixing" drug prices seems more like an emotional (i.e. political) talking point than a real silver bullet for health care costs.

http://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html

pgl -> Observer... , January 14, 2017 at 11:17 AM
Ever noticed that marketing costs are 30% of revenue? This is a by product of the monopoly power in this sector. Dean Baker has often noted we could have the government do the R&D and then have real competition in manufacturing.
libezkova -> Observer... , January 14, 2017 at 10:40 PM
Don't be a lobbyist for Big Farma.

You forgot that those researchers often produce useless or even dangerous drags, which are inferior to existing. Looks as scams practiced with hypertension drugs.

This rat race for blockbuster drugs is the same as corruption in financial industry.

http://www.alternet.org/story/148907/15_dangerous_drugs_big_pharma_shoves_down_our_throats

pgl -> anne... , January 14, 2017 at 11:16 AM
Actually the industry profile is very relevant but goes in a different direction - if US firms were compelled to charge market (not monopoly) prices, we would better compete with foreign firms.
pgl -> Observer... , January 14, 2017 at 11:14 AM
Any excuse to charge sky high prices for drugs that don't cost that much to manufacture? If these monopoly profits were not so high, we would buy more drugs and employ more people.
Observer -> pgl... , January 14, 2017 at 12:57 PM
Do you think we would really buy materially more drugs if prices were lower? Particularly enough more, at those (30-50%?) lower prices, to generate the funds to employ more people?

(If that actually generated at much or more funds, it would seem like the pharma companies, seeking to make as much money as possible, would have already set prices at that lower per unit level.)

In any case, that seems like a LOT more drugs.

Perhaps Anne has data on the number of scripts per person in the US vs OECD.

pgl -> Observer... , January 14, 2017 at 01:06 PM
There are lots of poor people who don't take drugs because they can't afford them. This will become especially true if the Republican repeal Obamacare.
anne -> Observer... , January 14, 2017 at 09:05 AM
The point of course is wildly exploiting ordinary people in need of healthcare in every possible way, or a reflection of what we have come to. Returning now to the market...

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 13, 2017] What was at stake why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine

Jan 13, 2017 | economistsview.typepad.com
anne -> Observer... , January 13, 2017 at 07:39 AM
https://twitter.com/lhfang/status/819677587408568320

Lee Fang ‏@lhfang

What was at stake & why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine:

https://theintercept.com/2017/01/12/cory-booker-joins-senate-republicans-to-kill-measure-to-import-cheaper-medicine-from-canada/

BERNIE SANDERS INTRODUCED a very simple symbolic amendment Wednesday night, urging the federal government to allow Americans to purchase pharmaceutical drugs from Canada, where they are considerably cheaper.

2:49 PM - 12 Jan 2017

Peter K. -> anne... , January 13, 2017 at 09:33 AM
Cory Booker, another progressive neoliberal....
pgl -> Observer... , January 13, 2017 at 09:37 AM
Very good. On health insurance, they get 20% gross margins. I have argued many times we can cut this to 10%.

[Jan 12, 2017] Almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 12, 2017] Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

Jan 12, 2017 | www.nakedcapitalism.com
Benedict@Large , January 12, 2017 at 2:53 pm

Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

RUKidding , January 12, 2017 at 3:26 pm

After spending day time hours publically going after Jeff Sessions (good), Booker uses the cover of darkness to reveal who he really works for.

Here's a clue: it isn't any of the 99%, whether in NJ or elsewhere.

Talk's cheap, but money walks – eh, Booker?

EndOfTheWorld , January 12, 2017 at 3:40 pm

Somewhere I saw that Bernie praised Trump taking on Big Pharma.

curlydan , January 12, 2017 at 3:33 pm

'specially if you're from Jersey. Kind of like Biden, Delaware, and credit cards. The strings on the puppets are awfully tight.

[Jan 12, 2017] 200PM Water Cooler 1-12-2017 naked capitalism

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"Hierarchies aren't natural phenomena within the human race. Outside of parenting, human beings aren't born with the inclination to be ruled, controlled, 'managed,' and 'supervised' by other human beings" [ The Hampton Institute ]. Hierarchies are artificial constructs designed to serve a purpose. They are a necessity within any society that boasts high degrees of wealth and power inequities. They are a necessity for maintaining these inequities and ensuring they are not challenged from below."

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of sehnsucht ("inconsolable longing"). For example, in 'Sad Strains of a Gay Waltz,' Stevens writes of American southerners (although the words just as easily apply to their author) as 'voices crying without knowing for what, / Except to be happy, without knowing how.' The object of Stevens's inconsolable longing changed over time. In his early professional days, when he first moved to New York City, it was his hometown of Reading, Pa. Writing to his future wife, Elsie, Stevens lamented that he 'lost a world' when he left there" [ The American Conservative ].

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 11, 2017] the DEPRAVED nature of the American "Health Kare" system

Jan 11, 2017 | www.nakedcapitalism.com
clarky90 , January 10, 2017 at 6:12 pm

For me, often it is the "small crimes" that exemplify the DEPRAVED nature of the American "Health Kare" system. (See the right hand panel of The Last Judgment Bosch triptych) https://en.wikipedia.org/wiki/The_Last_Judgment_(Bosch_triptych)

US drugmaker charges 200 times UK price for common worm pill

A US drugmaker has put a price tag of more than $800 on a pinworm treatment - 200 times more expensive than the equivalent medicine on British pharmacy shelves, in the latest example of "price gouging" in the world's largest healthcare market.
Impax Laboratories (Bastards!) started selling mebendazole this year at an average wholesale price of $442 per pill, according to figures seen by the Financial Times, which were checked with several US pharmacy chains including Walgreens and CVS.

Most cases of pinworm, a parasitic infection also known as threadworm, require two pills, meaning a course of treatment costs about $884. The drug is available prescription-only in the US but can be bought over the counter in the UK, where Boots, a British chemist chain, charges £6.99 for a pack of four pills, or £1.75 each.

The pinworm parasite, which is common in children, affects 200m people a year worldwide and up to 40m in the US. It is recommended that family members are treated for the highly contagious infection at the same time, meaning a household of five's treatment costs more than $4,400.

https://www.ft.com/content/f0080fe4-c3ad-11e6-9bca-2b93a6856354

"Mebendazole came into use in 1971, after it was developed in Belgium.[4] It is included in the WHO Model List of Essential Medicines, the most important medications needed in a basic health system .[5] Mebendazole is available as a generic medication.[6] The wholesale cost in the developing world is between 0.004 and 0.04 USD per dose .[7] In the United States a single dose is about 884.00 USD as of 2016.[8]

https://en.wikipedia.org/wiki/Mebendazole

[Jan 11, 2017] TrumpCare, Pre-Existing Conditions, and Continuous Coverage naked capitalism

Notable quotes:
"... By Lambert Strether of Corrente . ..."
"... 'Do not go without health insurance, because if you get sick, you won't be able to afford any'. ..."
"... why isn't Bernie jumping up and down for Medicare expansion? ..."
Jan 11, 2017 | www.nakedcapitalism.com
By Lambert Strether of Corrente .

Let me begin by summariing (from thi s excellent post by Jane Timm of NBC ) what we might politely call Trump's intellectual journey on health care policy:

As GOP lawmakers begin the process of repealing President Obama's landmark legislation, it's worth taking a look at the eight times Trump has changed his position on Obamacare since announcing his bid for president more than a year and a half ago:

1. Repeal Obamacare. Look to Canada for inspiration.
2. Repeal Obamacare. Cover everybody.
3. Repeal Obamacare, but 'I like the mandate'
4. Repeal Obamacare. Replace it with something.
5. Repeal Obamacare. Not everyone will be covered.
6. I do want to keep parts of it, we might just amend it.
7. Begin to repeal on day one.
8. 'Be careful' - don't take the blame!

Do Trump's views even matter? Some answer no, arguing that Trump will just delegate everything to Mike Pence, Tom Price, and the rest of the Republican nomenklatura . We'll see, but I don't think The Donald sliced through not one but two party establishments like a hot knife through butter with the goal of handing off power to the Mikes and Toms of this world. So Trump's views matter. We just don't know what they are! Interestingly, Zeke Emmanuel met with Trump on health care policy. His reaction : "I found him engaged, curious, and he asked a lot of thoughtful questions and had a lot of opinions, as you might expect." So, whatever the reasons for Trump's shifting positions, I don't see them as random. Or focus-grouped, either. So there's that).zd

That said, Trump does seem to want TrumpCare to cover pre-existing condtions (or at least be seen to). Politically, that's sensible, since pre-existing conditions skew old , and Trump's base is older . Covering pre-existing conditions is also the right thing to do, as Trump himself seems to recognize :

Trump has consistently supported requiring insurers to cover those with pre-existing conditions, a regulation called guaranteed issue. "I would absolutely get rid of Obamacare," Trump said in a February 25 during the Republican primary, but "I want to keep [the provision regarding] pre-existing conditions. It's the modern age, and I think we have to have it."

Code Name D , January 9, 2017 at 6:21 pm

I don't agree. The "free rider" problem distorts the issue of afordabity. Young people do not buy coverage because they can not aford it – regardless of weather they want it or not. Issurance is so expensive its pricing people out of the markets.

