121 replies »

1. Great Post!

2. Where *are* the women? At the risk of sounding shrill, vasectomies are covered. Birth control often is not. So we’re not even supposed to make the decision to avoid pregnancy ourselves? No wonder our premiums are higher.

3. “We have too many small hospitals in this country that are not used at maxiumu capacity. This is one reason why hospital care is more expensive in the U.S. than in Europe. (You can Google this, or I could, and
   provide the reference.).Some of these hospitals shoudl be closed– zeroing in on the hosptials that are providing sub-par care because they are just not that safe.Some could be turned into community heatlh centers or long-term health centers.Fewer hospital beds would mean somewhat longer waits for non-emergency elective surgeries but this would not hurt the health of the nation”

   COMPLETELY AGREE WITH MAGGIE MAHAR ON THIS

   Dr. Rick Lippin
   Southampton,Pa

4. Bob–

   Thank much for the source. I’ve put it in my file.

   On Medicare spending on hostpials, you write: “Medicare could solve this in 30 days if it had the guts to pay hospitals on what I call a ratcheted per diem basis.Medicare would come up with a number like $2000 a day that will fit into a national budget.
   The patient diagnosis would mean nothing
   Medicare would come up with a number like $2000 a day that will fit into a national budget.

   . DRG;s would be history.
   6 days for a bypass would pay $12,000 and 6 days for pneumonia would pay $12,000.”

   Here, I have to disagree. Health care is not a commodity. Six days in the hospital for one patiient will require far more care than six days for another.
   And we cannot assume that these will “balance out.” (Some hospitals see far more difficult cases. Some hospitals see much poorer patients, who are less healthy overall.; Other (often small surburban hospitals) see easier cases.

   I firmly believe that we need to cut health care spending, but we must use
   a scalpel, not an axe.

   The patient diagnosis does mean something; it means everything.

   But we have have enough reserach to set prices as to how much it should cost an hospital (on average) to care for a healthy patient who has had a hip replacement, per day, vs. what is should cost to take care of a 80-year-old burn victim per day, or what it should cost to care for a preemie baby in an ICU per day.

   Those are the standards that can be used when paying “Accountable Care
   Organizations” a bundled reimbursement to pay for all of the care that
   a particuarl patient (who fits a particular medical profile) needs when suffering from a particular condtion. If the providers are able to achieve a good outcome (again compared to an average for that particualr situation)
   at a lower cost , they receive a bonus that they share. If they don’t they’
   receive no bonus, and in some cases, are paid less than average.

   This will encrouage hospitals and doctors to work together (either they all
   win or they all lose) and to recognize that “doing more” doesn’t necessarily lead to better outcomes.

   But I do agree that patients can wait somewhat
   longer for catract operation, hip operations and outpatient testing.

   We have too many small hospitals in this country that are not used at maxiumu capacity. This is one reason why hospital care is more expensive in the U.S. than in Europe. (You can Google this, or I could, and
   provide the reference.)
   Some of these hospitals shoudl be closed– zeroing in on the hosptials that are providing sub-par care because they are just not that safe.
   Some could be turned into community heatlh centers or long-term heatlh
   centers.

   Fewer hospital beds would mean somewhat longer waits for non-emergency elective surgeries but this would not hurt the health of the nation.

5. Bob –

   Americans are nowhere near ready for anything that looks like overt rationing. Refusing to pay for services, tests, procedures and drugs that either don’t work or cost more than they’re worth is not rationing though. Fixed budgets for hospitals would probably result in rationing. With over 5,000 hospitals in the U.S. from large urban teaching hospitals to small rural community hospitals with very different cost structures, I don’t know how such a budgeting approach would work. Some areas are growing in population while others are stable or falling. It would be a nightmare in such a large, diverse and complex country like the U.S. Besides, we have lots of other strategies that we can try first and that have a lot of potential to mitigate cost growth. We should try them and I’m pretty sure we will. We do have overt rationing for organ transplants but that’s because there aren’t enough organs for every patient that could benefit from one and we’ve developed elaborate protocols to determine who gets them and who doesn’t. That’s acceptable because there is no viable alternative.

   I attended a conference a couple of years ago at which a healthcare expert from Germany made a presentation about the German healthcare system. If I remember correctly, she noted that when hospitals were paid on a per diem basis, they liked to admit patients on a Friday so they could spend the weekend not receiving much care which made those days quite profitable for the hospital. Patients often were in the hospital longer than they needed to be in order to maximize payments. My understanding is that Germany moved toward the DRG system for hospital based care after that.

   It’s no easy task to get the incentives right. I think bundled payments make sense for surgical procedures. Capitation probably makes sense for primary care and maybe for managing chronic diseases like asthma and diabetes. We need good price and quality transparency tools so both patients and referring doctors can easily find out what services, tests, procedures and drugs cost at contract rates and patients need to be exposed to higher coinsurance amounts if they insist on going to a more expensive hospital when its quality is not better or even worse but it has a recognized brand name.

6. To Maggie and Barry:

   I get my Medicare statistics from The Statistical Abstract of US — their health care section is about 25 pages and iit is terrific.

   The Abstract has some statistics on utilization that are fascinating and depressing. I don’t have my notes handy tonite so i am going from memory, but here are the basic numbers from 1990 to 2010 for Medicare Part A.

   The number of people on Medicare went from 34 million to 47 million during that period.

   The number of hospital admissions for seniors went from 12 million a year to 15 million a year.

   Medicare Part A spending went from $60 billion a year to $180 billion a year.

   While I realize that Medicare Part A has some home health expenses and medical education subsidies and DSP subsidies for the uninsured, still and all the “answer” to medical inflation is this:

   UPCODING

   Hospitals have gotten steadily better at reporting the DRG’s that pay the best.

   Medicare could solve this in 30 days if it had the guts to pay hospitals on what I call a ratcheted per diem basis.

   Medicare would come up with a number like $2000 a day that will fit into a national budget.

   The patient diagnosis would mean nothing. DRG;s would be history.
   6 days for a bypass would pay $12,000 and 6 days for pneumonia would pay $12,000.

   If hospitals exceeded their budgeted days i, say, the 12th month of the fiscal year, then all days over budget would be reimbursed at $300 a day.
   Some doctors and hosptial staff might take a month off, as they do in Canada.

   This is approximately the formula that Germany used throughout the 1990’s to control hospital costs.

   It would lead to longer waiting times for hip surgery and cataracts and outpatient testing.

   Well, if we want to control expenses I think that is part of the bargain.

   I may be wrong and I welcome any corrections.

   But where I am not wrong is that Upcoding will kill us financially/

7. “For one, doctors will be paid bonsues if they keep their patients out of the hospital.”, as said by Ms Mahar above. I am a physician, and that comment really bothers me, as it smacks of the past efforts of capitation by private insurers that did not help quality of care in any fashion.

   And the fact that she asks for Bob Hertz to provide his source for his comments about growth of Medicare patient population size, what is that about? Oh, if it is only 65 million, then that supports a possible counter proposal of her’s?

   This morning’s CNN show at around 7:45AM showed that obesity, sorry for the pun ahead, as it grows as anticipated will end up increasing health care costs by almost a trillion dollars, by 2018, I think was the target date, and they were clear to note it did NOT include child/adolescent populations.

   Does that figure into medicare numbers as they stand now!?

8. Bob –

   I agree with your estimate of 70 million Medicare beneficiaries by 2022. There are 47.6 million as of the end of 2011 according to statehealthfacts.org. There were roundly 40 million births in the U.S. between 1947 and 1957. Of the 2.4 million people who die in the U.S. each year, roughly 75% are 65 and older but, as of the end of 2011, 15% of Medicare beneficiaries were less than 65 years old – presumably those on social security disability for at least two years and dialysis patients. There will probably also be some upward creep in the number of people collecting social security disability benefits over time.

   The interesting part, to me at least, is that Medicare spending per beneficiary increased by 6.3% per year from 1991 to 2009 from $3,435 to $10,365 according to statehealthfacts.org. About 46% of that is for hospital care excluding care performed by physicians in a hospital setting. Without the addition of the prescription drug benefit in 2006, per capita spending still would have grown by 5% per year over that 18 year span.

   In the fiscal year ended on September 30, 2011, total Medicare spending rose less than 4% and for the first seven months of this fiscal year, it’s only up 2.5% adjusted for differences in the timing of payments from one year to the next and that includes the increase in the number of beneficiaries. So, per beneficiary spending has been very well controlled recently.

   As Maggie noted, there is also lots of opportunity to treat patients in a more cost-effective way. We still have a long way to go there. There is also a lot of potential to combat fraud more intelligently and aggressively. Assuming the economy gets back on a reasonable growth path, I think we could see stabilization in Medicare spending as a percentage of GDP and I wouldn’t even be surprised if it’s a bit lower in 2022 than it is now. As I said in my last post, I’m pretty optimistic about this issue.

9. Bob-

   Thanks for your detailed reply.

   Can you give me your source for calculating how many will die before they turn 65, how many now on Medicare will die, etc. (Not questioning the numbers, but would be interested in reading the analysis and using the source in the future.)

   Just a few easons why the situation may not be as dire as it seems:

   1) There is now a fair consensus (based on the Dartmouth research, http://www.dartymouthatlas.org) as well as other reserach that 1/3 of Medicare dollars are now squandered on unncessary treatments that provide no benefit; preventable errors, etc.

   I’m not suggest ing that we will be able to cut Medicare spending by 1/3 or anything close. But as we eliminate waste it is quite possible that, over a decade, we would cut Medicare spending by 10% or even 15%.

   For one, doctors will be paid bonsues if they keep their patients out of the hospital. (Hospital care is,a s you know one of the most expensive componeents of health care) Never before have they had an incentive to avoid hospitalization.( In many ways, it is often easier for a doctor to hospitalize the patient. )

   Palliative care is growing– more and more patients will be discharged from the hospital and allowed to die at home–with palliative care– rather than in an ICU. Aetna has figured out that it’s worth paying for pallilative and hosptice care because, evven if patients live longer (and often they do) the costs of dying at home rather than in an ICU or even a regular hospital bed are so much lower.

   Officials at Medicare know this, and I’m pretty sure that HHS secretary Sebelius will use her new power to raise payment for “undervalued servcies” by raising payment for palliative and hospice care. (Meanwhile she will lower payments for some surgeries for patients who medical evidnece shows will not benefit.)

   Greater use of palliative and hospice care will have a major impact on the cost of end-of-life care.

   In a recent poll about 25% of doctors say they plan to follow new guildelines on testing (which means less screening and testeing.)
   75% still resist, but 25% is a good beginning.

   As “shared decision-making” spreads, patieints whoreceive full information about risks, benefits, and side effects are likelly to elect fewer elective surgeries. (Research shows that when they have all of the informaiton, this is what happens.) Knee & hip replacements are just two examples. (Recovery is painful and after 10% of knee replacements, patients are still in great pain. When they have this information, some patients will say “Actually, it doesn’t hurt that much. Maybe I’ll try physical thearpy. . . Hip & knee replacements are God-sends for patients who have been immobilized by pain, but recovery is no picnic. It may not be worth undergoing the operation just so that you can continue playing a competitive game of tennis . . .

   Nurse practitioners are going to be doing more and more primary care and chronic disease management. The chronic disease management will help patients stay out of the hospital, and nurse practioners are
   significantly less expensive than PCPs.

   I expect that Medicare will begin negotiating with drug-makers and device makers on prices within the next few years. Medicare will institute a formulary, and there is no reason that it couldn’t save as much as the VA has.

   Finally, as I mentioned a great many boomers will be in much better health when they turn 65 than 65-year olds who entered the Medicare system 20
   years ago. Of course this means that they will live longer, but over the next 10 years, that won’t be adding to costs. (We could expect that many who make it to 65 will live another 10 years.)

   Of course boomers over 65 wilil suffer from chronic diseaes, but becuase they are in better overall health, I think we’ll stand a much better chance of keeping them out of the hospital. (That is key to costs.)

   As to Medicaid patients: Medicaid needs an overhaul. Utlimately, it probably should be merged with Medicare. But over the next 10 years, community heatlh centers will play a larger role in providing continuous, affordable care for these patients who, today, often have a hard time
   fnding a specialist (or even a primary care doc) will to see them in the
   private practice fee-for-service system.

   The Affordable Care Act provides funding to expand community health centers capacity by 50 percent.

   It’s impossible to “mark up” just how much savings will be achieved as a resullt of a particuarl provision in the legislation, but there are so many
   provisiions that aim at savings . . Cumulatively, they are likelly to have
   a major effect.

   I would add that we have no choice. We don’t have the resources to
   double Medicare spending over 10 years, and as they say on Wall Street
   “What can’t happen, won’t.”

10. Note to Barry and Maggie —

    You are correct that Medicare has seen a slowdown in the cost per enrollee.

    However, the number of enrollees is still going to grow from 45 million to about 70 million in the next decade. You just take the number of baby boomers who will turn 65, subtract those baby boomers who will die before they get to 65, subtract the current seniors who will die, and add back in the disabled who will qualify for Medicare…….. and you get to 70 million in 2022.

    70 million times $13,000 per person, which would be a 2% growth factor that we would be lucky to achieve, yields a Medicare budget of $900 billion a year. Add to that the cost to Medicaid for dual eligibles and nursing home patients, and I think you will see real strain on the federal budget no matter what.

11. I agree with your view. It’s the same (but in reverse) with auto insurance. Single males pay much more than single women.

12. Mandating everyone buy health care is just wrong. We have raised several generations, starting with the boomers, who overall as a group think accountability and resonsibility went way of the DoeDoe. As I have said over and over here at THCB, I have no interest paying for health care for smokers who refuse to quit, and will add people with poor lifestyle choices who become morbidly obese and will not make efforts to learn weight loss lifestyles.

    Let all the PPACA stallwarts call me Hitler, fake MD, and other clueless terms. People who make poor choices in wants and goals do not get free rides in cultures that practice accountability and responbility. Let Obama and the incumbents of more than 15 years from both parties stay around another 4 or more years, and this country is doomed from within and outside.

13. Why not have a highly rationed national healthcare plan for all, paid thru taxes – then people who are not smart enough to continually share the high cost of healthcare risk, will be forced to pay regualarly and continuously for healthcare, and continuously have RATIONED healthcare, instead of blaming everyone else for becoming ill at the wrong time – namely when they CHOSE not to have health insurance.
    We have a serious problem in the US, that students aren’t taught financial basics like a checkbook, credit cards, wills, insurance – health, disability, auto, renters/home, long term care, life, etc?? We’ve raised several generations of basic financial illiterates.

14. Bob & Barry

    Barry is correct. I’ve wirtten about the slow-down. More to the point, Peter Orszag , the former Congressional Budget Driector has written about it. (just Google Orszag and Medicare spending.)

    Both the growth in health care spending in private sector and growth in Medicare spending has slowed. Medicare spending is now rising by roughly 2% a year. That’s more or less in tandem with GDP, which means that Medicare spending, ,as a % of GDP is not growing. And our Medicare bill will not double in 10 years. (The baby boomers will be joining Medicare ranks over a period of about 30 years. And when they first join, many will be significantly healthier than 65-year-olds of the past. These are the more affluent, better-educated boomers who began jogging, gave up smoking & red meat years ago. Meanwhile, older, less healthy boomers wil be dying off. Of course some of the boomers will live long enough to develop
    Alzheimer’s –and that will be extremely expensive.)

    Much of the slower growth in health care spending among the under 65 population in the private sector could be due to the recession–it’s hard to be sure. Certainly some people are putting off going to the doctor, not filling prescriptions and putting off elective surgeries because a) they have lost their jobs and their insurance b) they can no longer afford their deductible (as premiums rise and employers shift more costs to employees) or c) their incomes just haven’t kept up with their basic expenses .,

    But the fact that spending has slowed in the Medicare sector is telling.
    As you say most people over 65 are retired, and so not suffering from the growth in unemployement.

    Moreover,while answering one of Barry’s first comments on this thread, I discovered that while real average after-tax income has dropped significantly for all age groups under 65 over the past 12 years, over the same span people over 65 have enjoyed signifcant growth in income.
    (This is because unlike earned income in a market where there are so many layoffs and job losses, Social Security is stable, and many retirees who are now over 65 have old-fashioned defined benefit pensions.

    Yet health care spending among Medicare recipients is slowing. This suggests that reform is beginning to have an effect. In part this is due to the fact that hospitals are anticipating the ffects of reform which it is fully implemented in 2014, and are cutting their costs now.

