The Audacity of Greed: Profiteering in American Medicine

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

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

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

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

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

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

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

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

Dave Zweifel, The Capital Times (Madison, WI)

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

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

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

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

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

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

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

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

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

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

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

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

Copyright 2006 The Capital Times

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

The HMOs and their managed care systems  ballooned from a headache to a plague

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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Old News ;-)

[Dec 05, 2017] A coalescence and consolidation of insurers effectively being single-payer, expensive private sector paying monopoly. This by-and-large parasitic industry consumes add 35-40% tot he costs feeding whose executives and employees do not contribute constructively to the CARE equation

Notable quotes:
"... Taking jefemt's thinking further, imagine the health insurance provider was not only monopolistic (owned the entire market), but was also a GSE (government sponsored enterprise). Now take it one more step and imagine it was an actual part of the government and not merely a GSE. ..."
"... I was thinking of this too as a reponse to Why Steve Bannon Wants You to Believe in the Deep State" [Politico]. "Like the Death Star, the American Deep State does not, of course, exist. " ..."
"... Indeed, I think of the insurance industry as being part of the deep state already. It seems that congress's preference is that this part of the deep state is outsourced. So that's it not a GSE, and not even a monopoly, but maintained as an oligopoly. And then, well hey whatever surplus it can hoover up is fair game. After all free-hand of the market and all that. [And heaven knows, we don't want to crowd that out.] ..."
"... The CIA has a long history of drug trafficking. The FBI traffics in blackmail. The NSA in network surveillance. DIA, special ops. NRO, satelite throughput. 11 more in the US of A and countless more globally. They all have opaque resources outside of regular channels. ..."
"... Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence? ..."
Mar 23, 2017 | www.nakedcapitalism.com
djrichard, March 22, 2017 at 5:35 pm

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

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

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

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

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

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

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

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

human , March 22, 2017 at 7:46 pm

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

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

Great documentary about the 80's cocaine business in Miami called "Cocaine Cowboys." It's real life Scarface. Guess who the Feds sent to get a handle on the cocaine smuggling? See-eye-aye man George H.W. Bush. Coincidence?

[Nov 30, 2017] Healthcare Costs and Its Drivers Today by run75441

Notable quotes:
"... We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ..."
"... Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume. ..."
"... In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents. ..."
"... Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA ..."
"... So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. ..."
Nov 25, 2017 | angrybearblog.com

I have been doing my typical reading on healthcare in the US and ran across several articles which seemingly come together at various points in the dialogue and are written by different authors. I decided to tie them together into a much wider and telling story.

An interesting point being was made by MedPage Today's Dr. Milton Packer on his blog, " people suffer and die because Payors (Healthcare Insurance) is cost effective ." He starts his discussion on the opiate epidemic in the US, opiates are being prescribed by doctors for pain relief and . . .

"Patients are becoming addicted to opiates after the initial 10 day prescription with one-fifth of patients still using opiates a year later. There is no need to prescribe opiates as other less addictive pain-relief formulations are available, which are not commonly prescribed." This raises the question of why?

Payers will not pay for the alternatives. The less-addictive opiates are more expensive and payers have declined to support them. Patients get addicted because prescribing for the lower cost and highly addictive opiates saves the payers money initially (me) .

September 17, 2017, the New York Time and ProPublica (independent, nonprofit investigative journalism organization) collaborated on an article concerning the opiod epidemic in the US.

At a time when the United States is in the grip of an opioid epidemic, many insurers are limiting access to pain medications that carry a lower risk of addiction or dependence, even as they provide comparatively easy access to generic opioid medications.

The reason given: Opioid drugs are generally cheap while safer alternatives are often more expensive.

While the pharmaceutical manufacturers, distributors , and doctors have come under scrutiny; insurance companies and the pharmacy benefit managers (CVS Caremark, Express Scripts and OptumRx) make the final decisions as to what is covered. It could be something as simple as a higher tier and deductible to block usage.

A little side trip here and a continuation of the above. A week or so ago, I ran across another MedPage Today article by Dr. Packer; " Who Actually Is Reviewing All Those Preauthorization Requests and How the System Works ." Dr. Packers was giving a talk on advances in medicine with regard to heart failures to a room of about 20 or so doctors who were retired.

Since many of them were no longer involved in active patient care, he wondered why they might want to hear a presentation on new advances in heart failure. Here was their answer:

Doctors: " We no longer care for patients, but we care about what's going on. You see, most of us are employed by insurance companies to do preauthorization for drugs and medical procedures ."

" Dr. Packer: I just gave a talk about new drugs for heart failure. Are you responsible for preauthorizing their use for individual patients? "

The answer; "Yes."

" So did I say anything today that was helpful? I talked about many new treatments. Did I say anything that you might use to inform your preauthorization responsibilities? "

"Oh, we've heard about those drugs before. We are asked to approve their use for patients all the time; but, we don't approve most of the requests. Nearly all of them are outside of the guidelines we are given."

" I just showed you evidence that these new drugs and devices make a real positive difference in people's lives. People who get them feel better and live longer. "

"Yes, you were very convincing. But the drugs are too expensive. So we typically reject requests, at least the first time. We figure that, if doctors are really serious, then they should be willing to make the request again and again."

" If the drugs will help people, how can you say no? "

"You see, if it weren't for us, the system would go broke. Every time we say yes, healthcare becomes more expensive, and that isn't a good thing. So when we say no, we are keeping the system in balance. Our job is to save our system of healthcare."