So called "continus coverage" is a typical market solution. "Can't aford it? Well we will keep raising rates until you can. If you can aford it, we will keep rasing rates until you can't."

There still are no price controles.

Frank Stain , January 9, 2017 at 2:00 pm

Are people that hate the mandate because it's government coercion really going to like the Continuous Coverage imperative? The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance. The imperative of Continuous Coverage says: 'Do not go without health insurance, because if you get sick, you won't be able to afford any'.
This replaces the soft nudge of the mandate with the the very firm stick of inevitable financial ruin and uncurable sickness if you make a mistake and get sick when you didn't expect to. Why is this preferable to a mandate? Because you can still gamble?
A subsidiary point: are junk catastrophic plans going to count for purposes of Continuous Coverage once they ditch community rating? Those plans aren't going to provide anything like the $$ in the system that allow for coverage of pre-ex conditions.

ProNewerDeal , January 9, 2017 at 2:30 pm

"The mandate is a soft penalty that taxes individuals who fail to be good citizens by getting their health insurance"

The mandate is an ATROCIOUS penalty that penalizes people who cannot afford to purchase a crapified health insurance premium, or those that can "afford the premium" but don't have $6K in emergency savings with which to pay the annual deductible – e.g. can NOT afford to actually use the "insurance". Reminder: US personal adult median income is ~$30K, & net wealth is ~$37K, so this would cover a large portion if not a majority of USians that you are poor-shaming by saying "fail to be good citizens".

Frank Stain , January 9, 2017 at 2:49 pm

I was sort-of quoting the elite liberal line, not trying to poor-shame. But surely it makes sense to call a financial penalty 'soft' in comparison to the much harder penalty of financial ruin + incurable sickness if you mess up by gambling you won't get sick, and then you do.

Roger Smith , January 9, 2017 at 2:56 pm

Atrocious indeed. It is a way to divert attention from the real problem and blame the perceived personality faults of random people you do not know. With all the talk of Trump being some variation of fascist, I cannot figure out how people reconcile this mandate (or forced auto insurance mandates).

I have noticed that a lot of the Obama administration's "legacy" or general work was made by fudging numbers and not actually solving any of the problems at hand. Charging people for not buying a service they already could not afford as a way to punish them into making your numbers look good seems to fit the bill.

J , January 9, 2017 at 3:19 pm

The insurance is for 'catastrophic' coverage only. There are many, many scenarios where you could have an MI, stroke, major trauma, cancer, etc. and end up with surgical, hospital, nursing home and rehab costs running into the $1M+ range. The insurance prevents you from complete financial wipeout; it doesn't exist to make your PCP appointments or Lipitor "free" every month.

Second point, we can argue all we want about who's going to pay for healthcare in this country – the individual, the employer, the government, or some combination thereof. Healthcare will be unaffordable to a large degree based on how fat and sick the US population is. It doesn't matter who's paying when the average healthcare consumer is now 50+ years old with a BMI of 30+, has diabetes, hypertension, sleep apnea, asthma, and continues to smoke, eat fast food, not exercise and has no intention to change.

Last point, we do not ration care at the end of life like other countries with single payor systems do. Most of a person's total lifetime cost of care comes in the last 6 months of life. An enormous amount of savings could be achieved by stopping futile care at the end of life. In my experience, hardly any Americans die at home, everyone dies in an ICU on a ventilator, with multiple IV drips running, often on dialysis too. This is insane. We as a society have to find somewhere to draw the line where certain things shouldn't be done – like dialyIng 90 year olds

steven , January 9, 2017 at 6:10 pm

I don't think anyone is addressing frank's point which is:

In what way is creating a penalty, which tells people who cannot maintain consistent coverage that they can be permanently locked out of the market, better than the individual mandate? The brunt of both approaches is borne by the same people and both approaches inflict pain to coerce behavior. The mandate is a penalty that can be removed at any time by buying a subsidized guaranteed issue policy and the ACA had mechanisms in place to make it feasible to get into coverage. Under repeal, If you have a coverage gap you then face much higher premiums or refusal of needed coverage with no mechanism(such as substantial enough subsidies) to ever be able to afford to get back into the market. Saying that this is better because the government isn't forcing you to buy insurance, when no one goes without insurance if they can afford it in the first place, seems rather silly. Pushing these people into high risk pools has been tried numerous times in this country and has never worked out as the costs are always enormous and there is never the public will to subsidize the pools to the extent needed to keep them afloat.

We know perfectly well that the republicans have no intention of providing the level of subsidy that is necessary to get everyone covered because they don't believe that doing without health insurance/health care is a problem that government should be trying to fix.

As for lambert's statement about trump not shaking things up in order to hand power to others:

Trump doesn't care about policy and has no views on how his power should be used other than to aggrandize his own name. He is a dreaming narcissist whose views change 10 times in a day depending on what he thinks is expedient. He is the perfect malleable president for congressional republicans, an amoral blank slate driven only by his vision of himself as benign dictator. There is no way to counter the clear and organized agenda of the republican establishment, that now completely controls congress, unless you have some coherent policy view of your own. Donald Trump is going to rubber stamp the republican party's agenda and then claim that everyone's problems are solved and most of his supporters will be stupid enough to believe all their problems have disappeared because their all powerful proto-fascist daddy figure waved his big d!#k around and said it is so.

KK , January 9, 2017 at 2:07 pm

How clever is the American system, no work, no medicine

Tom , January 9, 2017 at 2:14 pm

Excellent, excellent snapshot of where we stand during this moment of calm before the storm (or rather, this moment between the current storm (ACA disintegration) and the next, bigger storm (ACA replacement).

Waldenpond , January 9, 2017 at 2:40 pm

This was for voteforno6

Here's what I found:

[There is no Constitutional provision explicitly giving the president the power to issue executive orders. Article II, Section 1 ("The executive power shall be vested in a President of the United States of America.") and Article II, Section 3 ("he shall take Care that the Laws be faithfully executed) have been cited as a grant of this power. Even so, presidential executive orders have the legal force of law if made pursuant to an Act of Congress. The authority for such orders can be either inherent or implied. The power is inherent when the executive order is derived from the powers conferred upon the President as commander-in-chief or, in international situations, as head of state; the power is implied when the order represents a reasonable interpretation of the powers expressly granted to the President under the Constitution.]

and

[Only two Presidential executive orders have been overturned by the courts. The first involved a 1952 presidential order issued by President Truman, Executive Order 1034, placing the nation's steel mills under federal control in order to prevent labor strikes from affecting steel production and thus hurting the national economy.[1] The U.S. Supreme Court determined that the Truman Order was unconstitutional because it overstepped the boundary between executive and legislative powers, holding that President's power to issue the order must stem either from an act of Congress or from the Constitution.[2].

The second executive order overturned by a court was issued by President Clinton. Executive Order 12954 prevented the federal government from entering into contracts with organizations that hire replacements for striking employees.[3] The court determined that the Order was regulatory in nature and preempted by the National Labor Relations Act, which guarantees employers the right to hire permanent replacements.[4]]

My understanding is the executive orders are legitimate if congress has not acted. With all the talk of mcr for all, basic income, ubi, unions, outsourcing, taxing the parasite class and guillotines, that movement needed to win or it will be crushed and I imagine the Ds and Rs will quickly rectify this in the next 2 to 4 years so if the wealthy were unfortunate enough to get someone like Sanders who might do something like this, it will be off the table.

grayslady , January 9, 2017 at 3:40 pm

Executive orders mostly work for issues that don't require congressional funding approval. Based on your excellent brief summary, Trump could probably lower the age of Medicare by Executive Order, but then he would have to find a way to pay for it. My memory may be faulty, but I believe that only Congress can impose taxes, not the President, so Trump would still need to propose a method of paying for Medicare-for-all that Congress would approve. Even if he found a way to pay for healthcare that didn't require congressional funding approval, if the funding source was considered to be too outrageous, Congress could impeach him.

ProNewerDeal , January 9, 2017 at 2:42 pm

0bamaBots & H1llaryB0ts spent years trashing Social Democrats/Sanders voters as "unrealistic" "far-left" "fair-dusty" "un-pragmatic".

Perhaps it was psychological projection, because IMHO 0bama & H1llary were un-pragmatic.

Imagine if 0bama earnestly tried to implement MedicareForAll in 2010? 0bama could've stayed sold-out to the other monopolistic industries that own US pols. Even the most strident left 0bama critics like say Glen Ford would have to say, "look, 0bama is a war criminal, has dictator-murdered US citizens without due process, tried to raise the social security age for GenX & younger, pursued the TPP; but 0bama deserves 1 prop for implementing MedicareForAll & saving 45K USians/yr per Harvard Public Health".

But no, 0bama & H1llary insist on staying sold-out to all major BigBiz groups. Fighting even 1 of them ala FD Roosevelt "I welcome their hatred" to investment bank$tas, is excessively pragmatic for these DLC neoliberal Reagan-clone scumbags.

Clive , January 9, 2017 at 3:07 pm

From an insurance industry point of view, certainly in the U.K. market which I doubt is significantly differently to the U.S., insurers hate complex underwriting. They either want scheme-compliant customers or, if those customers turn up and are found to be wide of scheme, they'd simply rather not have them as customers.