    I suspect that reform is also part of the story accounting for slower private sector spending on health care. In any case, going foward, if Medicare is
    forcing hospitals to cut expenses, and causing doctors to think about
    prescribing fewer tests, etc,, private insurers will follow Medicare’s lead in refusing to pay for unnecessary care, penalizing preventable errors in hospitals, etc. Many doctors also are becoming more cost-conscious. A recent poll shows that about 25% say they plan to follow new gudellines on testing because “this woud be best for their patients.”

    There are a great many provisions in the ACA that aim at breaking the inflation curve, and some will work. Over time (5-10 years), I expect that
    health care spending will be growing no faster than GDP. Then we might focus on trying to elminate enough waste & fraud so that health care
    spending actually represnts a lower percentage of GDP.

    Bringing the discussion back to the original topic, this is one of the reasons why we will be able to afford first-dollar coverage for the preventive care that women need.

15. Bob –

    Healthcare cost growth has finally started to slow in the last couple of years for both the commercial sector and the public programs. While the conventional wisdom attributes much of the reason for the slowing growth to the recession, we’ve seen slowing on the commercial side in areas not seriously impacted by the recession. People with Medicare don’t lose their health insurance either because of the recession yet cost growth remains low this fiscal year following less than 4% cost growth last year despite a growing number of beneficiaries.

    We’re just starting to get serious about attacking fraud more aggressively and systematically. More intensive case management is being applied to the high cost cases including the expensive dual eligible population. Better discharge planning is starting to reduce hospital readmission rates. Accountable care organizations have the potential to do a better job of coordinating care and steering necessary and appropriate care to the most cost-effective high quality providers. Reasonable tort reform and a more sensible approach to end of life care, especially for patients with Alzheimer’s, dementia and cancer could rein in cost growth as well. Gradually moving away from fee for service payment in favor of bundled payments and capitation should be helpful as well. In short, I’m optimistic about our ultimate ability to get our arms around medical cost growth over the intermediate to longer term without significant new taxes.

16. Actually when I propose that Medicare taxes go up 1%, which brings in about $70 billion a year, I want that money to help subsidize a variety of non-PPACA programs for those under 65 (such as lending money to the uninsured at zero interest rates to help them pay for emergency operations, or helping the unemployed and self-employed pay for catastrophic health premiums.)

    My reason for using a Medicare tax is that it is very collectible. Most employers even small ones use a payroll service that would just make a click in their computer programs.

    I definitely do NOT believe that a 1% increase will be enough to pay for traditional Medicare in the future, unfortunately.

    The sheer demography of baby boomers turning 65, plus Medicare inflation even if it is contained, will drive Medicare costs for seniors from $500 billion in 2010 to about $1 trillion in 2020. That is a rough number but let’s work with it for now.

    Medicare has three sources of revenue — the payroll tax that is now set at 2.9%, monthly premiums paid by seniors, and general revenues that amount to about 3% of taxable income from those who do pay income taxes.

    So you have total national income today of about $8 trillion, and $500 billion or 6% pays for Medicare.

    If Medicare costs double in 10 years, I promise you that American incomes will not double. Say that total national income climbs to $10 trillion.

    $1 trillion for Medicare thus means a higher payroll tax, higher monthly premiums, and higher income taxes

    The only way to avoid this, budget-wise, would be to reduce the defense budget by 80%. If we want a Danish welfare state, or something like it,
    then we have to have Danish budget priorities.

    I am not sure that would be a bad thing, but in any event, we should be ready for higher taxes.

17. Nate –

    I agree with your comment on CA. Even I may move out of NJ in a few years, in part because of high state and local taxes.

    At the federal level, I’ve argued for some time that the capital gains tax rate is too low relative to the top ordinary income tax rate – 15% for capital gains (and qualified dividends) vs. 35% for ordinary income. If we’re going to maintain the current tax structure, I think the capital gains rate should either go back to 28% where it was under the Reagan reforms or included in the base for calculating the Alternative Minimum Tax which it was from 1969-1985. Republicans, by contrast, want to drive the tax rate on investment income to zero while it’s more or less OK to tax wages every which way to Sunday. I don’t buy it. I’m not a fan of the VAT either mainly because it’s a potential money machine that will likely increase the size of government beyond what we already have.

    My objection to singling out high income people for what I call further soaking is that it attempts to convey to the rest of the population that they can have something for nothing. We already have a population that wants more services than they’re willing to pay for. They want someone else (the rich) to pay. At the end of the day, the broad middle class has to pay for the broad middle class. The rich can help to pay for the poor within reason.

    Maggie –

    Threads veer off topic all the time. When they do, a lot of useful, at least to me, information often comes out or is exchanged. I’ve learned lots of valuable information about healthcare and health insurance from off topic comments.

    As for Nate, while he probably wouldn’t be able to get a job as a diplomat, he has many years of real world experience in the health insurance business and is a virtual encyclopedia about the industry’s inner workings and history. I for one appreciate his comments even when he disagrees with me which he does from time to time and I’ve learned a lot from him. I don’t think off topic comments push people away from commenting, at least on THCB. At the same time, personal attacks should be edited out or, preferably, not made in the first place.

18. Just read through the history of comments to see what was deleted and it was pretty bad. All of Maggie’s responses are left, unchallenged, making it appear she is correct and the retorts, facts and “abusive” flare, gone. Its one thing to maybe delete a sentence or two here and there but to delete entire post filled with facts because they disprove Maggie’s arguments smack of HealthBeat.

    I’m Not in any way saying they are not 100% within their right to do so, but people should realize what it is and dissent is not allowed. Pull the party line or else. People need to learn the difference for themselves between propaganda and discussion.

    No thanks.

    Been fun. Good luck and health to all.

19. Writing a post here is a waste of time, most of the commenters have their fixed position and find commenters like me who are independent and moderate truly frightening and unable to manipulate. I appreciate the recommendation, but blogs are a double edged sword in the end. And, I did not read any comment I could interpret as an effort of transparency to what your agenda is by forwarding posts here.

    And if you think my comments are hijacking your thread, I honestly do not know what else to say but you give me too much credit. Refute me with statement of fact to your mission statement and I will be ignored. It seems to happen at other threads. And that is the way it is.

    Tell the blog authors to get rid of the anchor of mine at the end of this thread currently, even I am tired of seeing it.

20. Then they tax the middle class more overtly than they already do covertly with fees and other “non tax” designations.

    The Republicans are a failure as representatives because they do not represent, just resent there are others in society that do not kiss that party’s butts. The Democrats are a failure because they want dependency and entitlement to justify enslavement.

    Independence and moderation, those words as much as terms not only scare what these 2 parties are about, but now empower them both to want to crush anyone who does not fully comply with their agenda. And both want to reenslave women, different tactics but same endpoint.

    Wow, listening to the rhetoric at sites like these the past few weeks since the Court heard arguments, Democrats are frightened. Hence the post above that now wants censorship.

21. It is very hard to fight hospitals, it was impossible but now that premiums finally got to the point people are uncomfortable they are willing to stand up to them. A payor can’t stand up to a hospital when the patient is crying to HR or threatening to sue. Hospitals know this and use it to their advantage, don’t pay what they want, they balance bill and threaten to destroy patients credit and take their house. Once that balance bill threat shows up its over.

    Just last week I had to go back and reimburse a hospital additional amounts over what our cost audits said was fair. We have strong case and would have prevailed but the administrator of the plan was tired of employees complaining about the threats from the hospital.

    When people argue healthcare is unaffordable I have to disagree, I see people waste money and WILLFULLY overspend every day. If it was unaffordable why do people keep doing the same thing and paying the high bills.

    Employers that have said enough are seeing huge savings, so there are solutions people just need to want to pay less.

22. “As you note, when it comes to healthcare, market competition doesn’t work very well.”

    Care to provide an example, competition works great when there is actually competition, i.e. the low dose CT scan for $99. Or elective surgery. The problem is competition has been regulated out of healthcare.

23. Isn’t that what CA has been doing the past 15 years or so. Every time they need to pay for something just tax the rich one more percent.

    “California collects a state income tax at a maximum marginal tax rate of 10.30%”

    And they are still broke, the rich are leaving, and they are broke.

    How many times do we increase the tax 1% to pay for Medicare? And what happens when the rich leave and stop paying, then what?

24. “At the same time, as more Americans turn 65, we may have to raise Medicare taxes as a % of income by, say 1%, and, I would suggest, perhaps begin taxing some small portion of investment income…”

    Maggie –

    Starting in 2013, the employee share of the Medicare tax will increase by 0.9 percentage point for individuals earning more than $200K and for couples earning more than $250K. In addition, investment and other non-wage income above those thresholds will be subject to a new 3.8% tax which is equivalent to the increased combined Medicare tax on wages of high income people, again above the $200K and $250K thresholds for single and joint tax filers, respectively.

    You can read more at: http://www.larkinhoffman.com/news/article_detail.cfm?ARTICLE_ID=636

25. Bob Hertz–

    Thank you.

    I haven’t read “Competing Solutions” but I’ll check it out on Amazon. ,

    I totally agree that “People should pay for health care approximately according to their income” rather than according to their gender, height, nationality, etc. etc. etc.

    “Approximately” is, of course, a key word. (Earlier Barry suggested that we shoudn’t demand that a billionaire contribute hundreds of millions to a heatlh care fund. No, we shouldn’t. That’s why there’s a dollar limit on how much of your salary is subject to the Social Security tax.

    These days, there is no limit on how much of earned income is subject to the Medicare tax– because health care in the U,.S. has become unreasonably expensive. But investment income (which typically represents the bulk of a very wealthy person’s income) is not subject to the Medicare payroll tax.

    Going forward, as you have said, we have to put a brake on the rise in health care spending (reducing waste, unnecessaery treatments, preventable errors),. At the same time, as more Americans turn 65, we may have to raise Medicare taxes as a % of income by, say 1%, and , I would suggest, perhaps begin taxing some small portion of investment income. Or, as Zeke Emanuel & Victor Fuchs have suggested in “Heatlhcare Guaranteed” we might institute a VAT and dedictte it to healthcare. (If you haven’t read the book, it’s brilliant. A VAT sounds regressive, but Emanuel & Fuchs explain why it isn’t.)

    Finally, you write “The PPACA does stumble toward that outcome” (paying for healthcare approximately according to income) “albeit with a million detours.” Though you add, ” I might not have done any better.”

    I agree that the PPACA is deeply flawed. But compared to major legislation of the past, it is at least as good. When the Social Secruity Act passed, it
    didn’t include African-Americans. Many in the Roosevelt administration were not happy about this (including Eleanor). But they wanted to pass the legislation, and over time, had faith that it would be improved—as it was.

    In order to pass Medicare legislation, LBJ agreed to let doctors and hospitals
    write their own checks, “charging whatever they want.” I write about this in
    “Money-Driven Medicine.: Johnson thought that because more and more specialists were graduating from med schools, market competition would quite naturally bring down their fees. He was wrong. As you note, when it comes to healthcare, market competition doesn’t work very well.

    Ultimatley I think it’s impossible to pass a major piece of legislation that is not deeply flawed–not when several hundred legislators are involved in the process. Inevitably, there will be “many detours.” Everyone has a special interest. Some of these are very valid special interests. (For example, autistic children) Others are not. But if you want to get the thing passed, you have to compromise.

    Over time the PPACA will need revision.

    But I find it extraordinarily that in these divided times, under a sitting president who was not elected by a landslide (as LBJ was ), we actually managed to pass a health care reform act that represents a decent start.

26. Determined M.D.

    You write: “expecting people just to spout off endless statistics and partisan echoes of post writers is not what this debate is about. Your post is interpreted as just trying to promote women are only fairly represented by Democrats and this legislation is a near cure all for their struggles. Why should that go unchallenged . . . ”

    Perhaps you didn’t read my last comment. I said that the post was meant as a platform for people to agree or disagree that women were being discriminated against–and agree or disagree as to whether reform should
    ask others to help subsidize their care.

    Too many of your comments on thisi thread have nothing to do with that issue. Too many are simply about me, like the last one: “Remember, the themes she writes for are enslave and entitle.” In the larger scheme of things (the healtlhcare debate) I’m just not that important.

    You are interested in Obama, and whether politics should be part of the heatlhcare debate.

    So why not write a post about that? You are articulate, and “determined”–
    no reason you couldn’t.

    It’s easier, I realize to hi-jack someone else’s post, using the comments section to take off on your own toot.

    Writing a post is hard work. But I mean it when I say that you could.

27. Should be “…write as an interpretation.”

28. Respectfully, expecting people just to spout off endless statistics and partisan echoes of post writers is not what this debate is about. Your post is interpreted as just trying to promote women are only fairly represented by Democrats and this legislation is a near cure all for their struggles.

    Why should that go unchallenged if it has merit? I’ll also offer this opinion, as a man, but agreed to by women I’ve discussed with in past moments: feminism had not truly aided women’s efforts at equality when the agenda becomes women want to be as controlling as men, and, men have little to no place at the table of gynecological matters like abortion and contraception.

    Frankly, I don’t understand why women haven’t figured out neither party of entrenched incumbents really care for their needs, just their votes. But that is for them as a gender to resolve. Shame on you for fostering that democrat agenda. As I always note, in the end reasonable and fair readers will see through the faux agenda of pretending to help the public when it is moreso about political party gain.

    That is fair for me to right as an interpretation.

29. Maggie, you are steadfast as always and I admire you a lot.

    Per Joseph White in his still-marvelous book Competing Solutions, from 1995………..

    People should pay for health care approximately according to their income.

    The PPACA does stunble toward that outcome, albeit with a million detours.
    I might not have done any better.

    Bob Hertz, The Health Care Crusade

30. Determined M.D.

    This post is not meant as a platfrom for you to vent your objections to the PPACA in general. It is intended to provide a platform for civil discussion of wheter discrimation against women under the current insurance system–if it is, indeed, discrimation or in fact fair.

    Should reform ask men to pay as much as women for insurance?
    If so why?
    If not why?

    If you would like to discuss other issues on THCB, you should submit a post to the editors focusing on whatever issue you choose. If they decide it would be of interest to THCB’s audience, they will publish it, and the thread will (or at least should) focus on the that topic.

    But when people join a thread and change the topic that de-rails the discussion. This means that potential commenters interested in the question at hand simply give up and go away.

    (For instance, one would have expected a number of women to have commented on this thread. In fact I can recall only two comments– one from a women who said she was not sure she wanted to ask men to support her
    health care needs, one from Bev M.D.

    Why didn’t more women comment, pro or con? )
    I believe that THCB editors have discussed this with you.

31. If that is the case, while I have no argument to vicious or cruel comments being deleted, who are you to insist on censorship just because people like me find your posts and thread comments to be over the top partisan commentary?

    I see my last comment still in place as the end of the thread. Wierd, but appreciated if kept on. You have had some valid points in your role at this site, but as I have asked before and now, tell us otherwise you are not as blue a Democrat supporter as one comes, and to me to a point where you do dismiss valid concerns by health care providers, like me.

    PPACA is not a good legislative effort, and while I firmly agree that some political intervention is needed, not just a democrat deluge without bipartisan drafting. If this is considered harsh commenting, this site will become irrelevant by the mid summer.

    And by the way, Nate, you are a bit harsh in some comments, can’t you find a more neutral way of saying “you’re off base or just cherry picking facts/opinions”?

32. As of yesterday THCB editors were deleting all personal attacks on this thread as well as comments derailing the thread–comments which had nothing to do with the topic of the post–discimriantion against women in the health care market, and how reform addresses these programs.

    At this point, there seems to have been a technical glitch, and virtually all comments (including many good ones that were on point) have been deleted.

    I assume the editors will restore them.(I’ve gotten in touch with them) .

    At the same time, I appreciate the fact that THCB editors are moderating the thread.

33. “Doctors don’t dictate excessive care, patients demand it.”

    It rather seems to be a mutually beneficial death grip on expenditures.

    “The waste we do see from providers is referring patients to the hospital”

    Isn’t waste generated within the hospital for in-patient also a significant factor? Also, wouldn’t co-pays and deductibles manage that?

    “The American consumer is flush with money to spend”

    Not what you hear from Republicans. But if what you say is true it must be because of Obama policies. :>)

    “From an insurer perspective a patient that never gets care then dies of a heart attack is very profitable.”

    That’s why insurers should never be given exclusive control of care decisions – or I guess, they would be accused of being a death panel.

    “This is amplified by the risk dropping off at 65 and going onto Medicare when I lot of these would manifest.”

    So, would that be a major factor in the cost of Medicare which would also support it’s existence?

34. Just to expand on what Barry says………

    Insurance companies have found out that it is easier to just raise premiums than to fight every hospital over every price.

    Plus, when an insurance company pays less than the hospital has billed, the patient is liable for the difference (in the private sector). Because we have so few laws against balance billing, the patient has been the kamikaze of cost control.

    This I assume is why Porter and Teisberg want to see strict rules against balance billing.

35. “In a hypothetical free market, one would think that insurance companies would pick the cheapest decent provider. That would help the insurer make more profits. It would also support price competition.”

    Bob –

    In the employer market, the individual member is not the customer. The employer is. Employees want the big well known academic medical centers in their network and employers want to keep employees happy to the extent that they can. So, in Boston, for example, at least until recently, employers felt that they had to have Massachusetts General and Brigham & Women’s in their network. Partners Healthcare knew that and exploited it accordingly. With lots of local and regional market power, they command higher prices than competitors for the same work even when their quality is no better. In NYC, the same dynamic goes for Columbia-Presbyterian, NYU-Langone, Weill-Cornell, Hospital for Special Surgery, Memorial Sloan Kettering, and a couple of others.

    This is why we need tiered networks and limited or narrow networks along with tiered drug formularies which we already had. Patients need to be exposed to some adverse financial consequences for unreasonable demands and irrational choices. Tiering also helps to create some countervailing power for insurers to push back against the powerful hospital systems.

    I also think that disclosure of actual contract reimbursement rates would help to open the eyes of both patients and referring doctors regarding cost differences among hospitals for care of similar quality and type. If lower paid hospitals clamor for the higher reimbursement rates paid to their more powerful competitors, insurers could argue that the expensive hospitals are in the non-preferred tier, patient out-of-pocket cost is higher, and we’re doing everything we can to steer patients away from them and toward the more cost-effective providers like you.

    I also agree with Nate’s point about preventive care. It improves quality of life and extends it which are obviously good things but it doesn’t save money.

36. I read a great quote recently;

    “Love Of Theory Is The Root Of All Evil”

    All these clowns that have never worked a day in delivery/insurance claiming FFS is the problem are idiots. They are sitting back in their ivory towers with no exprience trying to interupt data they aren’t smart enough to grasp and comming up with these crazy theories. Doctors don’t dictate excessive care, patients demand it. The waste we do see from providers is referring patients to the hospital for an outpatient MRI instead of a free standing imaging center or prescribing an expensive brand instead of trying a generic.

    The American consumer is flush with money to spend, They are going to find someplace to spend it. From the data I generate, not what I read from others over the internet, the problem is the price we pay for the care people demand. Brand Rx and Hospital charges. Not elective hospital care but back surgery, transplant, etc.

    Kaiser can still get sued and members can still elect other plans, Kaiser is even more succible to individual selection as a lot of their members have plan choice at enrollment.

    In CA I think only emergency care goes outside the Kaiser network, in OH all but PCP now that they closed their hospitals. Not sure about GA, and I think there is on other State they have some lives.

    From an insurer perspective a patient that never gets care then dies of a heart attack is very profitable. A patient seeing their doctor quarterly to treat their heart condition is expensive. This is why its a mistake to say prevention saves money. It increases quality of life and prolongs it but it cost a fortune. Not many illnesses are cheaper treated vs ignored. This is amplified by the risk dropping off at 65 and going onto Medicare when I lot of these would manifest.

    Kaiser does take on sicker groups, so do I. Its hard to make money on $200 PMPM in premium. Give me $400 PMPM and some good claims management and I can make a fortune. Kaiser has much more ability to manage claims, especially in CA, the incremintal cost of treating a person in a hospital you own is minimial compared to paying a non affiliated hospital. FOr example if I owned Metro Health in clev

    plane boarding finish when i land

37. One of Nate’s comments a few posts ago was that the price of a procedure will triple after it is covered by insurance.

    This is not too bad as a one-line summary of American health care since 1965.

    It is kind of the King of Unintended Consequences.

    Several economists have tackled this issue — I read only sporadically in this area,
    so their names escape me. (Henry Aaron? Uwe Reinhardt?)

    I do know that when Medicare first came on line, providers were encouraged to raise prices right in the payment formulas.

    There were also higher payments for hospitals that built new facilities.

    Since about 1985, though, it is a little more mysterious (to me, at least) why insurance coverage triples prices.

    In a hypothetical free market, one would think that insurance companies would pick the cheapest decent provider. That would help the insurer make more profits. It would also support price competition.

    I assume that this kind of dynamic is what holds down the cost of common car repairs to roughly the rate of inflation. The price of a brake job does not triple if one has a warranty.The wonderful guys on Car Talk give out price estimates to a national audience every Saturday and no one proves them wrong.

    American health insurers have in general been more passive about paying
    high prices. Of course one can just junk a broken car and that is an effective protest against price gouging. Not easy to do that with a person and plus medical care is relentlessly local.

    Anyways, Nate’s comment on price tripling stays in my mind.

38. Nate –

    Thanks. That’s very helpful. The thing that has me scratching my head about Kaiser is that we keep hearing from experts that as much as 30% of U.S. healthcare spending is waste, either unnecessary or marginally useful care including, presumably, futile end of life care, defensive medicine and fraud.

    Kaiser employs salaried doctors and does not use any productivity metrics, as I understand it, in determining individual physician compensation. So, the docs don’t have any incentive to overtreat. They make extensive use of electronic records which should minimize duplicate testing and adverse drug interactions. Kaiser is both the payer and the provider though I’m not sure what percentage of Kaiser’s medical claims cost are incurred outside of their own system for care they can’t provide within their network. I also don’t know what percentage of their 8.8 million members are on Medicare or Medicaid.

    You suggested that Kaiser attracts a disproportionate number of people who either don’t expect to use much healthcare or are very engaged in their care. However, I’ve heard doctors suggest in the past that engaged patients can be more expensive to treat than passive patients. Also, a CA based insurance broker who works with small and medium size groups told me a couple of years ago that unhealthy groups that other insurers don’t want and bid high to push the business away can usually get a more competitive deal from Kaiser which would imply a certain amount of adverse selection toward Kaiser.

    I also read just yesterday that over 25% of U.S. doctors are now employed by hospitals on a salaried basis though most of those hospitals use a revenue metric to help determine bonuses if any. If we want to move away from the fee for service payment model in favor of some combination of bundled payments and capitation with the expectation that we can reduce healthcare costs or at least reduce the cost growth rate, the Kaiser experience doesn’t seem to offer much promise on that score.

    Separately, Harvard Pilgrim Healthcare recently introduced a narrow network product that excludes the high priced Partners hospitals – Massachusetts General and Brigham & Women’s. The premium is only 10% lower than the broad network offering.

    What am I missing here?

39. if your referring to purely care, like taking their medicine, following instructions, going to the doctor I would estimate;

    1 year 0%
    3 year 2-3%
    5 year 5-10%

    Long term would be very dependent on the variables. Industry and turn over for example. If your high turnover industry there would be no long term savings. If your a school district or something where your employees stay with you 30 years then you could see some money, the beneficiary initially would be medicare until they live to 100.

    If you have a population high in diabetics you could see some more immediate return if they were not compliant.

    Health is not where the money is at. Redirecting to different providers or dropping a PPO on the other hand could save you 20% first year. More aggresive Rx formulary could quickly save you 5% first year.

40. Maggie –

    I read your links about Kaiser. I have a healthy respect for Kaiser. A former college roommate has a family business in San Francisco with about 40 employees insured by Kaiser. He personally had a major surgical procedure at a Kaiser hospital a few years ago and was well satisfied with his care. Northern CA is their best market and HMO’s have been more accepted there than in other parts of the country for a long time. I also like the idea of the payer and the provider being on the same team as well as the use of electronic records. These two factors should result in less duplicate testing and adverse drug interactions and fewer unnecessary or inappropriate surgeries, tests and procedures.

    On the other hand, I ask again where the cost savings are. While I’ve long believed that preventive care doesn’t save money on a lifetime cost basis because well cared for people are more likely to live long enough to get expensive diseases like Alzheimer’s and dementia, the Kaiser experience doesn’t appear to show any short term savings either even though their efforts to keep people well are largely successful.

    Kaiser’s favorable experience with reducing the incidence of heart disease in Northern CA to 30% less than the rest of the local population should suggest that their number of hospital inpatient bed days per 1,000 members should be lower than their competitors. If it is, why doesn’t it show up in lower costs and lower health insurance premiums? It can’t be just the extra cost of smoking cessation programs. Only about 20% of the population smokes these days and as you noted, the majority of them are poor and are likely to be less engaged in their healthcare to begin with.

    No matter how good a health plan’s processes are, patients still need to take their medications consistently and follow their doctors’ advice and recommendations to be as healthy as they can be. I also think it’s important to remember what Steve Schroeder told us a few years ago about what influences an individual’s health status. That is: 40% is driven by personal behavior and choices, 30% relates to genetic makeup, 20% is caused by socioeconomic status and environmental factors and only 10% is attributable to the quality of healthcare that we have access to.

    Nate –

    If you were to compare two groups of 1,000 people each comparable in age, gender, socioeconomic status, and initial health status one of which was actively engaged in their care and the other wasn’t, how much difference in healthcare costs would you expect to see between the two populations over a one, three and five year period? Specifically, how much difference should engagement make vs. just passively accepting physician recommendations or just not going to the doctor even when you should?

41. Barry–

    You observe that Kaiser’s health insurance is not notably cheaper than other health insurance, so why do I say that Kaiser is more efficient?

    Becuse Kaiser provides better heatlhcare for the same dollar–a bigger bang for your buck. Better outcomes. More comprehensive care. Free smoking cessation programs.

    If you don’t believe me, look at what Kaisers’ patients have to say in this
    Consumers’ Union (Consumer’s Report ) poll.. Kaiser comes out on top. http://moneyland.time.com/2011/10/18/why-are-customers-of-this-health-insurer-so-happy/#ixzz1tvmOEgEd

    According to the report:
    “Kaiser Permanente, a non-profit that insures some 8.8 million Americans nationwide, stands “head and shoulders” above the other large insurers
    Read more: http://moneyland.time.com/2011/10/17/health-insurance-surprises-smaller-is-often-better-and-patients-prefer-hmos/#ixzz1tvoUaaT3

    “Because Kaiser is both the insurer and the provider, it has a larger incentive to invest in preventive care, wellness classes and free smoking clinics. Many other insurers and health systems avoid sinking money into such programs because patients switch insurers so frequently that such spending winds up benefiting another company. But as the Consumer Reports’ ratings show, Kaiser patient satisfaction is high and patient turnover low, so it makes more sense for the insurer to invest for the long haul in patients’ health.”

    Read more: http://moneyland.time.com/2011/10/18/why-are-customers-of-this-health-insurer-so-happy/#ixzz1tvolwBld

    Just one example of how Kaiser improves its customers’ health: in Northern California, Kaiser has reduced death from heart disease among its 3 million members so significantly that it is no longer the leading cause of death. In fact, After Adjusting for Age and Gender, death from heart disease is more than 30 percent lower among the Kaiser population than among Northern Californians who receive care through another insurer. (BARRY : Please note Kaiser’s success is measure After Adjusting for Age” which answers your earlier assertion that Kaiser just didn’t have as many older patients as other insurers and that’s why it’s heart attack rate is lower. That’s just not true.)

    Doctors also like Kaiser, and compete for jobs working there: “In California, Kaiser hires just 11 percent of the doctors who apply for positions.”

    Barry, I really wish that, before accusing me of getting my facts wrong, or distorting the facts, you would do a little research yourself–or, at least ask me for proof (if I haven’t provided any) rather than assuming that I am lying.

    I wrote the above piece for Time.com (Time magazine online.) They are not particuarly “left” and wouldn’t have hired me if I regularly got my facts wrong.

42. Bill & Bob Hertz

    You write:

    “I’m normally pretty tolerant of a wide range of views, but Nate’s opinion that Medicare is unsustainable is not acceptable.

    “I agree that it needs to do a much better job of providing value and being a savvy purchaser of health care on behalf of our seniors.

    “Painting it as unsustainable is quite different. I don’t find it acceptable to go back to the pre-Medicare poor health status of the elderly as he implies we should do. We should be ashamed as a country and society if that’s how we advocate treating our elderly citizens

    “A good place to start is by linking the Medicare payroll tax rate to Part A cost trends. The basis for the shortfall is that for political reasons, the tax rate hasn’t changed in over a decade despite significant cost increases in Part A benefits.

    “Medicare also needs to improve on what it pays for and how much it pays. This is not rocket science, but rather requires a level of frankness and tough decision making which our current generation of political leaders find quite challenging.

    “The need to change Medicare and address these concerns may make it unsustainable to you. To me it signals a great opportunity to improve on how we care for our seniors by funding it at a realistic level and by providing more effective stewardship over the resources it uses.. . “.

    In another post, you add: “Nate, actually I don’t disagree with any of your facts. All of them point to the need for changes to the way Medicare is run.

    “A good place to start is by linking the Medicare payroll tax rate to Part A cost trends. The basis for the shortfall is that for political reasons, the tax rate hasn’t changed in over a decade despite significant cost increases in Part A benefits.”

    “Medicare also needs to improve on what it pays for and how much it pays. This is not rocket science, but rather requires a level of frankness and tough decision making which our current generation of political leaders find quite challenging.”

    “The need to change Medicare and address these concerns may make it unsustainable to you. To me it signals a great opportunity to improve on how we care for our seniors by funding it at a realistic level and by providing more effective stewardship over the resources it uses.”

    Bill, couldn’t agree more.

    Medicare does have to rethink what it pays for and how it pays. Under the ACA it will be moving away from fee-for-service (which encourages “more care, not necessarily better care”) and the ACA
    gives the Secretary of HHS the freedom to use medical evidence to lower
    fees for “over-valued services” and raise fees for “under-valued services.”
    (She doesn’t have to go through Congress to do this.)

    Medicare has already begun to do this, lowering fees for some testing, and private insurers are following Medicare’s lead.

    I also suspect that, in the not-too-distant future, Medicare will use medical evidence on risks and benefits to create a drug formulary. Just like every other government in the developed world, we will refuse to over-pay for very expensive drugs that are no better than the (sometimes safer) drugs they are trying to replace, covering the expensive drugs only for patients who can’t tolerate, or wouldn’t benefit from the less expensive medication. (Medicare already only pays for some things under certain conditions.)

    As we learn to lower costs while focusing on quality, not quantity, finding the money to cover everyone (including women under 65 who need maternity care) will no longer be such a problem.

    Bob–

    You write: “My own feeling is that free-market insurance is basically unreformable. If we want to do better for persons who are self-employed, part-time, or have low-paid jobs, we should just expand public coverage.

    “This takes taxes, if we are going to be grownups and pay for the government we want.:

    Yes– though this assumes that the government we want is one that cares for people who work part-time, have low-paid jobs, etc. I agree that this is the sociey we want to live in, but not everyone would.

    You conintue; ” But If the taxes have a broad enough base, they will not cripple anyone. For example, raising the payroll tax by 1% on employers and 1% on employees will cost $42 a month for someone making $50,000 a year. And yet the payroll tax for Medicare has not been raised in its percentage since 1990.

    “The political challenge is that the people who pay the most taxes are not in the individual market at all. People with higher incomes tend to have the best employer-paid coverage. They do not lose a minute of sleep over the travails of the individual market, so they resist paying taxes to expand public insurance.

    “this changes big time if they are laid off……a health care liberal is a conservative who has to go on COBRA.” .

    Yes, I agree that raising payroll taxes by 1% would not be crippling for middle-class Americans (individuals earning $50,000) and will be needed, especially as the country ages and more Americans are on Medicare. (Though I wouldn’t suggest a payroll tax increase during this recession.)

    You are also right that the people who benefit most from public health care are middle-class, working class and poorer Americans, while those who pay a larger part of the bill (in absolute dollars) are wealthier Amercains because they are paying a % of income, both through payroll taxes and through income taxes that help fund general revenues. Under health reform, they will be paying higher income taxes to help fund universal coverage.

    Some of those wealthier Americans do not agree with you and Bill that as a society, we have a reponsibility to provide high quality healthcare for
    seniors–or maternity care women. They are not “ashamed” to say that this is just unsustainable–even though every other developed country does this, and, (despite our debt) we are still wealthier than most. The weallthiest 10% of Americans are very, very wealthy by European standards where the gaps between the rich, the middle-class and the poor just aren’t as wide.