If an insurer is forced to take whatever business rolls up at its door, one way of avoiding having to specialist underwriting is to simply use pricing to deter anyone with a functioning brain cell from ever actually buying a policy. In other words, the fact that you genuinely need underwriting is used to whack the premium or the co-pay up. Okay, technically you are not denying coverage but in practice that's exactly what you are doing because most people will (certainly under the ACA) just pay the fine.

What the politicians - who know diddly squat about insurance product design - hadn't counted on though is, as noted though (correctly) above, you still get a death spiral because a lot of just-above-impoverished and slightly to moderately-severe unwell people will still enter the pool because they realize that even expensive (in-effect catastrophe) insurance is still better than pay-as-you-go. What you're going to deter is a mass market of impoverished or just-above-impoverished but slightly unwell (some sort of pre-existing condition which probably won't result in huge claims - a significant proportion of the potential pool will be this class of customer) potential customers who, in bulk, would contribute the vast proportion of your float (the reserves to pay out claims), because they think, usually correctly, they won't make a mega huge claim and are paying money for nothing.

If any changes in U.S. healthcare policy is considered which involves, to some extent, insurance (assuming Single Payer is off he table, which, however lamentable, sounds like reality) then policy makers really must consult with insurance marketing experts. Failure to understand consumer behavior in this industry will result in policy failures - yet again. None of this is new or not throughly understood - travel insurance has a vast trove of market and customer data to determine who chooses to take out medical expenses cover, who doesn't and why they don't (i.e. chose to spin the roulette wheel and risk not having coverage).

All of which makes me think - remind me again what is so wrong with Single Payer?

oho , January 9, 2017 at 3:19 pm

' remind me again what is so wrong with Single Payer?'

Of all the black swans out there--I'd bet that the most likely black swan is Trump expanding Medicare to under-65's in some form.

Seriously. Nixon to China >>> Takes a jingoistic, nationalistic, hotelier w/massive health insurance bills to like the idea of dumping those costs onto the government.

Trump is already on record liking drug re-importation from Canada and sticking it to Big Pharma.

(but again, it's the most likely of unlikely events) and I'm not holding my breath

Carla , January 9, 2017 at 8:53 pm

' remind me again what is so wrong with Single Payer?'

It treats everybody the same, something the 1% absolutely cannot abide.

A decade ago, I was traveling in Italy with a friend. When we were staying in the beautiful walled city of Lucca, he developed an infection in his index finger. We asked at our B&B where he might get treatment and were directed to the ER of a hospital about 2 blocks away. We joined a couple of other people in the waiting room and after about 5 minutes, someone came and took my friend to an examining room. Nobody in the ER spoke English and we had no Italian. About 10 minutes later, my friend emerged with a neatly bandaged finger and a prescription for antibiotic ointment written in Italian. He explained to me that they had lanced the finger, drained the pus, applied a disinfectant, and bandaged him up. When he took his credit card out to pay, they smilingly waved it away. You see in Italy, if you are hurting, you receive care and treatment because you are a human being.

American one-percenters just can't stand that. Apparently it somehow robs them of their specialness.

Thor's Hammer , January 9, 2017 at 11:09 pm

During my first week of employment in Vancouver Canada the financial secretary of the company called me into the office. "Have you received your Care Card yet?

"I'm a f--ing Yank– Don't I have to become a landed immigrant to apply?

"You are in a civilized country now– we don't allow anybody to go without health care."

I filled out a single page form and was immediately covered for all medical expenses including my pre-existing cancer. Administrative cost for universal coverage– a fraction of the bureaucratic overhead doctors face in the US in order to comply with the ACA & Medicare regulations.

During my stay in Canada I never stood in a line waiting to see a doctor or was placed in a room awaiting a fly-by visit by a doctor seeking to maximize his "production" as is often the case in the USA.

grayslady , January 9, 2017 at 3:46 pm

The favorite method of U.S. insurers to avoid paying for true insurance is to eliminate potential service providers. For example, under your Obamacare policy, all forms of contraception are supposed to be covered; but if no gynecologist in your network performs IUD insertions, then, essentially, you are denied coverage. Happens here a lot with surgical specialties, wherein no doctor in a particular network is qualified to perform certain surgeries even though Obamacare allows for coverage.

sj , January 9, 2017 at 8:47 pm

You know, I'm getting rather tired of the argument that Medicare payments are so abysmal. Doctors will leave, boo-hoo, yadda yadda.

Under the system we have now, those potential losses just get shifted to the uninsured. I just had a medical procedure and reviewed the billing from the hospital.

Cost of the procedure: $6600. Write off for insurer: $5564 Payment by me (since I had not met the deductible) $1036. My insurance company paid nothing.

Now, I'm lucky. I have insurance, and I had been stashing money into an FSA account and so I actually had the $1K. But in what world is it okay to penalize those unable to afford insurance by charging them six times as much as they write off for an insurance company. I

The whole healthcare-for-profit business is obscene. It's the "for profit" part that is subsuming the time of doctors and their staffs. Not the "patient care" part.

The so-called doctor exodus is a red herring. If someone becomes a doctor so that they roll in the money, I don't want to be their patient. Let them leave. Maybe we can actually get back to a healer model.

--
Lot's of interesting articles to be found with this search:

https://www.google.com/#q=how+much+time+to+doctors+spend+working+with+insurance+companies
--
I'm not even going into the fact that so often doctors start out so deep in debt they might feel the need to gouge their patients. That a different, if related, issue.

John k , January 9, 2017 at 3:25 pm

Trump's base is 50+. So what if he drops Medicare to 50+? Even somebody 45 would be happier thinking he would be covered in five years. And 50-65 is more in need than 35-50.
Midwest would be happy, and lots of reps from Midwest just trump proposing this would give it a life of its own and make dems look like pikers.

Course, this would someday be expanded, dooming health insurance does trump owe them anything? Didn't that industry donate to her?
Meanwhile, other corps should be happy to get their sickest workers covered always puzzled other industries haven't lobbied for Medicare expansion.

And with talk of changing Obamacare, why isn't Bernie jumping up and down for Medicare expansion?? Do all dems have undying fealty to insurance?

reslez , January 9, 2017 at 3:41 pm

> why isn't Bernie jumping up and down for Medicare expansion?

Clearly Bernie hasn't learned the art of the deal. But I think everyone figured that out after the primary.

As many problems as there are with Medicare I honestly believe expansion is the only way for Trump to square this circle. In addition it's the best solution for the country in the short-term. Think of how many billions of dollars will be saved on administrative overhead alone.

I don't see how Trump or the Republicans can get around Obamacare repeal, it was a core campaign promise. He can drag Congress along with promises of privatizing it in the future. That's a battle I'm willing to fight. Maybe they'll try to privatize it at the same time, though. I think they'd have to preserve a "public option" either way, simply because there are tons of seniors the health insurers won't touch with a 50 foot pole.

MyLessThanPrimeBeef , January 9, 2017 at 4:06 pm

Contrasting with Medicare for all, Medicare from 50+ on is the lesser of 2 evils (the other being keeping the status quo).

In the spirit of 'not letting good be the enemy of perfect,' i am interested and would like to know more if more people are advocating this.

Why should people die because they can't afford healthcare? Why should people go into debt to get treated? This is more important than no college education without free tuition.

Carla , January 9, 2017 at 9:04 pm

I agree. In the spirit of 'not letting the good be the enemy of perfect,' we should only let people 49 and under die because they can't afford healthcare.

Who needs people 49 and under, anyway?

james wordsworth , January 9, 2017 at 7:46 pm

The crazy thing is that Medicare for all has a solid business argument in its favor (although not for the AMA or big pharma, or big insurance). All companies pay similar amounts for coverage per employee (no more time spent wasted with analyzing plans), so a level playing field, while not as good as a field tilted in your favor, is better than one tilted against you. Great for small companies trying to get new employees, Individuals can start their own businesses without having to worry about losing health benefits (or the high costs of small plans). Everything about medicare for all screams economic efficiency (you know, having doctors doctor, not spending 50% of their time arguing with insurance companies).

Of course this all flies in the face of the american mantra of self reliance and that is where a great economic argument gets destroyed by the reality of a messed up culture in a modern world. Self reliance is great, but in an urban modern world, cooperation works better.

ProNewerDeal , January 9, 2017 at 8:16 pm

+1 IIRC 1 of the US auto mfgers explicitly claimed that the factories in Canada were more cost efficient for them, solely due to the health care costs.

It is as if US business leaders are adherents to neoliberal religion, that for-profit businesses will ALWAYS in ALL product/services provide a better product/svc per $ cost than a government or nonprofit private org can.

The same scenario exists with info tech, ppl wil bitch about Microsoft as OS vendor or office suite software vendor, when they could pay for corporate-level support from Ubuntu Linux or LibreOffice. They bitch about getting jacked by Oracle or SAP ERP, when say 10 MNCs could found a nonprofit dedicated to creating industrial/MNC-level ERP software that could be installed on-site or cloud-computing hosted. Etc.

Dr Duh , January 10, 2017 at 1:23 am

My idea, which helps ameliorate but doesn't solve the problem of the uninsured is to incentivize physicians to provide charity care. As it stands, you take significant risk for minimal to no reward.