    Your final comment underlines how and why the debate over health care reform is, inevitably, a political debate about sharing wealth, You note that some wealthy taxpyers “resist paying taxes to expand public insurance” but “this changes big time if they are laid off……a health care liberal is a conservative who has to go on COBRA.”

    Yes, I’m afraid that this true. Though it’s important that remember that some very wealthy Americans believe strongly in sharing resources.

    Your final comment illustates how some political questions come down to questions about moral and ethical values. Do we as a society have an obligation to pool our resources to care for those who need our help, including the elderly, children and pregnant women?” In other words, “Am I my brother’s keeper?”
    I would say yes becausem :There but for fortune . . ”

    I have good insurance. I was born on second base; I was lucky enough to receive scholarships that led to an excellent education. This is one reason why I feel that those of us who are relatively lucky should “give back.”

    This is why my discussions of health care will always seem “too political” to those who disagree with me.

    But I’m not introducing politics into the discussion. Politics, and the difference between how conservatives and liberals feel about taxes (and sharing ) is at the very root of the discussion.

    So, call me a bleeding-heart liberal. But this is not about Obama. ( I’ve felt this way for many, many years before Obama was on the scene.) It’s about progressive values.

    .

43. Barry–

    Regarding getting to VA hosptials: the VA docs I talk to remark on how willing VETS are to travel to the hospitals. They like being with other Vets, they like the docs, they like being in a place that they can call their own.
    (As you know, much of society is not particularly sympathetic to Vets, particularly Vietnam Vets.

    Driving 25 minutes to a hospital is what most people do in rural America.
    In most cases, a Vet who does not have a car or can no longer drive has a family member, a neighbor or a Veteran’s organization who will take him to the hospital.

    People in rural America who are not veterans and go to private sector hosptials often have to travel much further. “20 percent of Americans live in rural America and most live within 90 miles of a hospital.” http://www.hhnmag.com/hhnmag/HHNDaily/HHNDailyDisplay.dhtml?id=7460008361

    Finally, not surprisingly, the VA is a leader and ealy adaptor in the field of telemedicine (beginning in 1999.) “It’s no longer just a project; it’s now part of standard practice,” said Adam Darkins, chief telemedicine consultant at the Veteran’s Administration. Darkins expects telemedicine use to soar in the next 18 months, with the opening of a handful of VA centers of excellence, which will be staffed by experts in different maladies.”

    Telemedicine will help cut costs nationwide, and in rural areas will, literally, be a lifesaver.

    The author points out that the VA succeed, in part, but cause its doctors work for the VA. In the private sector, some doctors are not enthusiastic about telemedicine and balk when hospitals ask them to use it. If the doctor is not am employee of the hostpial, the hospital cannot tell him how to practice medicine.

    But the excellent of the VA is based, not just on its technology, but on a culture created by a self-selecting group of Docs. Many could be working at more prestigious hospitals where they could earn more. I asked one specialist who is on the faculty at Dartmouth, and works at a VA hospital why he chose it: “I just like working with the vets,” he said. And many doctors like being part of an efficient system. They’re happy to work on salary, ,rather than fee-for-service, even though many would make far more in the private sector. This also means that there is no incentive for over-treatment. And, as I mentioned, because they are government employees, their is little conflict of interest– they are not allowed to take money from drug-makers, device-makers, etc., for any reason. This is the opposite of “Money-Driven Medicine.” (Of course a great many docs who work in the private sector also are not “money-driven”, but the VA is good example of what it means when money is no longer a driver. .”

    You’ve indicated that you’ve never gone to a VA hosptial, even though you’re a Vet. But the Vets I talk to lilke being treated in a place where they are with other Vets, and are treated by a self-selecting group of docs who chose the VA because they like the patients, and the culture.

44. None of this thread has been about healthcare, access or affardability. It is all about the charade of coverage and “social justice”. Still no care.

    Most people do not need care. Most people do not want the government in the exam room. If they can make you buy coverage they can make you use it. If they can make you use it, they can deny it to you.

45. Back to the issue of women’s access to health insurance, women are indeed overrepresented in low wage occupations including restaurants and bars, retail trade, and hospitality and tourism. However, with the exception of retail trade, employees in the other low wage industries mentioned derive a significant portion of their income from cash tips. This suggests that their income as reported to the IRS is likely understated, in some cases significantly. Indeed the underground is economy is all around us which suggests that the income statistics that you frequently cite can’t be completely trusted.

    While the IRS is quite good at matching up documents like W-2 and 1099 forms, they are not very good at all at finding unreported cash income. When people become eligible for subsidies under PPACA this problem is likely to get worse as yet another incentive to game the system is created while honest taxpayers who earn their income in the above ground economy pay most of the bill. At the very least, people should be subject to rigorous income verification requirements to qualify for a subsidy and penalties for cheating should be significant and appropriate.

46. Nate, actually I don’t disagree with any of your facts. All of them point to the need for changes to the way Medicare is run.

    A good place to start is by linking the Medicare payroll tax rate to Part A cost trends. The basis for the shortfall is that for political reasons, the tax rate hasn’t changed in over a decade despite significant cost increases in Part A benefits.

    Medicare also needs to improve on what it pays for and how much it pays. This is not rocket science, but rather requires a level of frankness and tough decision making which our current generation of political leaders find quite challenging.

    The need to change Medicare and address these concerns may make it unsustainable to you. To me it signals a great opportunity to improve on how we care for our seniors by funding it at a realistic level and by providing more effective stewardship over the resources it uses.

47. I’m normally pretty tolerant of a wide range of views, but Nate’s opinion that Medicare is unsustainable is not acceptable.

    I agree that it needs to do a much better job of providing value and being a savvy purchaser of health care on behalf of our seniors.

    Painting it as unsustainable is quite different. I don’t find it acceptable to go back to the pre-Medicare poor health status of the elderly as he implies we should do. We should be ashamed as a country and society if that’s how we advocate treating our elderly citizens.

48. Maggie –

    If we look at Kaiser, Mayo and the VA, I think it’s important to ask what can we learn and, more importantly, what can be replicated across the rest of the healthcare system in order to reduce costs and/or improve quality?

    Starting with the VA, I think the only thing they do that could be replicated is comprehensive use of electronic records and that would require a substantial upfront investment in both money and provider time in learning how to use it.

    Even though veterans are a sympathetic group among politicians, the VA doesn’t even have the capacity to serve all eligible veterans let alone expand treatment to non-veterans. For veterans themselves, while in may be comparatively easy to get to a VA facility in Manhattan and the rest of NYC, that’s not the case outside of large cities. I live about 40 miles from NYC. The nearest VA hospital is in East Orange, NJ about 25 miles from here. For those who don’t drive or can no longer drive, to get to East Orange requires a one hour or more train ride to Newark. Then you can take a public bus which runs once every 30 minutes and travel about 40-45 minutes before arriving at the hospital. If you opt to take a cab from the train station to the hospital, it costs $20-$25 each way which many people can’t afford. Even if the care quality is great, getting there can be a problem even in the NYC metro area. In more rural areas, patients may need to travel hundreds of miles to get to a VA facility.

    For Mayo, they have a collegial culture and a very good medical process for diagnosing and treating medical problems. However, if you already know that you need a hip replacement or a CABG, their charges are very high and many insurers don’t include them in their network because so many patients are coming from a considerable distance away anyway. Even Mayo cannot completely replicate the culture at its Rochester, MN facility in its other locations. The issue for the broader system is how many of the country’s 800,000 doctors would be comfortable working in the Mayo environment where teamwork and collaboration are required.

    Kaiser is a giant system with some 8 million members. Doctors are salaried and comprehensive electronic records are used. Salaries are quite competitive within the market. Revenue generation doesn’t factor into the compensation equation. Yet, its costs are not much different from other systems nor are its health insurance premiums lower than what competitors offer. Assuming Kaiser doctors are able to spend an appropriate amount of time with each patient, they probably see fewer patients each day than doctors elsewhere which means more doctors and support people are required to handle to workload. Most other large systems that employ salaried doctors incorporate productivity metrics like revenue generation or relative value units billed into the compensation scheme. Without it, doctors probably wouldn’t see as many patients as they do now and we would need a lot more of them along with support staff. The bottom line is that there are no easy answers and certainly not any one size fits all answers to providing better care for less money.

49. Much of the debate on these posts centers on insurance companies.

    Anyone who is at all close to the individual market know that it is unreliable and sometimes unfair to consumers.

    Free-market insurance is like that. If you study the history of disability insurance, long-term care insurance, flood insurance, and general liability insurance, you see huge swings in profits and premiums, many recissions of coverage (both legal and shady), many claims contested or denied, and companies jumping in and out of the market.

    No form of private insurance pretends to be universal. We should not expect health insurance to be better.

    The compromise has been to provide a floor of social insurance, knowing that private insurance will fail to reach some people (both those who are poor, plus those who have money but choose to gamble and not buy coverage.)

    For example, some parents do not buy life insurance, so Social Security provides a monthly income if the parent dies with a child under age 18…..basically, public life insurance.

    Most workers do not buy disability insurance, so once again Social Security is there as a safety net.

    Most seniors do not buy long-term care insurance, (or they do buy it but then drop it when premiums go up). Medicaid is public insurance, with all its flaws.

    My own feeling that free-market insurance is basically unreformable. If we want to do better for persons who are self-employed, part-time, or have low-paid jobs, we should just expand public coverage.

    This takes taxes, if we are going to be grownups and pay for the government we want. But If the taxes have a broad enough base, they will not cripple anyone. For example, raising the payroll tax by 1% on employers and 1% on employees will cost $42 a month for someone making $50,000 a year. And yet the payroll tax for Medicare has not been raised in its percentage since 1990.

    The political challenge is that the people who pay the most taxes are not in the individual market at all. People with higher incomes tend to have the best employer-paid coverage. They do not lose a minute of sleep over the travails of the individual market, so they resist paying taxes to expand public insurance.

    (this changes big time if they are laid off……a health care liberal is a conservative who has to go on COBRA)

    Anyways, one of the strategies of Democrat reformers has been to expand public insurance essentially by stealth……….nudging up public programs and hiding the payment in some sort of unfunded mandate. The expansion of Medicaid in PPACA is a huge deal, for good or ill. Let’s see if it survives.

50. KIM, BARRY & OTHERS

    You question whether “less than half of women have access to affordable insurance through their job”?

    I got this fact from a speech that Louise Slaughter made on the floor of Congress. Usually, Congressional staffers make a big effort to fact-check eye-popping numbers like these, knowing that they will be quoted widely.

    These days, organizations like Factcheck.org are quick to call out a
    Congressman (or woman) if they get their facts wrong. And the opposition will broadcast the error.

    Nevertheless, it struk that me since a number of you questioned the stat–and cited evidence– “maybe Slaughter was wrong. .. .

    I thought “I should have fact-checked here myself, rather than assuming her staff did it . .

    This is what I found:

    “Women are significantly less likely than men to have access to their own employer-based coverage. While men and women have similar rates of job-based insurance coverage overall, less than half of women (48 percent) are eligible to get health insurance through their jobs, compared with 57 percent of men. So although two-thirds of mothers are either breadwinners or co-breadwinners, their jobs often do not come with health benefits. This translates into women losing an average of $4,508 for single coverage and $10,944 for family coverage in employer contributions to health benefits each year.” http://www.americanprogress.org/issues/2012/04/health_insurance_gap.html

    The same article points out that “Although about two-thirds of women between the ages of 18 to 64 have employer-based insurance coverage, only 38 percent of women are enrolled in an insurance plan they receive through their own employer, while 24 percent receive employer-based coverage as a dependent on their spouse’s or partner’s plan. In contrast, 50 percent of men receive insurance coverage through their own employer, and only 13 percent of men receive dependent coverage.”

    Why is it important whether women get coverage from their own job? The same piece elaborates: “In part because dependent coverage on a spouse’s plan is such a significant source of coverage for women, single women are twice as likely to be uninsured as married women.”

    Moreover “Being a dependent on a spouse’s plan leaves women more susceptible to losing coverage when premium costs rise and employers reduce their contributions to family coverage, when a spouse loses his job, or in the event of divorce. During the Great Recession of 2007-2009, many male-dominated industries were hit hardest. As men lost their jobs, more and more households went from having two incomes to being a single-income, female-headed home. But these families did not just lose a husband’s or father’s income—many also lost their health care coverage. As of 2010 over 2 million women lost health care coverage when they lost their own or their husband’s job during the recession.”

    Why are women less likely to be offered coverage through their own jobs?

    “Working women have less access to employer-based coverage in part because even when they have full-time employment they are more likely to be employed in low-wage jobs that do not offer benefits. As a result 10 percent of women who work full time are uninsured. Women are also more likely to hold part-time positions and jobs with small businesses that generally do not offer health benefits. ”

    Of course, some women are Offered insurance by their employers but
    can’t afford it (NOTE Slaughter was talking about how many women have access to AFFORDABLE insurance through their jobs.)

    (This thread already has established that women tend to be particuarly cautious about heatlh care coverage. They want comprehensive coverage–not catastrophic coverage. They go to doctors more frequently. They believe in preventive care. And if they have children, they really want comprehensive coverage for their children. So, it seems reasonable to assume that, in most cases, if they could afford the insurance their employers offered, they would take it.)

    Why are women less likely to be able to afford insurance? “In 2011, women earned 77 cents for every dollar earned by men , an average of $10,622 in lost wages every year.”

    Now one could argue about whether women earn less because : 1) they just
    dont’ work as hard (distracted by family duties) or 2) just aren’t as
    qualfiied.

    But there is much evidence that equally qualified women doing precisely the same job are paid less than men in the same job. You can Google the evidence. (At this point, I’m getting tired.) Or, if you dont’ believe me, ask your sister, your wife, or a woman friend.

    Even with employer-based coverage, women have higher out-of-pocket costs than men.

    This, I think is what caused confusion. I quoted Slaughter saying that “less than half of women have insurance through THEIR (own) jobs.)

    In part because dependent coverage on a spouse’s plan is such a significant source of coverage for women, single women are twice as likely to be uninsured as married women.

    Being a dependent on a spouse’s plan leaves women more susceptible to losing coverage when premium costs rise and employers reduce their contributions to family coverage, when a spouse loses his job, or in the event of divorce. During the Great Recession of 2007-2009, many male-dominated industries were hit hardest. As men lost their jobs, more and more households went from having two incomes to being a single-income, female-headed home. But these families did not just lose a husband’s or father’s income—many also lost their health care coverage. As of 2010 over 2 million women lost health care coverage when they lost their own or their husband’s job during the recession.

    Even with employer-based coverage, women have higher out-of-pocket costs than men.

    According to the Kaiser Family Foundation,

51. Nate–

    I’m responding to one of your comments because you offered a very specific detail that I knew I could reserach quite quickly and easily.

    (If other readers Google some of your other points, they, too, may find them misleading.)

    You wrote: “People underestimate the power of the market when freed from government.

    “Recent studies have show low radiation CT scans are better then X-Rays for screening lung cancer. University Hospital offers them for $99 and Cleveland Clinic came out with a deal for $125. ” You continue “The key piece of information though;
    UH and the Clinic offer low-dose CT at prices significantly lower than the $300 or more that a person would normally pay, since insurance does not cover the scans.”

    This is all true about prices for low-dose CT at UH and CC.

    What is not true is that ‘market competition” has anything to do with this.

    I found your source for these facts (Cleveland.com– the numbers all come from one article, but it did not say anything about “the market” driving lower pricing. (In two articles from Cleveland.com on the subject, the “market” was never mentioned.)

    Instead, we are told: “The impetus for both programs stems from the landmark findings of the National Lung Screening Trial (NLST), which showed that screening with low-dose computed tomography (CT) instead of standard X-rays reduced the risk of dying from lung cancer by 20 percent in the high-risk population. The CT scans are more effective in spotting nodules and tumors.” (http://www.cleveland.com/metro/index.ssf/2012/04/cleveland_clinic_follows_uh_in.html#incart_mce

    In other words medical evidence–coming from the “comparative effectivness resarch” that the Affordable Care Act funds, called for the change. The ACA also gives the HHS Secretary the power to reduce Medicare payments for “over-priced services” based on comparative effectivness reserach.
    Both Medicare and private insurers have already begun to lower payments for some tests.

    CC did not lower its prices to “compete” with UH. It waited until more studies came out (see article– http://www.cleveland.com/metro/index.ssf/2012/04/cleveland_clinic_follows_uh_in.html#incart_mce “Preliminary data from the study was released in late 2010, but it wasn’t until data supporting that study was published in the New England Journal of Medicine last year that the Clinic began designing its own screening program. ”

    Just the other day, the CEO of UH explained what is driving its push to cut costs,( like the cost of CT scans) as it prepares for full implementation of the Affordable Care Act.

    “Chief Executive Thomas F. Zenty .. focused on how the system’s cost-reduction measures and quality improvements have prepared the hospital for the challenge” (of change.)

    “We cannot predict the future, but we can prepare for it,” he told the crowd of about 300 gathered at the Marriott East in Warrensville Heights.

    “We must move forward, not backward,” he said.

    “Zenty noted that the hospital system increased efficiency with the launch in 2011 of its accountable care organization, or ACO, which serves employees and their families. The ACO, one of the most talked-about provisions of the Patient Protection and Affordable Care Act, is a cost-saving method of delivering care by a network of doctors and hospitals. ”

    The ACO is another major feature of the Affordable Care Act which calls for rewarding hospitals and doctors who agree to accept “bundled payments” (rather than fee-for service payments.) This includes doctors who do not work for the hospital, but saw the patient before he entered the hospital– or followed up after he left the hosptial

    These bundled paymetns will be higher if they achieve better outcomes at a lower cost. If they fail, their bundled payment will be lower. The bundling of payments means that doctors, the hospital, and everyone invovled in an episode of care have a financial incentive to co-ordinate with each other, and work together for the very best results.

    Financially, they all gain or lose together.

    The CEO of UH adds, “The hospital also recently applied to the federal government to open its ACO to several thousand Medicare patients. . . . ” http://www.cleveland.com/healthfit/index.ssf/2012/05/university_hospitals_ceo_says.html

    He said nothing about competing with other hospitals in an effort to increase his market share.

    His focus is on reducing the hospital’s costs.

    Why?

    Because hospitals know that, under the ACO, beginning in 2014,their revenues will be cut (the Affordable Care Act calls for cutting Medicare payments to hospitals by 1% each year over 10 years (compounded, this adds us) and it institutes financial penalities if hospitals don’t reduce preventable erorrs that hurt patients (while increasing costs) and infection rates which lengthen patient stays and hurt patients. (So much for the notion that the Affordable Care ACt does nothing to reduce health care costs.)

    Btw, these provisions of healthcare reform legislation have nothing to do with the issues the Supreme Court is considering. This is why hospitals are preparing now: they assume these provisions will be implemented in 2014.

    With Medicare taking the lead, private insurers are likely to follow. Medicare’s cuts in payments to hospitals (They, too don’t want to overpay.)

52. People underestimate the power of the market when freed from government.

    Recent studies have show low radiation CT scans are better then X-Rays for screening lung cancer. University Hospital offers them for $99 and Cleveland Clinic came out with a deal for $125.

    The key piece of information though;

    “UH and the Clinic offer low-dose CT at prices significantly lower than the $300 or more that a person would normally pay, since insurance does not cover the scans.”

    Knowing these 2 getting out for only $300 would be a shock. That $6,500 CT scan would be a fraction of that price if consumers paid. We, as a no value adding payor, push people away from hospitals for MRI and CT. What would normally cost $2400 is only $600 in free standing facilities.

    Lets look at it if Maggie was in charge, she would mandate this $99 test be covered 100% by the PPACA preventive care benefits which would triple the cost. Add in the 15% overhead and Maggie just turned a $99 bill into a $345 premium increase. And what does the consumer get for that additional $246? Nothing.

53. “Many specialsits charge $180–$250”

    This is a meaningless number, who cares what they charge, we only care what they are paid. An empowered consumer would never pay them anything close to that and they would also see them far less.

    Our Median income is also much higher then other industrialed countries that have high out of pocket cost then we do.

54. “The truth is that, for years, insurers have kept a very pretty large percentage of premiums — so large that, in the past, they were pretty profitable.”

    And what percentage of the market do insurers make this profit? 30 maybe 40% maximum. Your picking small slivers of the market and pretending its systemic.

    Pretty profitable? Like 87th most profitable industry? WOW that has to end. Where did Pharma, providers, and those on the other side fall in relation?

    “we just cannot afford to keep on funneling as many dollars to insurers’ investors”

    Then why do liberals keep stoping self funding? Self Funded plans solve the carrier profit issue yet Liberals States go out of their way to inhibit it. NY and CA specifically.

    “health insurance industry can show that it is providing value for those dollars, by improving the quality of care while reducing costs.”

    Its not the insurance companies job to improve quality of care, its their job to distribute risk, why can’t liberals grasp this?

55. “conservatives suggest that health care reform “over-regulates” insurers by requiring that when covering large groups, they must spend 85% of premiums on medical care– keeping no more than 15% to cover administrative expenses, profits, executive salaries etc.”

    Where is your link to back this up? I want to see a meaningful conservative that says this.

56. Bob–

    In another well-informed and provocative comment, you write:

    “Nate comes close to a home run with his 4:56 pm post about people having a combination of cheap catastrophic insurance plus self-pay on physician’s care.

    “I have been advocating this combo on my Health Care Crusade for years.

    “However, to really make it work you would need a few rather left-wing provisions, such as:

    “a. price controls on drugs with no subsitutes
    no concierge doctor can afford to take on a cancer patient or maybe even an athsma patient for $79 a month, unless all drugs go generic or are somehow limited in price.

    “b. reference pricing and full cost disclosure on lab tests and outpatient proceduresa $6,500 CT scan will destroy the concierge pricing too. Someone must stop hospitals from charging 400% more than office based doctors for identical tests.

    “c. some kind of relief for older insurance buyers.”

    But from what Nate has said in the past, I doubt that he would agree to what you descirbe as “left-wing provisions.”

    I would add that we would also need subsidies for middle-class Americans to help them pay physicians’ bills (or regulation of what specialists can charge.)

    Today the average (median) American household enjoys joint income somewhere in the range of $55,000 (before taxes.) Many specialsits charge $180–$250 (or more) per visit. If a middle-class patient is suffering from a chronic disease–or trying to get a disease diagnosed– he may need to
    see one or more specialists many times over the course of a year– or 2 or 3
    times each year for many years. I

    Add on the cost of lab tests that the specialist prescribes. And drugs (even if prices are regulated.)

    If more than one person in the family (children as well as adults) need to see specialists we are easily talking about many more visits than the average middle-class family could afford (on top the premiums for catastrophic insurance.)

    This is why every other developed country in the world provides comprehensive insurance for all of its citizens.

    (Many well-educated fairly affluent Americans just don’t realize how little
    income middle-class and working-class Americans earn. Half earn of America’s middle-class earns less–often considerably less– than the $55,000 average. I know many people who don’t know any famlilies living on
    less than $35,000 or $40,000 a year.

57. Peter there is a whistle blower lawsuit right now against the major lab companies accusaing them of signing losing deals with a private insurance carrier to get exclusive contracts then presure providers to sign exclusive with them.

    They would gouge or try to the other patients of the providers.

    That being said 70-80% discount on lab work is normal. If it wasn’t such a small amount of total spend it would probably be the biggest problem right now,

    http://www.huffingtonpost.com/2011/10/26/whistleblower-laboratory-corporation-of-america-medicare_n_1032654.html

58. Bob–

    You write: “While I am thinking about it, there was a fascinating article about 5 years ago by Adam Gopnik and Malcolm Gladwell about Canadian vs American health care.

    “The point was made that men are drawn to catastrophic insurance that covers helicopter rescues but does not cover office visits.
    (because most men have very few office visits, especially under age 50).

    “Whereas women are drawn to comprehensive health insurance, since they have such frequent contacts with doctors.

    “The two authors kind of interview each other back and forth, and both are very articulate.

    “I wonder if this gender difference explains quite a lot of the divisions right in this set of blog posts.

    “The gender difference also explains why so many men (including me, I am afraid, closet socialist and all) who were a little baffled and almost annoyed at the fuss about covering $40 contraception visits in the debates a few months ago.”

    Yes, I too, remember the Gopnik/Gladwell article. And what they say may explain the gender difference in these posts. Men are not as impressed by
    comprehensive coverage and preventive care (like contraceptoin). They like the idea of “heroic” care– the big operation after you get really sick. But waiting until you get very sick and need that operation is very expensive for
    the rest of us.

    I also agree when you suggest that “many Republicans seem to adopt a crude libertarianism and oppose all subsidies to those under 65….., and it is not only crude but cruel, since so many of these ‘libertarians’ have been getting government or university health insurance all their adult lives.”

    But I can’t agree when you say that perhaps “the Goodman/Heritage crew” are right when they suggest that we are in danger of “over-regulating” insurers.

    As you noted earlier, for years, insurers have been selling “Swiss Cheese” policies that don’t cover many of the benefits that people need. Often lower-income people buy these policies because premiums are much lower and this is all they can afford. Others buy them because they just can’t take in all of the fine print; they don’t recognize the holes in the policy until they become sick and fall through one of them.

    As you know isurers also have been denying care to many (including children) because of pre-existing condtions.

    Finally, conservatives suggest that health care reform “over-regulates” insurers by requiring that when covering large groups, they must spend 85% of premiums on medical care– keeping no more than 15% to cover administrative expenses, profits, executive salaries etc.

    The truth is that, for years, insurers have kept a very pretty large percentage of premiums — so large that, in the past, they were pretty profitable. (For years, premiums have climbed more than the underlying cost of care. Even if it’s only 2% more, over time, that compounds.)

    But as a society, spending more than we can afford on heatlh care, we just cannot afford to keep on funneling as many dollars to insurers’ investors– not unless the health insurance industry can show that it is providing value for those dollars, by improving the quality of care while reducing costs.

    In the 1990s, insurers tried to reduce costs –and succeeded–but too often, they did this by shunning the sick (cherry-picking) or denying needed care.
    Sometimes they were right when they denied care-it just wouldn’t have helped the patient. But in other cases, they refused to cover needed care just becuase it was expense.

    As you know, following the backlash against “managed care” in 2000, insurers became much more liberal about covering everything–whehter or not medical evidence showed that it was needed– and paying brand name
    hospitals, specialists and drug-makers whatever they asked. Insurers then
    passed those inflated costs along to customers int he form of higiher premiums, premiums shot up, and insurance became more and more unaffordable.

    The big problem is the underlying cost of care. We over-pay for almost everything, and we pay for a great many unncessary services and products–treatments that provide no benefit to the patient. This means we are putting the patient at risk, without benefit.

    We now have medical evidence revealing where many dollars are wasted.

    (Scroll up to see Dr, H. Gilbert Welch’s excellent Op-ed on overtreatment.)

    Finally, very good non-profit insurers have managed to improve the quality of care by using medical evidence to form very good networks of provideres.
    Insurance from some of the best non-profits is not necessarily cheaper than
    insurance from non-profits, but coverage is much better– more comprehensive, and higher quality. For instance, Kaiser (a non-profit) has been very successful with low-cost or no-cost smoking cessation programs.
    When it comes to treatment for heart dieases Geisinger is able to guarantee
    outcomes — or give money back.

59. Barry–

    If you read my comment, you will find that two of the articles about VA care came from 2010 (two years ago) and 2003 (9 years ago.) This is not 12-year-old reserach.

    Please don’t misinform readers about the evidence I offer.

    If you would like to find many more recent studies about the quality of VA
    care, you migiht try Googling for yourself.

    I am happy to do some research when answering reader’s questions & comments. But it seems to me that if a reader doesn’t believe the reserach I have found, he might want to do some research himself.

    You ask: “Do VA patients have access to state of the art cancer treatments and drugs? How do their risk adjusted mortality rates and 30 day readmission rates stack up against private hospitals.”
    Barry, you’re a bright man. I know you know how to look this up.

    I have five relatives who get their care from the VA, including my brother-in-law in NYC.

    They are all very happy with it.

    Of course, five patients represents a very small pool. But you represent a pool of one.

    This is why I prefer to look at large studies in peer-reviewed medical journals rather than relying on anecdotal evidence.–whether from people I know or from readers.

    (Btw– My brother-in law’s primary care VA doctor figured out how to greatly improve his hearing– after hearing specialists that he went to in Manhattan’s private sector failed to come up with a solution. VA docs are often academic docs, which means they are pretty bright and research oriented. And becuase they are gov’t employees, they are not allowed to take any money from drug-makers, device makers or others offering “consulting fees”etc.

    This is why their formulary for drugs is entirely based on medical evidence, not kick-backs.

    The VA, along with the Mayo Clinic and Kaiser took Vioxx out of its formulary long before the drug -maker was forced to take it off the market. (The manufacturer had covered up evidence that the drug caused fatal heart attacks and strookes. ) As a result, many Vets lives were saved — along with lives of Mayo Clinic patients, and Kaiser patients.

    This is why an evidence-based formulary is in patients’ interests– though both drug companies and those who invest in them object to the idea.

60. While I am thinking about it, there was a fascinating article about 5 years ago by Adam Gopnik and Malcolm Gladwell about Canadian vs American health care.

    The point was made that men are drawn to catastrophic insurance that covers helicopter rescues but does not cover office visits.

    (because most men have very few office visits, especially under age 50).

    Whereas women are drawn to comprehensive health insurance, since they have such frequent contacts with doctors.

    The two authors kind of interview each other back and forth, and both are very articulate.

    I wonder if this gender difference explains quite a lot of the divisions right in this set of blog posts.

    The gender difference also explains why so many men (including me, I am afraid, closet socialist and all) who were a little baffled and almost annoyed at the fuss about covering $40 contraception visits in the debates a few months ago.

61. Statistics are only as reliable as who created them for what agenda. At the end of the day, the opinions of actual patients and their course of progress, or regress, is what matters most. And, where is all the wonderful commentary by VA providers themselves vouching for the system?

62. And why PPACA will fail if it does not account for the role of smoking in greater health care expenses by that population.

    Or, are you just trying to protect one of your voting blocks? And, I would agree that the majority of smokers are not as financially sound, but, some are. They get a pass too? Doubt the well off vote Democrat.

63. Nate comes close to a home run with his 4:56 pm post about people having a combination of cheap catastrophic insurance plus self-pay on physician’s care.

    I have been advocating this combo on my Health Care Crusade for years.

    However, to really make it work you would need a few rather left-wing provisions, such as:

    a. price controls on drugs with no subsitutes

    — no concierge doctor can afford to take on a cancer patient or maybe even an athsma patient for $79 a month, unless all drugs go generic or are somehow limited in price.

    b. reference pricing and full cost disclosure on lab tests and outpatient procedures

    — a $6,500 CT scan will destroy the concierge pricing too. Someone must stop hospitals from charging 400% more than office based doctors for identical tests.

    c. some kind of relief for older insurance buyers.

    I have a catastrophic policy right now, and at age 64 it costs almost $500 a month for a $4,700 deductible. $100 a month it ain’t.

    The Heritage/Cato crew and John Goodman say that the answer is to subsidize the 64 year old, rather than over-regulate the insurance industry.
    I think they are right…….but many Republicans seem to adopt a crude libertarianism and oppose all subsidies to those under 65….., and it is not
    only crude but cruel, since so many of these ‘libertarians’ have been getting government or university health insurance all their adult lives.

64. Maggie –

    I’ll preface my comments about the VA by noting that I’m a vet myself with a 30% disability rating due to a law passed by Congress a couple of years ago that requires the VA to presume that anyone who served in Viet Nam for even one day and who has one of a number of conditions, including ischemic heart disease, has the condition at least in part because of exposure to agent orange and is therefore entitled to disability compensation. That rating also puts me in priority Group 2 (Group 1 is highest) out of 8 groups for access to VA healthcare though I have no intention to use it.

    I have a few questions about your references to the quality of care at the VA. First, why is there no more recent information than 12 year old data? How is quality defined and what was being measured? Personally, I would be less interested in whether everyone who should be prescribed a beta blocker or a statin drug or a blood thinner was than in their surgical procedure outcomes including CABG, DES, hip and knee replacements, cancer treatments, etc. Do VA patients have access to state of the art cancer treatments and drugs? How do their risk adjusted mortality rates and 30 day readmission rates stack up against private hospitals? Are there any substantive differences between the compliance rate of the VA patient population and the civilian population? Appropriate prescribing and minimizing duplicate testing are important but people probably care more about surgical outcomes, mortality rates, readmission rates and infection rates.

    Peter 1 –

    Lab tests have notoriously high list prices compared to the prices that most insurers actually pay. I think your experience is not unusual at all. Hopefully, you can avoid hospital based care including outpatient procedures.