The uninsured don't pay and Medicaid pays pennies on the dollar compared to private insurance. To make matters worse these are typically the sickest and the unhealthiest patients, i.e., they put off coming in so their disease is often at a crisis point and have bad nutrition, obesity, tobacco addiction and weak social support systems. They are bad outcomes waiting to happen. To cap it off, they are the most likely to sue you, they have stronger economic incentives to do it and have less social trust in physicians.

I know plenty of people (mostly anesthesiologists) who routinely complain about being paid despite being compelled to do all this work and take all this risk (including non-trivial risk to their own health from needle sticks and the like). I think that a big part of the resentment is that they are compelled to provide charity care as a condition of maintaining their privileges at the hospital.

Instead, let physicians write off charity care at their standard rates, i.e., I normally get $903 to come in at midnight and take out someone's ruptured appendix then take care of them in hospital for a week and provide follow up care for 90 days, but if the person is uninsured, I can deduct the $903 from my adjusted gross income as if it were a charitable donation. Further, physicians could be protected from civil liability for charity care. Though they would still be subject to criminal liability for criminal misbehavior and professional sanctions for substandard care, a bad outcome would not lead to a lawsuit.

I think the most important thing is that this would remove the compulsion to work for free. Most physicians and certainly anyone who has started in the past 10 years didn't do it for money. There's far more money and less stress in finance or tech. Most physicians like taking care of people. It's certainly the best part of my day, but being forced to do something sticks in the craw.
While this would certainly push up physician income.

meeps , January 10, 2017 at 2:14 am

Thanks for the extra detail regarding the 'continuous coverage' conditions.

The 18 month contract term reeks of post-ACA era grandfathered plans (my spouse's employer has a 12 month no coverage contract term) which is the very feature that prices us out of it. People who were priced-out under Obamacare are in for another brain-freeze should the incoming administration order up another self-licking ice cream cone.

I'm concerned that Pence will declare that having two X chromosomes is a pre-existing condition, but that's a subject for another post.

Trump seems to have some opportunity to cultivate an image as the 'most beautiful deal-maker ever' if he can deliver an improved Medicare For All plan. Of course, there's a risk that Republicans will crapify it first and then claim they delivered. But that strikes me as equally risky for Trump and the Republicans. Obama should never have staked his name and the reputation of the Democrats on Romneycare. They lost all credibility and the party is going extinct. I have a low opinion of Trump's branding but I suspect he thinks it's just great! It'd be inept beyond measure to sully it with something even worse than Obamacare. I'll refrain from placing odds just now

dejavuagain , January 10, 2017 at 8:48 am

In the old pre-existing conditions day, the other game played by the insurance companies was to challenge insureds for failing to disclose pre-existing conditions to the insurance company. Even if the insured was not aware of the existence of the pre-existing condition, the insurance company would deny coverage. So, in every big claim, the insurance company would simply deny coverage. Good luck.

And, I was the victim once of an insurance company "losing" my check, and cancelling my health insurance. Scary walking around without health insurance for a few months.

[Jan 11, 2017] Obamacare Republican Leaders Trying to Quell Revolting Senators

Notable quotes:
"... as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians. ..."
Jan 11, 2017 | www.nakedcapitalism.com
At least some Republicans seem mindful of the concept, "If you break it, you own it."

Even though Obamacare polls as having more opponents than supporters (see here and here ), many of the people who have benefitted from the program are strong supporters. In addition, those who have gotten coverage via Medicaid expansion may not realize that the ACA is the reason. And even with a majority of the public typically polling as not liking Obamacare, only 20% are willing to ditch it with no replacement .

So it should not come as surprise to find that the Republicans, finding themselves in the unexpected position of being able to end Obamacare, are in a squabble over what to do about the, um, opportunity. Obamacare repeal was not a Trump priority and as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

But it appears that regardless of what Trump is willing to do regarding Obamacare, he seems cognizant of the risk of creating disarray and being blamed for it a concern he oddly does not have on other issues. It's likely that this caution is purely cynical: that he understands how complicated implementing a replacement or even a stopgap would be, and he does not want Congress spending time on the Republican party bete noire of Obamacare to the detriment of pushing through Trump's priority items, particularly early in his term when he has the best chance to take ground quickly.

And the Republicans are divided enough to potentially forestall quick action. Politico and Bloomberg put different spins on the same story. Politico goes with the party line: GOP leaders vow to plow ahead with Obamacare repeal . The wee problem is that GOP leadership isn't what it is cracked up to be. Remember how Boehner was repeatedly unable to bring the unruly Tea Party faction to heel? And one of the first acts of the incoming House, to gut its own ethics office , turned into a PR disaster and was quickly scuttled. dbk , January 10, 2017 at 6:42 am

as Lambert has pointed out, Trump has even made statements that sound remarkably un-Republican, like copy the Canadians.

I get the impression T is clued in about how popular a "Canadian-style" health care plan could potentially be.

That there are this many R senators in doubt/on the fence about this particular repeal might lend hope to the possibility that there might be divisions re: other issues, including key nominees. Let's hope the D's have their staffs working full-time on who might be willing/inclined to break ranks for particularly problematic nominations.

My personal concerns here are those for AG (someone who has emerged straight out of 1963) and the Dept of Education, but the list is long and opinions may differ about priorities.

Normal , January 10, 2017 at 7:53 am

They need the lobbyists to write the replacement law ASAP. Then they can proceed with reckless abandon.

Kemal Erdogan , January 10, 2017 at 8:53 am

But, the trouble is the obamacare is more or less what lobbyists wanted.

So, no I see a real trouble here. However militant the republicans seem they would not shoot themselves in the foot. My take is that they will claim that they replaced the law with something better while not touching anything meaningful at the core of it for the simple reason that for such a system to work, it must be more or less the same as what obamacare is. Think how M. Romney's plan looks very similar to Obama's.

The fact is the other workable alternatives are far too much to the left for their liking. So once such a low is introduced that even marginally helps the mid-lower classes, they tend to stick, unless the country falls into open dictatorship that is.

Code Name D , January 10, 2017 at 11:33 am

Ding ding ding!!! That's the billion-dollar observation here. Obamacare is Free-market economics at its best. For it to fail would generate an intellectual crisis among neo-liberals and libertarians alike. To repeal the ACA is to admit that free markets don't work.

For the industry, their bottom line is literally – the bottom line. That ACA is failing is already apparent. So, something must be done to stabilize the ACA before it collapses completely, and give single payer advocates even more political clout than they already have. Wait too long, and single payer might -gasp- be placed on the table.

But I am seeing some odd behavior from the Democrats. They seem to be actively pushing the healthcare battle onto the floor. Keep in mind they are convinced the ACA both works and is extremely popular. If they can get Republicans to repeal the ACA, then they win the mid-term elections and retake congress.

Trump may act the buffoon. But his election proves he is smarter than most people suspect. You underestimate Trump at your own peril. Sending out mixed messages is probably Trumps version of his poker face, while at the same time he is able to read his opponents projections as they react to various seemingly random messages. The further the ACA descends on its death-spiral, the more clout he will acquire to compel changes according to his vision.

Art Eclectic , January 10, 2017 at 12:07 pm

Actually, I don't think the Dems think the ACA works an is extremely popular, I think they see the opportunity to nuke the thing and get single payer on the table. With Trump on records as admiring the Canadian system, that provides an opening (real or not) that would simply not be possible with any other political figure in the oval office. Not even HRC could have pushed through single payer against Republican opposition, Obama did the best he could with Romneycare. The only shot at single payer comes in the form of forcing Trump's hand, so they might as well take their shot.

Sound of the Suburbs , January 10, 2017 at 7:59 am

In a globalised world you just have to look around to see how expensive the US healthcare system is.

Check international league tables and copy someone else's cheaper and better system.

It's that easy.

DJG , January 10, 2017 at 8:43 am

President Susan Collins, as Atrios used to refer to her. And here she is again, a wise elder on health care. Sheesh. The flashbacks of her wondrous bipartisanship and moderation are starting to overwhelm me already.

And President John McCain, who has squandered whatever moral authority he may ever have gained from his stay in the Hanoi Hilton, telling us how to deal with Boris and Natasha.

And Ron Johnson, the most clueless man in Wisconsin except for Scott Walker.

They don't have two synapses to rub together among the three of them. Not one of them has a sense of political economy. They mainly react, and not well. They will end up making Trump look like a statesman. And, ironically, they would have taken the same positions with Hillary Clinton.

So Obama and Trump are not transitional or tranformational. We are marking time as the roofing tiles drop off the buildings from neglect.

Eclair , January 10, 2017 at 8:58 am

Colorado, one of the states that fully embraced the ACA, extending Medicare to hundreds of poor and disabled residents (the state's uninsured rate dropped from 15.8% in 2011 to 6.7 percent in 2015), is bracing for impact, according to the Denver Post.

Of course, the state's voters overwhelmingly rejected a proposed health care cooperative that would have provided residents with universal health coverage a la Canada in last November's election.

Thankfully, we can all saunter over to our neighborhood pot store and stock up. Who needs doctors anyway.

marym , January 10, 2017 at 9:11 am

AHIP demands for Obamacare replacement – The first link to TPM shows a screen shot. Haven't found an actual link to an AHIP publication. The second link to NYT has a discussion of some of the items.

http://talkingpointsmemo.com/dc/insurer-trade-group-lists-its-demands-of-republicans-in-obamacare-repeal-fight

http://www.nytimes.com/2016/12/06/business/health-insurers-obamacare-republicans.html

Code Name D , January 10, 2017 at 11:07 am

Hahahah! They only THINK they are working on it. The TPM is your typical corporate boardroom speak. "Seek solutions for this, that, and the other thing. Send the right messages. Reassure the confidence fairy. Don't rock the boat." In other words, they delegate solutions to minions to figure out while they pose for the camera.

marym , January 10, 2017 at 11:29 am

Agreed on your general assessment of TPM, but not sure I understand your comment. The screenshot is presented as a copy of the actual demands from AHIP, the insurance industry. It does use some pseudo-caring-about-"consumers" language, and I'm no expert, but generally these demands seem to say – keep the money coming; don't send us too many poor/sick people; don't make any rules; or at least none that we don't write.

PKMKII , January 10, 2017 at 9:30 am

The dogs chasing the car finally got it, and now they don't know what to do with it.

RUKidding , January 10, 2017 at 10:36 am

It's to laugh, otherwise we'll all cry and/or pound our heads against brick walls.

It's my understanding that CA has used ACA in a useful way that is benefitting citizens who otherwise would be really up the creek with no paddle. So be it.

ACA is what friggin' BigPharma, BigHospital, BigInsurance, et al, wanted. IOW a Republican's wet dream of a "health care" insurance system. But because the Blackity Black black black Kenyan Muslim got the credit for it, rather than RMoney well then it's simply terrible. If RMoney had enacted the exact same thing, the R Team would be extolling it's virtues 24/7/365.

The impact on me, personally, is smallish. I get that it's been a worthless POS for many, but there are the 20 to 30 million who truly benefitted from it. I know some people personally in that category, and I read comments in blogs from others.

Of course, the most draconian of TeaPartiers simply want to repeal ACA and that's the end of it. You're on your own is their Ayn Randian rally cry. Frankly what's always bugged the sh*t out of me is that the R Team wasted the last 8 years endlessly (was it 60 times?) attempting to vote out ACA, but they spent not one iota of a second in devising a replacement. They have zip, zilch, nada, bupkiss to offer. What a worthless group of grifters.

I doubt that Trump gives a stuff what happens to his voters, other than that he probably has a notion that he'll need their fealty and votes in 4 years. Therefore, Trump may try to get something that has some minimum usefulness enacted.

I can't wait. /s

[Jan 06, 2017] Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Notable quotes:
"... They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. ..."
"... They spoke anxiously about rising premiums, deductibles, copays and drug costs. ..."
Jan 06, 2017 | economistsview.typepad.com

Chris Lowery said... January 05, 2017 at 06:42 AM And an interesting take on Trump voters' views on healthcare
http://www.nytimes.com/2017/01/05/opinion/the-health-care-plan-trump-voters-really-want.html?ref=opinion

The Health Care Plan Trump Voters Really Want
By DREW ALTMAN•JAN. 5, 2017
This week Republicans in Congress began their effort to repeal and potentially replace the Affordable Care Act. But after listening to working-class supporters of Donald J. Trump - people who are enrolled in the very health care marketplaces created by the law - one comes away feeling that the Washington debate is sadly disconnected from the concerns of working people.

Those voters have been disappointed by Obamacare, but they could be even more disappointed by Republican alternatives to replace it. They have no strong ideological views about repealing and replacing the Affordable Care Act, or future directions for health policy. What they want are pragmatic solutions to their insurance problems. The very last thing they want is higher out-of-pocket costs.

The Kaiser Foundation organized six focus groups in the Rust Belt areas - three with Trump voters who are enrolled in the Affordable Care Act marketplaces, and three with Trump voters receiving Medicaid. The sessions, with eight to 10 men and women each, were held in late December in Columbus, Ohio, Grand Rapids, Mich., and New Cumberland, Pa. Though the participants did not agree on everything, they expressed remarkably similar opinions on many health care questions. They were not, by and large, angry about their health care; they were simply afraid they will be unable to afford coverage for themselves and their families. They trusted Mr. Trump to do the right thing but were quick to say that they didn't really know what he would do, and were worried about what would come next.

They spoke anxiously about rising premiums, deductibles, copays and drug costs. They were especially upset by surprise bills for services they believed were covered. They said their coverage was hopelessly complex. Those with marketplace insurance - for which they were eligible for subsidies - saw Medicaid as a much better deal than their insurance and were resentful that people with incomes lower than theirs could get it. They expressed animosity for drug and insurance companies, and sounded as much like Bernie Sanders supporters as Trump voters. One man in Pennsylvania with Type 1 diabetes reported making frequent trips to Eastern Europe to purchase insulin at one-tenth the cost he paid here.

Surveys show that most enrollees in the Affordable Care Act marketplaces are happy with their plans. The Trump voters in our focus groups were representative of people who had not fared as well. Several described their frustration with being forced to change plans annually to keep premiums down, losing their doctors in the process. But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept.

When told Mr. Trump might embrace a plan that included these elements, and particularly very high deductibles, they expressed disbelief. They were also worried about what they called "chaos" if there was a gap between repealing and replacing Obamacare. But most did not think that, as one participant put it, "a smart businessman like Trump would let that happen." Some were uninsured before the Affordable Care Act and said they did not want to be uninsured again. Generally, the Trump voters on Medicaid were much more satisfied with their coverage.

There was one thing many said they liked about the pre-Affordable Care Act insurance market: their ability to buy lower-cost plans that fit their needs, even if it meant that less healthy people had to pay more. They were unmoved by the principle of risk-sharing, and trusted that Mr. Trump would find a way to protect people with pre-existing medical conditions without a mandate, which most viewed as "un-American."

If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.

Several states are addressing the problem of surprise medical bills. But other steps urged by these Trump voters will be harder to achieve, including controlling drug costs. Republican health reform plans would probably increase deductibles, not lower them. And providing the more generous subsidies for premiums and deductibles that these voters want would require higher taxes, something the Republican Congress seems disinclined to accept.

In general, the focus among congressional Republicans has been on repealing the Affordable Care Act. There has been little discussion of the priorities favored by the Trump voters who spoke to us. But once a Republican replacement plan becomes real, these working-class voters, frustrated with their current coverage, will want to know one thing: how that plan fixes their health insurance problems. And they will not be happy if they are asked to pay even more for their health care.

Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation.
Reply Thursday, January 05, 2017 at 06:42 AM pgl said in reply to Chris Lowery ... Excellent story. Yesterday Pence and Paul Ryan lied to us. They are basically assuming Trump supporters are really stupid. This says these supporters are smarter than the GOP frauds assume:

But asked about policies found in several Republican plans to replace the Affordable Care Act - including a tax credit to help defray the cost of premiums, a tax-preferred savings account and a large deductible typical of catastrophic coverage - several of these Trump voters recoiled, calling such proposals "not insurance at all." One of those plans has been proposed by Representative Tom Price, Mr. Trump's nominee to be secretary of Health and Human Services. These voters said they did not understand health savings accounts and displayed skepticism about the concept. Reply Thursday, January 05, 2017 at 06:53 AM JohnH said in reply to pgl... The partisan hack opines...oblivious to the fact that people might have good reason to be angry at skyrocketing prices for what used to be known as catastrophic coverage.

Sad that there seems to be no one but Bernie and his supporters to stand for real health care reform. Instead the debate gets left to partisan hacks, who have nobody's interest in mind except the party's. Reply Thursday, January 05, 2017 at 07:42 AM Peter K. said in reply to JohnH... Obamacare is basically Romneycare, a Republican plan set up to be an alternative to universal care.

Know-nothing Republicans hate it because Obama signed it into law.
Reply Thursday, January 05, 2017 at 07:45 AM pgl said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

As in reigning in the monopoly power of Big Pharma. We should also reign the doctor cartel. And of course end the oligopoly power of the health insurance sector. Of course Paul Ryan is in the pockets of the latter - so it ain't gonna happen under his "leadership". Reply Thursday, January 05, 2017 at 06:55 AM EMichael said in reply to Chris Lowery ... Now is not the time to ignore what was actually the "real" problem.


" Republicans Hate Obamacare Because _______


I'm not one to defend the worst parts of Obamacare and those who find themselves on the receiving end of the mandate with no subsidies have some genuine complaints, but generally the bit that goes in the blank there is "it was the blah president's signature legislative achievement."

http://www.eschatonblog.com/

And yes those whose incomes are too high for subsidies do have a complaint.

But for the most part, the single most important "problem" with the ACA is that healthcare in the US is incredibly expensive.

One day people will stop attacking the ACA because of something the ACA had absolutely nothing to do with.

I am thinking that will be when it is gone, and people will then be shocked to see that healthcare in the US is very expensive. Reply Thursday, January 05, 2017 at 07:31 AM JF said in reply to EMichael... Yes, it is expense. This results from pricing that is free from any real market balances or alignments. The incentives are all misaligned.

Need to stop using the word, 'cost' so much. It is all about a non-market space where pricing is unfettered.