    I don’t expect us to get to insurance rates of $1,000 per year anytime soon, other than for young healthy males with high deductible plans, but there is a lot that we can do to attack healthcare costs instead of demonizing insurers.

65. achieving better outcomes based on what? If you start out third world and improve from their your still third world.

    Forget the academics talk to Vets and see what they say of the system. If you just need to get a drug or basic care its cheap/free. If you need major care or want choice then they need private insurance. I’ve worked with 1000s of vets on jhealth insurance, they had VA available yes they still paid for other insurance, must be a reason for that.

    Access is big, you could easily drive hundreds of miles for care.

66. Peter 1–

    I totally sympathize about health care providers (hospitals, labs, whoever) gouging when individuals “self-pay.”

    Under health care reform that will disappear because a) the vast majority of Americans will be getting group coverage and get “group rates” and b) under the new rules, providers will no longer be allowed to charge the uninsured (who self-pay) more.

    “The Affordable Care Act stops hospitals from charging the full list price for patients who do not have insurance.” http://www.healthinsurancequotes.com/2012/04/how-hospitals-typically-handle-uninsured-patients/

    If you read (or just search) the full text of the Affordable Care Act, you will find more detail.

    I realize that most people don’t have the time to read the Affordable Care ACT- It is very long, and detailed ((as it must be. )

    But the good news about how it controls costs is in thousands of details.

    Since I write about health care and health care reform for a living, I have
    read the full text of the legilsation– several times. And I constantly go back to it to “search” various details.

    I wish that reform’s most vocal critcs would at least “search” various topics in the legislation before suggesting that it doesn’t control costs.

    If I often sound frustrated and irritated when replying to reform’s critics, it is because so many haven’t read the bill–or even tried to read it. They are simply repeating
    when they have heard on TV or elsewhere. (When a topic is complicated, TV soundbites just aren’t a reliable source of information.)

    If they read the Affordable Care Act the wouldl find that it focuse on bringing down health care costs while focusing on quality.

    I have written about this extensively on http://www.healthbeatblog.org.
    You can Google the posts.

    Peter Orszag (former CBO director) also has written about this,
    , documenting how Medicare spending is already falling, as hospitals begin to cut expenses because they know that, under the ACA, they will have to
    improve outcomes while charging less– or suffer the financial consequences. (Hospital CEOs– or their lawyers and other advisers– have read the legislation)..

67. $1,000 is very attainable. That would be enough to pay for catostrophic coverage that provided european level coverage and paying providers cost plus a reasonable profit. FYI hospital cost + 500% is not reasonable.

    All physician care would be self paid. There was an article today about PCP in CA offering basic coverage to illegal immigrants for $25 per month.

    http://www.wellchild.org/

    That wont be acceptable for everyone but a good PCP package for $50 per month per person is very doable.Family of four would pay $200 a month for PCP plus roughly $100 per month for hospital insurance. Your looking at $3,600 a year for a family. Rx would be on top of that but generics treat 80%+ of all illnesses for a couple dollars a month.

68. Determined M.D.–

    You write “You have your sources, I have mine.”

    I would be genuinely interested in your list of sources, offering
    medical evidnece from journals where the evidnece has
    been reviewed by other M.D.s, showing that the VA has not
    been achieving better outcomes since the late 1990s.

    As for smoking the vast majority of U.S. adults who still smoke are
    very poor. (See Steve Schoeder’s Shattuck lecture in the NEJM– http://www.nejm.org/doi/full/10.1056/NEJMsa073350

    Schroeder knows a great deal about smoking since he ran the smoking cessation program at
    UCSC.

    These low-income Americans don’t have the income to pay more for health care. You can’t get blood out of a stone.

    And, under heatlh are reform, if you try to jack up their premiums, you will simplly increase the subsidies that taxpayers have to pay to cover insurance for these low-income folks.

    This is the reason why the ACA does not call for higher premiums for smokers.

    Since you brought up smoking, smoking cessation program are another areas where the VA excels. (Many Vets still smoke. The VA has been particularly successful in helping men suffering form post-traumatic-stress
    syndrome stop smoking. ) You can Google this.

69. “And making the young pay for the old, that is akin to plain slavery.”

    How about the old paying for the education of the young, or the childless paying for the education of others kids? See, the thing is when the young get old, some young person will help balance their overall health cost.

    But we will not lower costs by craftier insurance risk management and carving risk groups into smaller and smaller pieces.

70. “The most significant problem with health insurance vs. other types of insurance as I see it is that it’s just too expensive for most people to afford. If family health insurance coverage could be had for $1,000 a year or less like car insurance or homeowner insurance, the mandate to buy wouldn’t be so terrible. At $15K or more, it’s a different matter even with subsidies. I think we need to focus more on driving down or at least stabilizing healthcare costs. That means everything from a more sensible approach to end of life care to tort reform to price and quality transparency tools to electronic health records to more aggressive efforts to combat fraud.”

    Excellent points Barry that seems to evade most people trying to “fix” the system, including Obama. As I’ve said before, forcing people to buy the most expensive system in the world will not work. However, I think you’ll fall way short of that $1000 unless, as in single-pay/government controlled systems, there are price controls.

    I have just returned from a doc visit for an assessment of hip pain. The holistic PA i(my consult) in the group also does wellness consulting. She suggested a base blood test of 6-7 factors. Quest is their lab with an in- house blood drawer. As a self pay I was quoted from Quest $634. After a bit more discussion on how that that was not going to happen the Quest guy said that they could bill through the practice at their rate. I hope you’re sitting down, the “new” price was $83. Not sure what insurance would pay but that kind of gouging cannot be expected to get you to $1000/yr.

71. You have your sources, I have mine.

    Umm, didn’t notice anything about tobacco in your reply?

72. Maggie –

    Regarding the idea of basing medical premiums on income, I don’t think it would be appropriate to finance medical care with a dedicated payroll tax on either wages or income from all sources unless it were capped at a comparatively low level. The reason is that health insurance can be easily priced. It’s not reasonable to expect, say, Mitt Romney to pay 15% of his $21 million of income ($3.15 million) for a family health insurance policy that’s worth $15,000 – $20,000 at most. That said, carried interest should be taxed at ordinary income tax rates, not capital gains rates but that’s a separate issue.

    Progressive taxes, within reason, are fine to cover government functions that don’t lend themselves to pricing including defense spending, law enforcement and environmental protection among others. Subsidies for lower income people could also be covered out of general revenue. I fear that eligibility for subsidies under PPACA though is going to result in lots of income underreporting and other attempts to game the system. Subsidies are likely to cost more than whatever the CBO estimates they will.

    In Germany, workers pay a roughly 15% payroll tax, including the employer’s share, for health insurance but the tax only applies to wages up to €45,000 or roundly $60,000. Germany finances health insurance for children with general tax revenue under the theory, according to Princeton’s Dr. Uwe Reinhardt, that they are a national treasure. Moreover, the top 10% of the income distribution is allowed to opt out of the public system and buy private insurance though not all do so.

    In Switzerland, people can buy a policy with a deductible as high as $2,300 CHF or about $2,500. Only about one-third of Swiss healthcare costs are financed by insurance premiums. A significant portion of hospital operating costs are financed by general revenue and out-of-pocket costs amount to about 30% of healthcare expenses at the population level.

    As for the VA, their drug formulary is highly restrictive. It has only about one-third as many drugs on it as the typical Medicare Part D plan. I, for example, take five drugs, all heart related including four generics plus Plavix which will lose patent protection later this month. Exactly two of them are on the VA formulary. My co-pays under my United / AARP plan are $8 for a 90 day supply for three of the generics, zero for the other one and $111 for Plavix. The VA serves about 5 million veterans including a significant number who are over 65 and can access Medicare if they’re not satisfied with either the quality or the timeliness of care within the VA. The poorer over 65 vets are also eligible for Medicaid (dual-eligible). The VA has only 155 hospitals nationwide. I’m sure that large numbers of people don’t live anywhere near one of those facilities.

    The most significant problem with health insurance vs. other types of insurance as I see it is that it’s just too expensive for most people to afford. If family health insurance coverage could be had for $1,000 a year or less like car insurance or homeowner insurance, the mandate to buy wouldn’t be so terrible. At $15K or more, it’s a different matter even with subsidies. I think we need to focus more on driving down or at least stabilizing healthcare costs. That means everything from a more sensible approach to end of life care to tort reform to price and quality transparency tools to electronic health records to more aggressive efforts to combat fraud.

73. Determined M.D.

    On the VA’s better outcomes, please see these conclusions from peer-reviewed medical journal articles:

    “Despite these adverse demographic and clinical characteristics, [Vets are poorer and sicker than most of us] the VA system has been documented to provide care that meets or exceeds that provided in the private sector, often by a wide margin, based on commonly applied performance metrics, rigorous research. . . ” Circulation, Cardiovascular Quality and Outcomes”
    http://circoutcomes.ahajournals.org/content/2/4/294.full

    In fiscal year 2000, throughout the VA system, the percentage of patients receiving appropriate
    care was 90 percent or greater for 9 of 17 quality-of-care indicators and exceeded
    70 percent for 13 of 17 indicators. There were statistically significant improvements
    in quality from 1994–1995 through 2000 for all nine indicators that were collected
    in all years. As compared with the Medicare fee-for-service program, the VA performed
    significantly better on all 11 similar quality indicators for the period from 1997 through
    1999. In 2000, the VA outperformed Medicare on 12 of 13 indicators.
    conclusions
    “The quality of care in the VA health care system substantially improved after the implementation
    of a systemwide reengineering and, during the period from 1997 through
    2000, was significantly better than that in the Medicare fee-for-service program. These
    data suggest that the quality-improvement initiatives adopted by the VA in the mid-1990s
    were effective. ” (NEW ENGLAND JOURNAL OF MEDICINE: http://www.ualberta.ca/~dcl3/ABCDreview/papers/2003_Jha_8117.pdf
    ”

    “In summaryIn summary, our findings indicate that the VHA has better outcomes for men than MA. The VHA’s performance offers encouragement that the public sector can both finance and provide exemplary health care. The VHA’s experience provides some general, potentially transferable, and useful policy directions that might benefit other health care systems in the public as well as the private sectors.” From Health Services Reserach 2010

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2838151/

    If you Google, you will find many more articles from peer-reviewed medical journals providing evidence that, since the late 90s, the VA has provided better care.

74. Sorry, I disagree vehemently with your VA assertion above, as vets who appreciate choice will tell you en mass. Their formulary system alone is both regressive and repressive, at least the last I heard about it until the recent revelations of it’s shortcomings have been publicized.

    Again, that large primate dancing wildly in the room can’t be indefinitely ignored. You want PPACA to survive to validate Democrat legislation. How it ends up negatively impacting on people’s lives is convenient irrelevantcy.

    You can’t provide equal and efficacious health care for 300 million people at bargain prices, which is what the VA is realizing. And as the spoken social Darwinist here, you shouldn’t. Giving everybody false hope they will get the same health care choices as those who are well off is, well, obscene.

    Again, no one wants to address the role of tobacco in the equation. Smokers do not deserve equal rights. And making the young pay for the old, that is akin to plain slavery.

    Not that I expect a reply.

75. Frankly Maggie, Nate does show evidence to back up what he says. Funny, i find that you have the same characteristics that you accuse Nate of having. Time to look in the mirror.

76. http://www.kff.org/womenshealth/upload/1613-11.pdf

    62% of women are insured and this is as of 2011.

    6% have individual policies

    12% on Medicaid

    20% uninsured

    Add the bottom three you only get 38%. But even that is wrong as we know a number of them have ACCESS to coverage and choose not to take it.

77. population stats are here

    http://quickfacts.census.gov/qfd/states/00000.html

78. Income is the wrong measure to be looking at, wealth is a more representative measure of ability to pay. In the 55-64 age bracket you already have millions of retirees. Included in that would be all your teachers with 30 and out pensions. They show no income but as the IRS data I linked previously shows have plenty of assets, more wealth then any other age bracket.

    “quoting the Women’s Law Center– Fully 50 PERCENT OF WOMEN DO NOT HAVE ACCESS to Employer Based INSURANCE.”

    http://www.bls.gov/opub/cwc/cm20071128ar01p1.htm

    “According to data from the Bureau of Labor Statistics National Compensation Survey (NCS), in March 2006, 71 percent of private industry workers had access to employer-sponsored medical care plans and 52 percent participated in such plans.”

    You have to know how to read numbers to catch they say 71% of workers have access. That does not include stay at home moms who have access through their husbands and now women under 26 with access through their parents. There is no possible way for 50% of women to not have access to insurance unless you include women covered by Medicare.

    According to Kaiser;

    “Over 57 million non-elderly women in the U.S. get their health
    coverage from their own or their spouse’s employer.”

    311 Million Americans
    74 million under 18
    40 million over 65

    197 million left
    100 million are women 50.8%

    And we know at least 57 million are covered by group plans already. That doesn’t include the millions who have access and waive.

    Your stat is wrong.

79. Maggie – I’m puzzled by the statement that 50% of women do not have access to employer based coverage. From a quick search, it appears (http://www.statehealthfacts.org/comparebar.jsp?ind=132&cat=3) that 57% of non-elderly women HAVE employer-based coverage, so even more have access to it and do not choose to buy.

    As for saying insurance premiums should be based on income, well, that only makes sense in a government-run system, which I gather you support. I would agree that subsidies should be based on income, but premiums need to be based on risk. Saying income-based premiums is how we do it for Medicare is very misleading, since premiums pay very little of Medicare’s cost — Part B is funded over 75% by general revenues, and Part A, of course, is funded by younger workers.

    I think this whole discussion is at heart an argument against private insurance and for a government system, which is a legitimate discussion. Medicare, or the VA, has a tremendous list of flaws that are fair game if that’s the discussion. One’s point of view on this topic is more likely based on ideology instead of facts, which abound on both sides.

80. Bob Hertz–

    You’re right when you say that “The PPACA attempts to tame the rough edges of the individual market, through the pricing and underwriting reforms”

    As for letting everyone into the Federal Empoloyees program, I have to say that if you look at the menu of coverage and pricing carefully , you might not be so enthusiastic. Often govt employees on the low end of the income ladder are forced to buy high-deductible plans becuase that’s all they can afford–and then they can’t afford to use them.
    And that’s just one problem.

    I would hold up the VA plan as a much better model. Average outcomes are better than in our fee-for-service system; fewer errors (thanks to their IT) and lower costs. The VA isn’t perfect– there are indiviudal VA hospitals that are not well run, but by and large, it’s excellent. See the book The Best Care Anywhere.

    However, the VA is underfunded and overcrowded with the many solliders who have returned from the Middle East with serious health problems– plus the Vietnam Vets who are getting older, and in many cases are
    suffering from long-repressed psychological problems.

    The VA can’t afford to treat the rest of us.

81. Peter 1–

    Thanks for making an excellent point which cuts to the heart of this thread:

    You write: “As this discussion is showing, minute risk adjustment is not the answer to making healthcare accessible or affordable or our society more healthy. A search of short mens’ health showed they have a higher risk of heart attack – do we rate on height to make sure tall men won’t be burdened with the cost? Risk adjustment to change bad habits might work and be more acceptable – as is done with auto insurance. Is having children a bad habit we should discourage.”

    Short men is a very good example. We could find many reaons to charge different groups more based on race, nationality, height, sex, where they live (Southerners in some parts of the country are more likely to be overweight than Manhattanites. For that matter people in upstate New York are more likely to be overweight. Maybe Manhattanites should get a break because they’re more stylish? Except we know that people who are thinner than average are, in fact, less healthy than people of average weight.
    (See Nortin Hadler’s newest book Being overweight is not necessairly unhealthy–if you exericse. Being Morbidly obese is. I write about this here
    http://reforminghealth.org/2012/02/28/obesity-fact-vs-fiction/

    In any case, the whole point of health insurance is to pool our money because in the end, none of us knows which one of us will fall ill. We
    can try to take care of ourselves, but sometimes those who took very good
    care of themselves live into their 80s— and after that, their risk of developing Alzehimer’s begins to climb . . . This is a very expensive disease, and the patient can live for years.

    As I said to Barry, in the end, anyone of use would rather be one of the lucky ones who paid more into the health care system than they took out.

    Btw- Peter — you might want to think twice about letting Nate bait you into replying to him. He doesn’t want a real disucssion: he’s not open to your ideas, or any disagreement with what he says. And he rarely cites evidence to back up what he says.

    Over time, I have watched a great many people simply stop replying to him on these threads. He winds up talking to himself (which is what he’s doing anyway).