Normally, the public brings in uniform rules of Commerce to apply here, or the public does the services directly. Alas. Reply Thursday, January 05, 2017 at 09:07 AM Peter K. said in reply to Chris Lowery ... "If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs."

Why don't the Democrats do this?

Progressive neoliberalism.... Reply Thursday, January 05, 2017 at 08:44 AM pgl said... "Michigan's expansion of Medicaid health insurance coverage has boosted the state's economy and budget, and will continue to do so for at least the next five years, according to a new University of Michigan study."

When Mike Pence and Paul Ryan appeared together to declare Obama's medical reforms a complete failure, it is odd that they never mentioned Michigan - which seems to be a success story. Reply Thursday, January 05, 2017 at 06:50 AM

[Jan 02, 2017] U.S. Healthcare Is A Global Outlier (And Not In A Good Way)

Jan 02, 2017 | www.zerohedge.com

Historically, the United States has spent more money than any other country on healthcare.

In the late 1990s, for example, the U.S. spent roughly 13% of GDP on healthcare, compared to about a 9.5% average for all high income countries.

However, as Visual Capitalist's Jeff Desjardins notes, in recent years, the difference has become more stark . Last year, as Obamacare continued to roll out, costs in the U.S. reached an all-time high of 17.5% of GDP . That's over $3 trillion spent on healthcare annually, and the rate of spending is expected accelerate over the next decade .

HIGH COSTS, HIGH BENEFIT?

With all that money being poured into healthcare, surely the U.S. must be getting better care in contrast to other high income countries.

At least, that's what one would think.

Today's chart comes to us from economist Max Roser (h/t @NinjaEconomics ) and it shows the extreme divergence of the U.S. healthcare system using two simple stats: life expectancy vs. health expenditures per capita.

Courtesy of: Visual Capitalist

THE DIVERGENCE OF U.S. HEALTHCARE

As you can see, Americans are spending more money – but they are not receiving results using the most basic metric of life expectancy. The divergence starts just before 1980, and it widens all the way to 2014.

It's worth noting that the 2015 statistics are not plotted on this chart. However, given that healthcare spend was 17.5% of GDP in 2015, the divergence is likely to continue to widen. U.S. spending is now closing in on $10,000 per person.

Perhaps the most concerning revelation from this data?

Not only is U.S. healthcare spending wildly inefficient, but it's also relatively ineffective. It would be one thing to spend more money and get the same results, but according to the above data that is not true. In fact, Americans on average will have shorter lives people in other high income countries.

Life expectancy in the U.S. has nearly flatlined, and it hasn't yet crossed the 80 year threshold. Meanwhile, Chileans, Greeks, and Israelis are all outliving their American counterparts for a fraction of the associated costs. buckstopshere , Jan 1, 2017 10:02 PM

A shorter life expectancy makes Social Security look more solvent.

Cooking the books.

junction buckstopshere , Jan 1, 2017 10:08 PM
The chart shows that Monsanto and the New World Order are succeeding, that more glyphosate herbicide in the food, more toxic chemtrails and more unneccessary operations are having the desired effect, to cull the American population. Helped immeasurably by the cocaine and heroin flown into the USA by the Bush Crime Cartel on Air Force cargo planes.
cheka junction , Jan 1, 2017 10:10 PM
nyc runs US health care. that tells one all he needs to know.
Pinch Dog Will Hunt , Jan 2, 2017 12:58 AM
Republitards and Freedumb-lovers need to watch Michael Moore's movie about this called "Sicko"

https://www.youtube.com/watch?v=thkBLpRwdSM

You need MORE socialism, not less.

Tards.

Chief Wonder Bread balolalo , Jan 1, 2017 10:42 PM
Australia, Norway, Switzerland, Germany, South Korea, Japan, Italy, U.S.

Which of these countries is not like any of the others? Haha. Multiculturalism is such a fantastic deal. Some "cultures" just don't make good lifestyle decisions such as thinking that grape drank and swisher sweets are healthful choices.

philipat cheka , Jan 1, 2017 10:35 PM
It is, of course, in part a "Lifestyle" issue but the US system is grossly inefficient because there are adverse incentives built in (Adverse selection etc.). The US still uses a "Fee for service" model which has never been able to control costs anywhere in the world. On top of that, high pharmaceutical prices in the US account for up to 90% of total Big Pharma profits ane Medical Malpractise insurance not only directly adds large costs but indirectly forces the use of an unnecessary number of tests and the use of the newest drugs etc. Without any sensible controls at any point in the system it will only continue to get further out of control, as ACA has illustrated.
Ballin D philipat , Jan 1, 2017 10:41 PM
What's the alternative to "fee for service?" Seems pretty standard to charge for services rendered.
philipat Ballin D , Jan 1, 2017 11:47 PM
Except that more services = more fees = higher costs. Hence multiple tests, multiple procedures and multiple drugs = higher costs and higher fees = inefficiency bias and higher still costs. Physicians are human and the Healthcare providers have become experts at maximising costs to breaking point. There are many alternative models within which to control costs through negotiated standard procedures and fixed costs for each procedure and drug formularies (including the use of generic drugs) etc. Single payer is used by much of the developed world where the supplier agrees to supply at a negotiated price or doesn't get to participate, which focuses their attention nicely. The benefits of scale, in whatever system is used, should result in lower prices but don't in the US where USG is already the largest single provider of healthcare (Medicare/Medicaid etc).
Canoe Driver philipat , Jan 2, 2017 12:36 AM
A lot of people, certainly not just doctors, are making a lot of money from this dysfunctional medical system. That is the difference no one is talking about. The money is not disappearing down a rabbit hole. It is being pocketed by thousands of multi-millionaires. It is a profit-based system. Medicine is the one field where Capitalism has no hope of efficiency. Why? Because the demand is infinite and inelastic. A recipe for the financial rape of millions.
dogsandhoney2 junction , Jan 2, 2017 12:43 AM
yeah,
and it also shows the effect of a
30% increase in psychological stress since 1980.
stress = ^stress hormones = stressed immune system =
anxiety/depression/cardiovascular disease/hyper inflammatory response/etc..

all to be treated by those in the stressed-out health care system,
usually with hyper-cost pharmaceuticals.

it's well past due date for the u.s. to become civilized by starting
single payer medical plans.

health insurance corporations = the terror.

sinbad2 heresy101 , Jan 1, 2017 10:48 PM
I wouldn't count on it.

Private healthcare and insurance is very profitable 2 of the 3 trillion the US spends on healthcare would go to shareholders and management of healthcare companies.

Mr Trump is a businessman and a realist. The media would be calling him a commie if he tried to fix it.

sinbad2 , Jan 1, 2017 10:38 PM
Americans would not have it any other way.

The countries that have the most cost effective healthcare, are countries that provide government run health insurance.

Americans would never tolerate claiming helthcare costs back from a Government run health providor, like in Australia, or waisting taxpayers money building hospitals.

Americans have to pay for their belief that private for profit health insurance is cheaper and better than government provided insurance.

Xena fobe sinbad2 , Jan 1, 2017 11:41 PM
Americans would accept single payer. But insurance companies would not.
TheEndIsNear I Write Code , Jan 2, 2017 12:05 AM
250,000 deaths in 2015 were due to medical error, the third leading cause of death in the U.S.
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medica...

38,300 people were killed on U.S. roads in 2015.
http://www.newsweek.com/2015-brought-biggest-us-traffic-death-increase-5...

33,636 deaths due to "Injury by firearms" of which only 11,208 were homicides, 21,175 were self inflicted suicides, and the remainder were due to accidental/negligent discharge of a firearm or "undetermined intent".
https://en.wikipedia.org/wiki/Gun_violence_in_the_United_States

brooklinite8 , Jan 1, 2017 11:07 PM
When I was visiting India I saw few women administer a baby birth basically in few minutes with bare hands, water, oil and some sarees. Here in the US I believe the bill comes around 5-10k at the least. Did we ever ask the question as to why do we need insurance to afford health care? Did we ever ask how has it become so out of control? Why has healthcare become such a big business? Where are the morals of humanity?

In USA the welfare of the state takes precedence to the welfare of the people. Human beings are valued at no different rate in USA than India. Welcome to the Land of the Free, Home of the Brave. Good Old USA. We are outliers and Everything we do should be an outlier. If not we will revisit and make sure it becomes an outlier. Lol

Canoe Driver brooklinite8 , Jan 2, 2017 12:57 AM
The total cost per childbirth in the US is said to be $50-65k. This figure is so outrageous that it is impossible to correlate it with the cost of providing the services. It is simply a bunch of profiteers taking their cut. And the profit can be several hundred percent of the underlying cost, precisely because the "customer" has no choice at all. Capitalism, which works well in many contexts, fails miserably in medicine. Demand is infinite and inelastic in the medical field.
hairball48 , Jan 1, 2017 11:15 PM
A shitty diet of sugar laden, high carbohydrate fast food products is what contributes to most Americans' shorter life spans, not "poor health care".