    The big problem is that he often derails the thread, taking it off topic to something like a debate about water consumption– and then virtually everyone just gives up replying to the post..

82. Where does this crazy distortion of fairness end? If you consume more healthcare why should you not pay more?

    Assume the crazies win this argument what is next?

    Women go to the doctor more often then men up until the late 50s, early 60s. Most office visits have co-pays. This means women will pay more co-pays then men. If it is sexist to charge women a higher premium for using more care then how is it not sexist to charge them more co-pays and co-insurance? So what does Maggie propose for that? Women get a 50% discount off out of pocket expenses? Does the provider get stuck with that bill or do Insurance pay the difference, widening the benefit gap even further.

    Women spend more on OTC items, why don’t we throw those in as well?

    Its sad that this country as deteriorated to the point we even discuss this type of institutionalized bias and sexism and take proposals like this seriously.

83. Bill–

    You make a good point when you write: “The Democrats and Obama Administration are correct in making health care reform a central theme of their campaign and in coloring it as a central issue to women.

    At one time there may have been justification for a bias in the health insurance system in a world where the primary breadwinner and recipient of employer health benefits was male, but that’s increasingly not true.”

    I would add only that, back in the Fifties, when fewer women worked,
    there were many single women who were their own breadwinner, and clearly paying higher premiums was not fair to them.

84. BARRY–

    First, thanks for your comment. Once again you’ve led me to do some interesting research.

    Let’s begin with with whether younger Americans should help to pay for care for older Americans.

    Older Americans are not as wealthy as many assume.

    Since 1990 real after-tax incomes of middle-class Americans have declined. And since 2000, 45-54 year olds (who should be in their peak earning years) have taken a major hit. Thanks to periods of unemployment, layoffs, job losses followed by taking a job that doesn’t pay as well, and salary cuts, 45-54 year olds Have Seen their Average (mean) Real Income Decline by 13.3% Over the 11 Years from 2000 to 2011.

    The only group that has taken a comparable hit are
    15-24 year olds.(down 13.2%)

    By contrast, 35-44 year olds saw real incomes decline by only 6.7%.

    Keep in mind that those who were 45-54 from 2000 to 2011 are now 50-59.
    and their peak earning years are over or comign to and end. (I don’t expect to see wages rise substantially in the next few years.). They’re never going to recover forom loss of income over the past 11 years.

    This is why they need the help of younger cohorts. Over time, 35-44 year olds are likely to more than make up for the 6% that they lost.

    In the past (before 1990) people in their late 50s were significantly wealthier than younger groups,, but that was because people in their peak earning years enjoyed healthy after-tax income growth.

    Since 1990, onlly the very wealthy have enjoyed good after-tax income growth. Some of these are relaively young and successful 30-something and 40-somethings.

    As for the young struggling with college loans, first under the new reform law , many young people will qualify for subsidies based on their low incomes. (This includes college-edcuated young people who haven’t been able to find a good job.) So they won’t be subsizidizing the care of older Americans.

    Secondly , this is a problem for only a relatively small percentage of young Americans because, thanks to growing inequality fewer and fewer Americans can afford to go to college. By 2025, it’s estimated that only 29% of Americans will have a college degree. http://www.mlive.com/education/index.ssf/2012/05/preparing_your_student_for_col.html

    Today, 2 out of 3 students take out a loan in college.

    So when we talk about young Americans struggling under the burden of college loans, going foward, we’re talking about roughly 20% of Americans.

    We hear a lot about these students because they are the sons and daughters of people who write, edit and publish newspaper stories.
    The vast majority of our children do go to college, and so we are keenly aware of their problems.

    But as a national problem, this isn’t as pervasive as the media suggets.
    Being an unemployed 22 year old with only a high school education is a much bigger problem–and wiill be, thoughout their lives..

    I don’t mean to sound unsympathic. Middle-class 23 year olds with huge loans are in a bind.

    . (Though in some cases, their situation was created by the fact that upper-middle-income and even affluent parents didn’t save for their children’s education during the “shop until you drop” 80s and 90s. Rather than saving, they spent, knowing that cheap governmennt loans would be available, and that their children wouldn’t have to show great need or merit to get those loans.(Before roughly 1980, most financial aid was based on merit, need, or a combination of both. That changed during the Reagon years. Full scholarships for low-income students with good grades disappeared, while more and more taxpayer money was used to fund loans. Some say this encouraged colleges to hike tuitiion.)

    Finally,Barry, you are right that under heatlh reform, older Americans under 65 will be required to pay higher premiums. Insuers can charge them three times as much– unlness their State decides to pass a law saying that they can’t be charged more.

    This, I think, is a major problem in the health care reform law, and something that we will need to change. (Or at the very least, many states will outlaw excessive premiums for older citizens.)

    AS noted, Americans in that 55-64 year old group have taken a big hit
    financially and many just won’t be in a position to pay those higher premiums. Thus they will be shut out of “universal coverage.”

    Two oyears ago, I pointed out that t, households in the 55-64 age group report ed average (median) joint income of just $55,400. Half earn less than that. Only 25 percent enjoy joint income over $100,000.

    In other words, fully one quarter of earn somewhere between $55,400 and $100,000—too much for a couple to qualify for much of a subsidy, too little to able to afford pricey insurance.

    Couples earning more than $58,280 will not be eligible for subsidies. A middle-class couple earning $50,000 would receive only a small premium credit. Under the refoorm law, insuers can charge them 3 times as mjuch in premiums. How can they afford that? They can’t.

    Consdier what has happened in Masschusetts where insurers are allowed to double (but not triple) premiums for older Americans. . For an older couple in Boston, an policy runs between $1,740/mo. and $2,000/month.—or $24,000 a year. (These are numbers that I repored 1 1/2 years ago–at the end of 2009.) http://www.healthbeatblog.com/2009/12/glass-half-empty-glass-half-full-part-3–older-americans-at-risk.html

    In the end, everything may turn on what state an older American lives in. States will have an opportunity to protect their older citizens. While the amended version of the reforms legislation sticks with the 3:1 ratio, it adds that if a “qualified health plan is offered in a State with age rating requirements that are lower than 3:1, the State may require that . . . plans comply with the State’s more protective age rating requirements.”

    I have a vague memory that Mass. finally came up with a solution for this problem because too many
    older citizens just couldn’t afford insurance–buit I don’t remember what Mass. did . . .

    Finally, Barry, you suggest that since so many Americans receive insurance through an employer who legally is not allowed to discriminate against women when setting what share of premiums employees pay, the fact that some women pay higher premiums is such a big problem.

    As I noted in the post, quoting the Women’s Law Center– Fully 50 PERCENT OF WOMEN DO NOT HAVE ACCESS to Employer Based INSURANCE. This is becaused many work for smaller employers, and of course, these days, many are unemployed. (When it comes to finding a new job, unemployed women have lagged far behind unemployed men.
    Those who are over 55 are likely to remain permanently unemployed– (you can Google this)– another reason that they need help, both from men, and from younger cohorts.

    To be fair, our insurance premiums should be based on income. This is how we pay for Medicare. Whiile one can geernalize about various groups(as tk points out, short men are more vulnerable to heart disease), African –
    Americans, women, etc. no one knows which indiivduals may need more
    care.

    Tall thin white men can develop cancer, or suffer serious heart disease in their 40s.

    This is why we pool our money, as fairly as possible, to cover health care, understanding that “there but for fortune . . .”

    Any one of us would rather be one of the lucky ones who pay in more than they take out of the health care system.

    The only group that saw incomes rise over that period were Americans over 65. This is thanks to the fact that unlike workers, retirees had a reliable income stream from Social Security and many in that cohort stilil had pensions (defined benefit plans) which are far more reliable than
    401ks (definted contirubtion plans) which fluctulate depending on t he investing skills of the individual investor.

    (You will find all of this informaiton and a couple of very good charts here
    http://www.advisorperspectives.com/dshort/updates/Household-Incomes-by-Age-Brackets.php

85. Women have a choice about engaging in sexual activity. If your not financially ready to have a kid then don’t get pregnant.

    It doesn’t matter how safly you drive just for being a male you pay more. The safest young mail driver will never pay the same rate as an average female driver based solely on his sex.

    Women have a choice about living healthy and if they do they will find that will lower their rate.

    Society does not have an intereast in every women having as many kids as possible, your liberal welfare programs paying them to do so has clearly shown the consiquences. We need mature prepared women to have kids to maintain society.

    Health Insurance is no more a necessity then life insurance. Health Care is a necessity, most people could forgo insurance and easily afford their entire lifetime of healthcare cost. People that lived a healthy and responsible life even easier.

86. OK Nate, give me the stats on people dieing from over water consumption and those dieing from diabetes and the outcome of high BMI. Then find how much the diabetics are costing us in health care.

    “Are you going to have people take their genetic test with them to the grocery store to determine their tax rate?”

    Yea, that’s not exaggeration is it. Have you taken your meds today?

    Well Nate we don’t ask people to do that for tobacco or alcohol and I can find some people that live into their 90s using both. Should we tax those products?

    “Every chemicle is a toxin in excess.”

    Glad to hear you admit it Nate. The difference is sugar is called a food – not labeled a toxin. What level of mercury or arsenic would you like to tolerate in your food Nate?

87. Marie–
    You write: “Go to Russia and see how it works there or even England and Ireland (you wait almost a year for cancer surgery there) that is coming to USA if Obamacare stays in place. Healthcare is so expensive now because Americans are fatter and more unhealthy than they ever been and frankly it is not hte taxpayers job to pay for anyone’s healthcare”

    I wonder where you get your information . . . Could you cite evidnece that people in England and Ireland die while waiting in a line for cancer surgery?

    As for health care being expensive in the U.S. because Americans are fatter, it is true that obesity contributes to many diseases, but a 2007 McKinsey & Co study that actually analyzes the numbers points out that obesity accounts for only a tiny part of the difference between what we spend on health care and what other countries spend.(See http://reforminghealth.org/2012/02/28/obesity-fact-vs-fiction/

    Finally, every other developed country in the world has a health care system based on the notion that we (taxpayers) should pool our money to pay for each others’ care.

    In the U.S. we accept the notion that we should pool our money to pay for the care of people over 65 (Medicare) and most people are happy that we have Medicare. Now, we have decided that, as a civlized society, we have a responsibility to make sure that everyone has access to comprehensive, high quality care.

88. Platon 20, Legacy, and Steve:

    Men have a choice about driving safelty, and if they do, they will find that a good driving record lowers their rates. (Even young male drivers can have a A ‘black box’ GPS device fitted into ther car to record data on how the car is driven. Factors like speed and braking are measured to give a score which will lead to a reduced premium if he drives safely.

    Women don’t have a choice about having ovaries, and society as a whole has an interest in women reproducing or we would become a nation of seniors with few workers to support our economy.

    .Life insurance is not a necessity; health insurance is.
    (Though I would favor pricing life insurance equally for men and women since men don’t have a choice about dying earlier.)

    Steve– Yes, while it takes a man and a woman to produce a child, women often wind up taking care of the child– another reason that we should subsidize their higher health insurance costs.

89. ““just like excessive consumption of water can kill you”

    And you said I have a flare for exaggeration.

    LOL Peter your ignorance is awlays good for a laugh. Ask any of the doctors on here, you can kill yourself drinking to much water. There was a radio station sued not to long ago for sponsoring a water drinking contest where someone died.

    “Water intoxication, also known as water poisoning, is a potentially fatal disturbance in brain functions that results when the normal balance of electrolytes in the body is pushed outside of safe limits (e.g., hyponatremia) by overhydration, i.e., over-consumption of water.”

    To even further prove my point specific to your insane sugar rants;

    “Water, just like any other substance, can be considered a poison when over-consumed in a specific period of time.”

    “By the time people get diabetes and a high BMI it’s a little late for a penalty isn’t it?”

    Not at all, both are easily curable with improved diet.

    One person’s healthy amount is unhealthy for another. Are you going to have people take their genetic test with them to the grocery store to determine their tax rate? Liberals LOVE progressive taxes, why don’t you want sugar tax to be progressive? Consume little you pay nothing, consume alot you pay alot.

    Every chemicle is a toxin in excess. See above.

90. “just like excessive consumption of water can kill you”

    And you said I have a flare for exaggeration.

    “Excessive sugar leads to diabetes and high BMI

    Care to look at the diabetes and high BMI rates? If that doesn’t constitute toxic what would you say does?

    “Why should people that consume a healthy amount of sugar be penalized?”

    They wouldn’t as they would be taxed less as are those that consume less alcohol and tobacco. Do you think we should not tax alcohol and tobacco? By the time people get diabetes and a high BMI it’s a little late for a penalty isn’t it? A tax would give people a wake up call every time they purchased and is far more efficient than BMI weigh-ins.

    Is any chemical a toxin?

91. sugar is not a toxin, boy you liberals have a flare for exaggeration. Excessive amounts of sugar are unhealthy, just like excessive consumption of water can kill you, should we tax that? Why should people that consume a healthy amount of sugar be penalized? Excessive sugar leads to diabetes and high BMI, the intelligent way to risk adjust is charge for those conditions. Oh wait that is how it is done today.

    Using your logic peter cars are dangerous, irrelevant of how one drives them, so all people should pay the same insurance rate. That is the same as saying all sugar consumption should be penalized.

    To your first point why are short men more susceptible to heart attack? Correlation / Causation, maybe its the higher BMI not that actual height.

92. As this discussion is showing, minute risk adjustment is not the answer to making healthcare accessible or affordable or our society more healthy. A search of short mens’ health showed they have a higher risk of heart attack – do we rate on height to make sure tall men won’t be burdened with the cost? Risk adjustment to change bad habits might work and be more acceptable – as is done with auto insurance. Is having children a bad habit we should discourage – not if you look at the tax deduction for having kids.

    Sugar is now slowly receiving it’s due as a toxin. Efforts to tax sugar to pay for increased health risk are not going very far. Where are conservatives who advocate that risk adjustment is the answer?

93. To Marie—AMEN. Obviously I am a woman also and could not agree with you more.

    @Maggie—maybe Laura doesn’t want to date and marry men.

94. The Democrats and Obama Administration are correct in making health care reform a central theme of their campaign and in coloring it as a central issue to women.

    At one time there may have been justification for a bias in the health insurance system in a world where the primary breadwinner and recipient of employer health benefits was male, but that’s increasingly not true.

    As with any major change, there will be issues caused as the health insurance system adapts to these new requirements, but I can’t argue with the rationale for ending a system where female breadwinners are treated inequitably.

95. What worked in MA does not mean it can work nationally! American is far and wide and very different from MA! Trying to implement a program of national healthcare won’t work. We don’t have the money, nor do we have the the will to make it happen. For those who want FREE everything it can’t work. Go to Russia and see how it works there or even England and Ireland (you wait almost a year for cancer surgery there) that is coming to USA if Obamacare stays in place. Healthcare is so expensive now because Americans are fatter and more unhealthy than they ever been and frankly it is not hte taxpayers job to pay for anyone’s healthcare. I am amazed that the few want to revamp the healthcare system for those who think everything shoujdl be free. Without capitalims all this goes away. Everyone lives in a 600 sq foot apartment and rides a bike! This is such a silly argument women love to have. Just because you are a woman and I am a woman myself does not mean you have some right to use your sex to push the envelope for services. Women are not mistreated in America get a grip.

96. more heart Bob? PPACA whiped out the entire individual market for those under 18, how can you claim the right doesn’t care when the left killed their insurance? The reality contradicts your politics, it’s like claiming the left is more compassinate because they pushed poor people into public housing projects.

    How has MA manipulated anything? They have done exactly what the politicians designed the program to do, create an alternative to Medicare with additional benefits.

    Democrat reform efforts have lead to higher group cost which has increased the uninsured rate, if it wasn’t for bad reform from the left these poor people in the individual market abandoned by the right would have good group coverage.

97. Nate and Barry have made a valid point, which is…….

    the individual insurance market has a lot of problems, a lot of inequities
    that do not exist in the larger group and medicare sectors….

    and by the way, it has had these problems for over 50 years. I once had a job with an insurance company administering health plans sold to seniors before Medicare. These were disgusting pieces of swiss cheese non-coverage, and this was a well-respected insurer.

    The PPACA attempts to tame the rough edges of the individual market, through the pricing and underwriting reforms that Maggie describes.
    Health care experts told the administration that this reform could not be accomplished without an individual mandate, given what happened in Washington, New Jersey, et al and their rather stunning anti-selection.