Health care is expensive because it's run by a de facto "health care mafia". I worked in the technical field of health care for 28 years. Excessive regulation is but just one reason health care is so expensive in the USA. Barriers to entry are another. Try to establish a medical school. See how long it takes. Fewer docs, the higher the price of docs. ECO 101. Don't look for a change anytime soon.

hairball

Miffed Microbio... hairball48 , Jan 2, 2017 12:14 AM
When I was an intern for clinical microbiology they gave us $300/month as a stipend. Today an internship costs $24k. This is on top of the 4 years degree. Plus the mechanization of the lab is continuing every year to the point there will be fewer jobs in the future. Hate to say it but my field is fucked. Much of my time is spent meeting regulatory compliance and it gets worse every year.

Miffed

tyberious , Jan 1, 2017 11:52 PM
Me, 20 years in Healthcare BS, MSPH, , started in reference labs, then trauma center, biotech and now in healthcare insurance quality improvement (Medicare). 1st of all the money is in the government, we all know that!

But my main response to the article is that the America sheep are being sheared! The assault starts at birth with 21 vaccines by adulthood( infant mortality), hormones in the food (preteen secondary sex characteristics)(breast cancer)(prostate cancer) , HFC (diabetes, heart diseases, and other complications) GMO's, glycophosphates, glutens, and the multitude of useless pharmaceuticals.

My point is Americans are being poisoned, not so much intentionally, but through fascist business models.

So recap: Chronic preventable illnesses, extensive bureaucracy, poor food choices (# 1 in my book), and a government that cares zero fucks about you!

chosen , Jan 2, 2017 12:18 AM
Doctors are way overpaid. Hospitals charge ridiculous prices that have no relation to reality. Insurance companies screw us even more.

The US medical system is worse than the university system. Both are scams whose main goal is to make the providers more and more money, and the users poorer and poorer. It is sick.

Canoe Driver chosen , Jan 2, 2017 1:12 AM
Basically, you are right. The idea is that the price is all the funds the "customer" has in the world, every time there is significant illness. This is because the demand for healthcare is essentially infinite and inelastic. If you want to live, pay us everything you have, then declare bankruptcy. That is what happens naturally in a for-profit medical system.

[Dec 30, 2016] Payment for Emergency Ambulance Services.

Dec 30, 2016 | dfs.ny.gov
The Office of General Counsel issued the following opinion on June 7, 2006, representing the position of the New York State Insurance Department.

Payment for Emergency Ambulance Services.

Re: Payment for Emergency Ambulance Services.

Questions Presented:

1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization ("HMO") has made partial payment of a bill?

2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization has denied payment entirely?

Conclusions:

1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the ambulance company may not bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract that provides major medical or similar comprehensive-type coverage. However, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the patient directly for the balance of the bill.

2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies available to the patient.

Facts:

This inquiry is general in nature.

Analysis:

N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See N.Y. Public Health Law § 4406(1) (McKinney 2002).

N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:

(aa)(1) Every contract issued by a hospital service company or health service corporation which provides major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law.

(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided pursuant to this subsection, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms of the policy.

(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.

(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection. . . .

N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney Supp. 2006), which applies to individual accident and health insurance policies issued by commercial insurers contain identical provisions.

In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge, which shall not be excessive or unreasonable.

Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.

Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the patient.

If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's Consumer Services Bureau.

Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies. For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.

This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation of the New York Insurance Law. No opinion is rendered on any other laws.

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.


1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36, dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.

[Dec 30, 2016] 20 things to know about balance billing

Notable quotes:
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
"... Montana Public Radio ..."
"... Sunshine State News ..."
"... The New York Times ..."
"... The New York Times ..."
Dec 30, 2016 | www.beckershospitalreview.com

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Here are 20 things to know about balance billing.

1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

2. Balance billing complaints are up 1,000 percent in Texas . According to the Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in 2015, an increase of 1,000 percent.

3. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times .

4. Emergency room services to blame, in part. A Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not. For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a 2015 study from the Centers for Public Policy Priorities in Austin.

5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient. When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance .

6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News . During a billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare, the patient was balance billed $1,170 for a total of five stitches.

7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

8. Payers have sued providers for 'excessive' out-of-network fees. Aetna has sued a half dozen out-of-network physicians in recent years, alleging gross over charging for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635.

9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of balance billing his account for an out-of-network rate after the patient submitted in-network payment rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation, Matthew Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However, Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.

10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. Those in rural areas often must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest after PacificSource contributed a policy cap of $13,000.

11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider-based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying a $30 copayment for in-network care with a Cleveland Clinic chiropractor, Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her insurance plan refused to cover.

12. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation does not apply to existing outpatient centers that already engage in the practice, however.

13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. The administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network.

14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.

15. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. The states of Illinois and New Yorkhave arbitration methods in place, and Florida , Washington and Pennsylvania are currently considering a similar resolution methods.

16. New York has some of the strongest consumer protection laws. Under New York law , consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes.

17. Florida state legislature is currently embroiled in a fight to pass balance billing laws. Legislation to outlaw balance billing in Florida has continued to creep through the state legislature since last fall. Introduced in both the house and senate, the bills have sparked conflicting and outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement rates, reports Sunshine State News .

18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from balance billing who went to in-network facilities for emergency services, reports Consumerist . In non-emergency cases, it would require providers to notify patients within 24 hours if an out-of-network specialist will be involved in an episode of care.

19. Consumers don't know how to navigate the legal waters. According to a Consumer Union report, 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn't know their rights to fight the bills. An overwhelming majority (87 percent) did not know which agency or department in their state government is tasked with handling complaints about health insurance. "So many times, people just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR .

20. The New York Times dedicated a series to consumer encounters with surprise healthcare bills. Elisabeth Rosenthal's series in The New York Times entitled Paying Til it Hurts examined the personal and financial implications of excessive, unexpected medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments often feature individuals with unaffordable balance bills like Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant he never knew was present during surgery.

[Dec 26, 2016] Are Psychiatric Medications Hurting More Patients Than They Help?

Notable quotes:
"... Scientific American ..."
Dec 26, 2016 | science.slashdot.org
(scientificamerican.com) 431

Posted by EditorDavid on Sunday December 18, 2016 @01:34PM from the depressing-anti-depressant-news dept.

An anonymous reader quotes Scientific American 's Cross-Check blog :

Two new posts on this website have me contemplating, once again, the terrible possibility that psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013, almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."

This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University of South Carolina, acknowledges the "inconvenient truth" that Americans' mental health has, according to some measures, deteriorated ...

It's all more evidence of something their blogger wrote in 2012. "American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis -- harmful medical treatment -- in history ."

[Dec 26, 2016] 5 Ways to Lower Your Medical Bills Personal Finance

Notable quotes:
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Nov 29, 2007 | US News

Insurance companies aren't the only ones who can negotiate a lower price -- you can, too. Here's how.

By U.S. News & World Report

Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another ailment: medical bills.

Six hours in an operating room, two knee replacements, medications and a five-day hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist, physical therapy, additional medicines and special exercise equipment to help him recover.

"One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills."

Luthra's insurance company was able to negotiate with the hospital so that it paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.

But individual patients can haggle for lower medical bills, too. Here are tips on how to go about it.

Work up the courage to ask. It's not just insurance companies that can negotiate.

"The typical insurer gets about a 60% discount," says Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and ask the chief financial officer , you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the CFO how much they or the person in the billing office are willing to give you."

Although it's common to negotiate with a real-estate agent or car salesperson you probably never will see again, it's much more difficult to negotiate with a doctor you trust to make you well and to provide continuing care for your family. Only 31% of Americans have tried to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated. But of those who tried, 93% have been successful at least once, and more than a third saved more than $100.

Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get a fair price as well as you do.

But even though almost 80% of physicians will prescribe a generic medication over a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey of physicians by the Center for Health System Change and the University of Chicago

If money is an issue, you need to ask your doctor if cheaper, medically sound options are available. The trick is to keep it friendly and ask nicely. For minor health ailments such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating required.

Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in other billing issues, so you need to find a person with the ability to adjust your bill.

"I would suggest the consumer go to the office manager," says Timothy Cahill, a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients. The office manager should be able to direct you to the person in charge of billing.

Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.

"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and the chief technology officer of Vimo.com, a company that uses public records to figure out what prices insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing terms, paying credit card transaction fees and sending collection agencies after patients who fail to pay.

Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your insurance should cover and try to negotiate a discount off the sticker price.

"As a consumer, just like a detective, you have to really understand the specifics of your insurance benefit plan, take the initiative of setting up conference calls (including yourself, the hospital and your insurance company) proactively, and you have to document everything," says Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just pay the bill as is."

This article was reported and written by Emily Brandon for U.S. News & World Report.

[Dec 26, 2016] How to avoid and handle surprise medical bills

Notable quotes:
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
thehill.com
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

When these out-of-network providers send you a bill for their services, you may have to pay the full amount out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill that your insurance fails to cover. And the balance bill generally requires you to pay more than the out-of-pocket amount you would have owed if you had been treated by an in-network provider.

Emergency rooms are one of the most common locations where healthcare results in surprise bills.

As detailed recently in an article by two Yale scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER visits to an in-network facility involved out-of-network physicians. The average balance billed to patients was $622.55, though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills.

Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill.

Several states have already enacted laws to protect consumers against surprise bills, although some of the statutes protect patients only in the case of balance bills for out-of-network ER services for a serious medical emergency. Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps you can take to protect yourself from such surprises.

Prevent surprise bills

The best defense against a surprise bill is prevention. If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available.

However, for a planned surgery or other procedure, you probably have time to speak up. Make sure that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask your physician and your hospital in advance if they can arrange to have only in-network providers treat you.

Some hospitals may have no in-network specialist for care you might require. Find out if another hospital in your area can provide all your necessary services on an in-network basis. In some areas, there may be no in-network specialists available of the type you need. In that case, inform your plan that its network lacks necessary services and find out if the terms of the plan or state law provide you protection from large balance bills in such circumstances.

Always refer to your plan by its exact official name. Often insurers have multiple plans with similar names but different networks. If you use the wrong plan name when inquiring about a plan's network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you have documentation. Ask for the names of the providers who will be involved in your care, and check with your insurer and with the providers themselves to see if they are all in your plan's network.

Check if your state protects consumers

If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services. Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.

At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.

If your state does not provide protection

If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate.

If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org, to estimate what the procedure typically costs in your locality. If your plan's reimbursement is based on an amount that is less than the typical charge, you can use this information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider's charge is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above the typical market rate.

If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth

[Dec 25, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
"... This piece is by Drew Anne Scarantino ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

How You Can Avoid Outrageous E.R. Bills (Really!)

When it comes to a trip to the E.R., the reality is that there's usually no time to shop around and compare prices in advance. But if you do some research before an emergency happens, you could potentially keep costs significantly down.

The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of dollars in savings shaved off a potentially outrageous E.R. bill.

This piece is by Drew Anne Scarantino.

[Nov 23, 2016] 7 Tips For Fighting And Paying A Big Hospital Bill

Notable quotes:
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Sep 17, 2013 | www.forbes.com

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

2. Vigilantly review the bills. "It's very common for hospital bills to contain errors and overcharges, so make sure you've actually received the services they said you did," Detweiler says.

Candice Butcher, vice president of Medical Billing Advocates of America, says if you're discharged in the morning (as most patients are), protest if you're socked with a full daily-room rate for the date you left the hospital.

And if you brought your medications with you, make sure you weren't charged for them by the hospital. "This frequently happens," Butcher says.

Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily-room charge, because, Butcher says, they are "considered the cost of doing business."

3. Challenge your health insurer's decisions, when warranted. Keep track of any hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy. If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections.

4. Negotiate bills once you know how much you'll have to pay out of pocket. If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital or clinic business office staff to arrange a payment plan."

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the advocacy firm Copatient.com, which charges 30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.

Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges no more than $3,000. Attorneys often charge 30% of the savings they achieve.

... ... ...

Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter TWTR -0.69% @consumermayer.

[Nov 22, 2016] Negotiating can cut hundreds off your medical bills

Notable quotes:
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
13 WTHR Indianapolis
But you can fight back against skyrocketing medical costs.

"I've heard discounts up in the area of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program development with Consumer Credit Counseling.

She says it's possible to negotiate down your medical bills - everything from ambulance rides to surgery. She says you can also bargain with your dentist, the lab that does your blood tests, the eye doctor - even the company that makes you prescription medication.

"Each company has a specific number you can call to fill out an application and many times, you'll get a discount, or you'll get the product free through the drug companies, if you qualify financially," Perron said.

All you have to do, with or without insurance, is make a call. Each case is handled differently. In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital. They'll work with you to make sure the cost is paid.

So how do you pay less?

There are a number of options:

  • Offer to pay in cash - You may get an up-front discount of 10 percent or more.
  • Ask about a payment plan - They're usually interest-free and determined by your budget.
  • If you don't have insurance - Some hospitals will give you a discount that is equal to what it may have given the insurance company.

Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill out hardship paperwork.

"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses and your other bills that you have to pay every month," said Perron.

Sholar called Indianapolis EMS.

"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people who drive the ambulance. That's just the way it is'," he said.

But he didn't give up.

"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor'," Sholar said. "The supervisor's name is John. John wasn't too happy."

Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed, but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.

"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't received a bill for that," he said.

But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling 911.

"I would have put a rag over it and got a ride here," he said.

Tips to Negotiate Your Medical Costs

Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:

First and foremost be informed. Understand what type of medical insurance coverage you have and what your co-pays or financial responsibilities are. Some insurance companies have contracts with certain medical providers to offer a discount if you receive treatment from a "preferred provider." We encourage individuals to meet with their Human Resource department or contact their insurance company to speak with a representative about their coverage and benefits prior to receiving medical treatment. This could reduce your financial responsibility significantly.

Apprisen recommends for you to review your itemized statement from your medical provider. If you feel there are discrepancies or charges in question, contact your medical provider to meet with their Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part of resolving your issues. Simply ignoring communication from your medical provider will not resolve the issue and could potentially lead to a negative impact on your credit rating if resolution is not reached.

Whether you have insurance or not, you are encouraged to contact your medical provider prior to treatment (if possible) to discuss costs associated with your treatment and to work out the possibility of negotiating those costs down. Many medical providers will consider giving discounts to individuals who are willing to pay the balance in full upon services rendered or within a short period of time after receiving treatment. If you find yourself in a position where you are not able to pay the balance in full, consider negotiating with your medical provider for a monthly repayment plan interest free. You are encourage to analyze your personal budget to insure you are able to make the financial commitment to your medical provider. Negotiating your medical bill then failing to follow through with the financial payment arrangement could negate your hard effort to reduce your medical bill.

If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision maker" to see if you qualify for any financial hardship programs. Most hardship programs require you to provide evidence of your financial situation and the award is based on financial need. Be prepared to give a full budget disclosure in order to be considered for the hardship program.

Apprisen's mission is "To help people improve their financial well-being through counseling, community outreach and financial education."

You can call Apprisen at 1-800-355-2227 or visit apprisen.com.

There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. You can find out more about those companies at objectivedx.com.

[Nov 22, 2016] Hiring a Guide to the Medical Bill Maze

Notable quotes:
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
Apr 29, 2013 | Bloomberg

When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based financial planner. "All of a sudden we were getting bills for over $30,000."

As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate. It negotiated with the physician's health-care group to reduce her bill to $7,000.

More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy because of illness have some form of health insurance. So hiring a medical billing advocate can be an essential part of the cure to financial ills.

Yet finding the right advocate can be tough, and those in the direst situations can ill afford the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson, co-president of the Alliance of Claims Assistance Professionals (ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people willing to pay you to help them." Despite long experience, Stephenson herself has trouble making a good living purely from advocacy, so she supplements her income by serving as an expert witness in medical lawsuits.

Employees working at sizable companies may already have access to a health advocate. Just over half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner, a senior consultant for Mercer's Total Health Management practice. Many employees don't know the benefit exists, he says, and the services generally aren't as customized as those of an independent billing advocate.

Credential Check

Unlike with more established professions such as accounting or law, there is no standard credential to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate has certifications in medical bill coding from either the American Academy of Professional Coders or the American Health Information Management Association.

Many people with those designations aren't advocates, however, working instead for hospitals or insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care system, you'll need someone who specializes in your specific kind of billing problem.

A good place to start is Claims.org, ACAP's website. It lets you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers' compensation and insurance for special needs children.

Privacy Issues

The best way to find the right specialist is to ask the advocate for a resume and references. This can be tricky, because laws about disclosing private medical information are so strict that some advocates have difficulty providing references. In order to do so, their clients must agree to discuss their medical history.

Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy firm VersaClaim in 2002, she ran an organization that helped doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.

A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible with my medical experience in real life?" she says. "Do the charges look realistic, or is there an $85 Tylenol?"

Location Matters

Another important factor to consider is an advocate's location. State laws vary in how they regulate insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty much universal, so the client's location doesn't really matter."

For a patient negotiating a lower bill directly with a local hospital or private insurer, having an advocate who knows the specific state regulations helps. State rules for advocates can also vary dramatically. Florida has some of the strictest. "Due to the large senior population in our state, we have a strong urge to make sure our people adjusting medical claims are licensed, competent and held to a high standard," says Matthew Guy, a spokesman for Florida's Division of Agent and Agency Services, which licenses and regulates advocates.

The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster, we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters must pass an exam and take 24 hours of continuing education classes every two years.

Contingency Basis

A handful of advocates will work on contingency if they think you have a negotiable claim. Most will impose strict conditions to ensure they get paid if they win. "When I started my practice, I did everything on contingency but learned very quickly that a lot of consumers who want you to take their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate at Life Bridge Solutions in Naples, Florida.

Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical bill savings.

Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of medical billing problems, including those of the uninsured. She has 25 years of experience in the health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says. For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors who have lost their capacity or desire to manage daily finances.

Instead of being a member of ACAP, Samotin is a member of the American Association of Daily Money Managers, a trade group for generalists. Only a handful of the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says. Nor does she expect rapid growth in the field.

"Because this is a disorganized profession, people entering the field have to be entrepreneurs," she says. "They have to hang out their shingle and go out and get clients. In my experience, the majority of people who are good medical analysts and advocates are not necessarily good business getters."

So until the profession matures, finding a good advocate will remain difficult, no matter how vital the service is.

(Lewis Braham is a freelance writer based in Pittsburgh.)

To contact the editor responsible for this story: Suzanne Woolley at swoolley2@bloomberg.net

[Nov 07, 2016]