    Personally I had a soft spot for the idea of letting individual buyers into the Federal employee program. (John Kerry proposed this among others.)
    This would raise rates for Federal employees, which would ultimately impact the taxpayers…….but I thought and still think that this would be workable. If anyone in this country can afford to take a little hit for the public good, it is federal employees.

    As Barry says, the very same insurance companies that run away from young risky patients are on television, every single night, advertising for medicare business and saying NOTHING about pre-existing conditions.

    Of course this is entirely due to risk adjustment programs, and Maggie herself has pointed out how Medicare-Advantage insurers have manipulated these programs already. They make more money on patients who can be classified with pre-existing conditions, at least for a few years. This totally reverses the insurer’s business plan, witness those TV ads that are otherwise completely bizarre to a veteran health care watcher.

    I would be fine with risk adjustment as a way to cure the individual market, but it would not be cheap. A lot of dollars have to move around, and the real bottom feeders of the individual market would make less profit. It would require higher taxes.

    Republicans have made the cynical calculation that the people who get hurt in the individual market are not a voting bloc that can hurt any incumbent. So they feel no guilt in abandoning this group.

    The Democrats showed more heart but not necessarily more brains so far.

    Bob Hertz, The Health Care Crusade

98. You don’t see me advocating to eliminate WIC do you? I was pointing out the sexist hipocracy of Maggie and those that think like here. When it benefits them they want discrimination, when it doesn’t they attack everyone as misognyst.

99. Health insurance companies discriminate against women for having ovaries in the same way that auto insurance companies discriminate against men for having testicles.

    Or at least that’s the flawed logic that passes for discourse on this thread. What a joke!

100. Presumably Maggie is also in favor of equalizing premiums for life insurance (higher for men based on their lesser longevity) and auto insurance (higher for men based on their driving habits).

     If not, one must ask why one type of insurance that most of us need (health insurance) would be treated in a different way than another insurance that most of us also need.

101. Thank you.

102. Determined M.D.–

     Cancer, of all types. is the #2 cause of death throughout the U,S. and so it seems reasonable to assume it’s now the #1 cause of death in N.
     California.

     It’s worth noting that many (not all) cancers seem to be genetic, or caused by environmental factors. The patient hasn’t done something reckless.,

     And a great many cancers cannot be cured, even if detected through screening. Often, a patient’s life may be extended for some time, but in the
     end, many cancers are fatal diseases.

     These are the accidents of fate that I was talking about in an comment above.

     We can’t blame the paitents, or the doctors. Medical science just hasn’t cracked the mystery of cnacer.

     On the other hand, when patients and doctors work together to manage heart disease, a combination of low-cost medications (aspirin) , changes of diet and exericse can greatly reduce mortalities. Kaiser provided
     incentives, and mortalities fell.

103. Maggie –

     Recent data that I’ve seen show that cancer is now the #1 killer by a small margin of people less than 65 years old. Heart disease is a close 2nd and is still the #1 killer across the entire population. I don’t know how many Medicare Advantage enrollees Kaiser has a percentage of its total membership. My sense is that it’s not a big player in the MA space.

     Insurers with a sizeable Medicare Advantage business are already providing insurance without underwriting. United and Humana are the two biggest MA insurers and, for Humana, it’s the bulk of their business. They do receive risk adjustment payments based on each individual’s risk score, however. Roughly 25% of Medicare enrollees are now in MA plans and that share is growing steadily. In Germany, 80 different factors are used to assess health risk and the Central Fund distributes risk adjustment payments to individual insurers as warranted. In effect, that replaces underwriting.

     On the commercial side of the business, a steadily increasing share of the market is fee based as opposed to risk based. Self funded insurers assume the risk and pay all claims though some may buy stop loss coverage as well. Insurers earn a fee to administer the plan, pay claims, provide a network and negotiate contract payment rates. The individual market is small in terms of members and even smaller in terms of revenue.

104. I am genuinely curious what is the number 1 cause of death among Kaiser members?

105. Bev M.D.

     I agree with your point that people need health care–not heatlh insurance.
     And, unfortuantely, in this country health insurance has been all about
     “underwriting ” (figuring out who is likely to get sick, and discriminating against them.)

     But in other countries, that is not true. Throughout Euopre, private sector health insurance companies are part of the system. (Single-payer exists in Canada & the UK but not on most of Western Europe)

     Those private sector insurers are regulated by the government, and are not
     allowed to discriminate.

     The Affordable Care Act follows the European example: it regulates insurers in a way that will force them to change how they do business..

     As the CEO of Aetna recently said, insurers are going to have to entirely change their business model: they won’t be underwriting, they are going to have to manage the health of large populations (i.e. try to keep their customers healthy, much the way Kaiser Permanente (a non-profit iinsurers in the U.S.) tries to do.

     In Northen California, Kaiser Permanente has succeeded in making heart disease no longer the No. 1 killer among its customers. (Throughout the rest of the country, heart disease remains the #1 killer.)

106. To equalize insurance costs for men and women of similar age, men will have to pay more so women can pay less because, as noted by others, women consume more healthcare than men until they reach their late 50’s. After that, men use more.

     At the same time, at the population level, insurers will tell you that people in the 55-64 age cohort use 5 to 7 times more healthcare than those in their 20’s. Even PPACA allows a 3 to 1 premium differential based on age and 4 to 1 for the high risk pools. So, the age band limits require the young to pay more than what’s actuarially justified so older people can pay less. At the same time, again at the population level, their income and assets are considerably lower than people in their 40’s and 50’s as the young are just starting out in entry level jobs. The fact that many are also saddled with significant school loans to repay only adds to their burden and the feeling of being put upon when it comes to paying for health insurance that they are likely to use comparatively little of.

     Within Medicare, beneficiaries in the least expensive counties use one-third to one-half as much healthcare as those in the most expensive (Miami-Dade) but everyone pays the same Part B premium. Is that fair? In Switzerland, by contrast, premiums vary among the 26 cantons so that the same policy in the most expensive canton costs twice as much as it does in the least expensive canton. That makes more sense to me.

     People who live in high cost areas are paid higher nominal wages than those who live in low cost regions for similar jobs. Yet, our progressive income tax structure requires the family with the higher nominal income to pay more in federal income taxes even though the standard of living that the pretax wage can support may be lower in the high cost region.

     As Nate notes, larger employers already equalize insurance costs for men and women. Over 160 million people, including family members, get their insurance through an employer with most of those in medium size and large groups. The issue is also irrelevant for Medicare and Medicaid as Nate points out.

     Personally, though I’m now insured by Medicare, I wouldn’t have a problem equalizing insurance rates for men and women even if I were younger and accessing insurance in the individual market. I would be willing to pay more so women could pay less but I always earned a pretty good income and could afford to. However, I think this argument might be more credible if women also supported equalization of insurance rates when it works against them including for auto and life insurance premiums.

107. Laura–

     I would just say that car insurance and health insurance are very different.
     First, in many (not all) parts of this country, one doesn’t have to have a car
     (or auto insurance). You can get to work via public transportation

     Health insurance, on the other hand, is a necessity. None of us know when we will need health care , and when we reallly do, it’s not a choice.

     In addition, women in this country earn less than men doing exactly the same jobs. And women are less likely to work for employers who provide insurance (Only 50% have work-based heatlh insurance.) Therse are reasons why men need to help subsidize health insurance for their
     daughters, sisters, future wives and mothers.

     I appreciate the fact that you’re willing to help out other women, because you feel a connection with them.

     But I’d urge to “feel connected” to men too. Or let me put it this way: those are the men you want to date, and eventually marry.

108. “Ah that’s right an entire government program for women that excludes men. Damn this sexist society we live in.”

     What does WIC stand for? All three letters? The program is not titled W. If you want to acknowledge the actuary generated data that women cost more, then you should also acknowledge that it is women who (usually) end up caring for the kids when families go bad or when births are out of wedlock (84%).

     http://family.jrank.org/pages/1574/Single-Parent-Families-Demographic-Trends.html

     Also, the plan does cover men when they are caring for children.

     http://www.mtlsa.org/wp-content/uploads/files/public_benefits/WIC.pdf

     Steve

109. Disclaimer up front, I can’t read Ms Mahar’s posts and voluminous retorts on accompanying threads, because every one has a limit to reading pontificating. So, if that diminishes this comment, so be it.

     However, what I could digest above is easy to me: another hack job by a Democrat operative to sell PPACA as part of the overtly identified smear campaign regarding who is caring about women for this election by Democrats. Yeah yeah yeah, republicans aren’t doing themselves any good by the stupid and ignorant stuff they have overtly said to now, but 2 wrongs don’t lead to validation.

     Frankly, I’m surprised if Ms Mahar was genuine in her concerns about women to not see PPACA will continue to discriminate against women with the eventual IPAB behaviors. $100 says 3 or less members will be female!

110. It’s interesting that your son feels that way, Maggie. I’m not sure I feel comfortable asking men to pay more for the costs of a group that they’re not related to. Personally I’m not crazy about the idea of paying more for my car insurance to help cover men my age who are more likely to get into car accidents.

     On the other hand, I do get what you’re saying about pitching in for others.

     I’m willing to contribute more (even more than men do) so that women, a group I feel connected to, can get the health care they need. And I feel comfortable asking other women to do the same so that I can get care if/when I need it.

     Then again, I actually haven’t ever seen a bill. You’ll have to come back to me in a few years when I’m off my mom’s health insurance and ask me how I feel.

111. by nature don’t doctors make people better? Even to a fault, do we need another system for treatment?

     Insurance when used as insurance works incredibly well. Insurance used as wealth redistribution doesn’t. Which makes perfect sense, why design an insurance plan supposedly based on acturial risk when your goal is really to take $100 from one person and give it to another, is that’s that what taxes are for?

     It would seem the simple solution instead of bastardizing the concept of insurance would be to subsidize women’s premium if you believe the world is sexist.

     Which reminds me, what does WIC stand for again Maggie?

     http://www.fns.usda.gov/wic/

     Ah that’s right an entire government program for women that excludes men. Damn this sexist society we live in.

     Now that I got that out of my system, WIC would actually be a better vehicle for addressing Maggie’s concern then distorting the functionality of insurance and demonizing everyone along with it.

     Speaking of Maggie’s militant femonism, how many young women die in war compared to young men….there goes that sexist society again.

112. This is why I have always said that insurance and health care are mutually exclusive. Routine practices to minimize risk on the part of insurance companies are (properly) decried as discrimination or cruelty by the public. You can’t have it both ways – insurance executives think like insurance executives. We need another system entirely for health care.

113. “Nate will say anything to get a response. This is why I don’t respond to him.”

     Ya that is why, it has nothing to do with being factually wrong.

     No matter how simple or polite the comment you can’t respond.

     Why when this issue affects less then 10% of women do you make such a big deal out of it? None of this applies to Medicare, Medicaid, Group insurance which is 70%+ of the population. Majority of the uninsured choose to be uninsured because of the cost, and you propose asking them to pay more.

     You never had a problem slandering people and calling them misogynst but as soon as someone factually challenges you the rules change. If you don’t like a harsh critique maybe you shouldn’t attack others so harshly? And try to so some fact checking outside the DNC talking points.

114. Kim & Peter 1

     Kim–

     Thanks for your comment.

     You’re right that women of child-bearing age do cost more. (Most comparisons of insurance costs assume that pre-natal care, labor, delivery contraception , etc. are covered.in an insurance plan )

     But I think most of us would agree that, as a society, we benefit if all
     women have good prenatal care, good care during labor and delivery– as well as the opporunity to avoid becoming pregnant when they are not in a position to support and care for a child.

     Otherwise, we all wind up paying for the cost of caring for children born with serious health problems. Some will be very, very expensive for a few years–until they die. Others will be in need of care for many years, and in some cases, unable to contribute to society.

     No one wants to live in a community where children and pregnant women dont’t get the healthcare they need.

     I realize that healthy young men may not be enthusiastic about paying for health care for others, but the vast majority of healthy young men who I know (including my son and his friends) understand that all of us are connected: Sons and mothers, and sisters and lovers, husbands and wives. We’re all vulnerable to the accidents of fate, and , in the long run, what happens to some of us is going to affect all of us.

     When we are very young, we all tend to think only in terms of “I.” (This includes young women: talk to a 17-year-old women and listen to how often the words “I” or “:me” come up. This is entirely human– young people are anxious, finding their place in the world, so they are concentrated on themslves.

     But as we mature, we pay more attention to others. What one novelist has called “the speck of self” no longer blinds us to the larger world.

     And we realize that we are all connected in a living organism, a web called
     “society” or a “community”.

     Finally, Kim thanks for your rational and respectful response to other readers.

     As Peter 1 points out, he wasn’t being facetious, but Nate will say anything to get a response. This is why I don’t respond to him.

     Peter 1– Thanks much for pointing out the difference)

115. “I believe use of genetic testing in pricing is not generally allowed, so looking for these genetic predispositions is (fortunately) hard to do.”

     Yes, wouldn’t insurance companies love to get their hands on that information. I was being facetious, but as you can see Nate is never that way.

     Insurance is never about health care, nor will it solve our cost problems. And I think your statement, “Community rating was once, decades ago, the norm, but it fell apart because people opted to shop for lower prices that benefit them instead of being fairest to everyone.” says much about where American society is today.

116. Nate, I don’t think we’re actually on different sides of the original issue, but your points illustrate my comment. For example, “race” is not always quite a clear-cut factor in sickle cell anemia — people with many genetic backgrounds can get it, and even among those of African origin it is not uniformly distributed. Charging by “race” would just be lazy underwriting, using an inexact proxy.

     I believe use of genetic testing in pricing is not generally allowed, so looking for these genetic predispositions is (fortunately) hard to do.

117. if a Ashkenazi Jew wanted to buy a policy to cover Tay–Sachs disease should they pay the same price?

     What about African Americans buying coverage for sickle cell anemia?

     Actuarial analysis is not racist, misogynist, or discriminatory in any manner. The results are not inflicted on someone because of those conditions it’s an outcome from those conditions. If a white person was predisposed to sickle cell anemia they would be charged more for a policy as well.

118. I don’t think it is all greed that people shopped. When your young your income is usually at it’s lowest. before you retire your usually experiencing your highest earnings. Why are we asking young people to subsidize old people? This is on top of the huge generational transfer as a result of Social Security and Medicare. In my late 30s I am already looking at 70% SS benefit, I’ll be the first generation to receive less from SS then I put in.

     PPACA is going to distort the cost of insurance so badly majority of people under 40 would be better off paying the penalty. They already have depressed wages and higher unemployment and now we are going to hit them again.

     http://www.census.gov/compendia/statab/2012/tables/12s0721.pdf

     look at home equity and business equity of those 45 to 65 compared to those under 35. It’s criminal that we are stealing more money from the future to satisfy the greed of the older generations. 55 to 64 is by far the wealthiest bracket and Maggie wants us to believe they need more.

119. Peter1: you may be being facetious, but I’ll reply seriously just in case. Well, in addition to the fact that pricing based on race would probably be illegal, it’s not realistic. The concept of race is pretty murky — where’s the bright line between “races”? Pricing one “race” differently than another smacks too much of the Nazis or KKK ideas about racial purity. We’re all the same race, basically.

     Plus, at some point there are socioeconomic issues cloud race distinctions in health spending as well, and it’s not fair to penalize people for that.

120. “For example, I hope no insurer is pricing differently based on race”

     Why not? Why, as a healthy white male, should I have to pay for the health problems associated with being another race?

121. I can’t speak to the pricing practices of all the insurers out there, but the fact of the matter as I understand it, based on over 30 years in the health plan business, is that women do cost more, until at least mid-50’s. Whether this is “penalizing” them for taking care of themselves or simple medical economics depends on one’s POV, I suppose.

     There are two separate questions: what is the actuarial cost of various classes of individuals, and to what extent is society willing to allow pricing variations based on those classes. For example, I hope no insurer is pricing differently based on race, but I doubt any don’t factor in geography. If we say gender should not be a considered factor in setting premiums, we need to have our eyes open to the fact that means men will have to subsidize women (until later in life, anyway). This is not whacking those evil insurance companies, it is talking money out of men’s pockets in the interest of perceived social justice. As an older male, I don’t much mind, but if I were a healthy young man who wasn’t too keen on buying insurance anyway, I very well might.

     Community rating was once, decades ago, the norm, but it fell apart because people opted to shop for lower prices that benefit them instead of being fairest to everyone. Jeremy Bentham might have objected but Adam Smith would not have been surprised.