" But you are not saving our healthcare system. You are simply making money for the company that you work for. And patients aren't getting the drugs that they need. "

"You really don't understand, do you? If we approve expensive drugs, then the system goes broke. Then no one gets healthcare."

"Plus, if I approve too many expensive drugs, I won't get my bonus at the end of the month. So giving out too many approvals wouldn't be a smart thing for me to do. Would it?"

Now before you start on insurance companies and doctors; understand, this is not as free a market place as many would assume.

In all of their political wisdom, Congress favors pharmaceutical companies over doctors, insurance companies, and the welfare of the constituents.

Through legislation, Congress has made it impossible for insurance companies to negotiate pharmaceutical pricing in Medicare Part D insurance and also the ACA .

Furthermore with the consolidation happening in healthcare, negotiation by insurance companies with a consolidating and growing healthcare industry is becoming more and more difficult as the former does not have as great of leverage. You have read my argument calling out of Single Payor, Medicare-for-All, Public Option, etc. as the cure for today's healthcare issues and rising cost not being enough as the ACA and Part D were specifically blocked or the cost issue unaddressed in the legislation written by Congress. If these issues are not addressed from the very beginning, we will be fighting the same issues with rising costs a decade later with other programs.

At this point, I begin to disagree with Dr. Packers as he goes on to say:

" So we spend more for healthcare than any other country in the world; but, Americans do not get the care they need. There is a simple reason. Treatment decisions are not being driven based on a physician's knowledge or judgment. They are being driven by what payers are willing to pay for. "

It is true that patients may not get some of the healthcare they need at the time due to denial, which can be appealed to the ACA, and can be a tiring process. It could be approved, passed on to patients, resulting in higher premiums the following year, and the Part D Risk Corridor program pay for it if excessive for the present year. What Dr. Packers does not mention is the rising prices and cost of drugs being blamed by pharmaceutical company on R&D, tooling up to manufacture, etc. The counter argument is much of the R&D is funded by the US government through tax deductions and write-offs for pharmaceutical R&D and capital Overhead. Pharmaceutical profits are double digit at ~25% beating out hospital supplies and healthcare insurance, which is already limited in what can be charged back to the insured by the MLR. To blame insurance companies totally for the higher costs in healthcare is false. Furthermore, a doctor's decision do not always lead to less costly cures or practices.

Maggie Mahar of Health Beat Blog would take the subject of costs a step farther and state Medicare will approve anything the FDA approves for usage regardless of the quality of outcome when measured against older proven treatments. Notably the VA does limit its pharmacy and its care is rated higher than that of today's commercial, for-profit healthcare to which most citizens are exposed.

Dr. Donald Berwick, President Obama's proposed appointment for Medicare and who was in charge of Medicare and Medicaid for 17 months stated;

"20 to 30 percent of health spending is 'waste' that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by Medicare and Medicaid.

He listed five reasons for what he described as the 'extremely high level of waste.' They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud .

Much is done that does not help patients at all and many physicians know it."

That is the same Medicare/Medicaid being touted by many proponents today as an alternative.

Speaking of costs and pricing for pharmaceuticals, there have been recent incidents of skyrocketing costs on particular drugs. A short while ago, I wrote a post concerning the appointment of Alex Araz as the new HHS Secretary replacing Dr. Tom Price. Formerly, Alex Araz was the CEO of the pharmaceutical giant Eli Lilly & Co.'s U.S. division . He also served under George W. Bush administration as the HHS General Counsel and Deputy Secretary. During that stint, he received praise for his management competence with the HHS; although, he did not have a healthcare background prior to this position.

Here it gets interesting when examining what took place during his tenure with Eli Lilly. One of the leading costs identified in pharmaceuticals increases has been in the rising cost of diabetes medication.

"While the Tweeter-in-Chief, Trump tells us presidential campaign contributor Alex Azar will be a 'star' who will lower prescription prices,"

Public Citizen's Peter Maybarduk (Director) had this to say: " Eli Lilly is notorious for spiking prices of a century-old isolated hormone during Azar's tenure as president and vice president. Eli Lilly raised the price of Humalog by 345%, from $2,657.88 per year to $9,172.80 per year.

Maybe President Trump in appointing Alex Azar to be HHS Secretary should have asked the 6 million diabetic Americans whose insulin prices have more than tripled under Azar's watch at Eli Lilly."

This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and throughput restricted manufacturing (capacity).

What I have tried to do is tie these articles together into one cohesive story of how the pharmaceutical industry, insurance, and healthcare can have an impact on healthcare costs. For those who are interested, my background does include working in the manufacture of hospital supplies and pharmaceuticals. Using various citations from these articles, I have tried to touch upon the impact of insurance companies, the healthcare industry, government intervention under the HHS, one particular Med in the market place, etc. Overall, what is going on in the marketplace.

Another article, I read the other day gets into the foundation of what is happening based upon a recently completed study by JAMA. Using this study, the Methods Man, Dr. Perry Wilson (MedPage Today) examines what is driving healthcare costs in his article Here's What's Really Driving Healthcare Costs using data from Factors Associated With Increases in US Health Care Spending, 1996-2013 and the US Disease Expenditure Project . Dr. Wilson breaks it down using three simple charts which I have consolidated to one.

Dr. Perry Wilson starts off making an overall point about the rising cost of healthcare from 1996 to 2013 and stating; "after accounting for inflation, healthcare expenditures increased $933.5 billion from 1996 to 2013."

Going on: "Healthcare expenditures in the US being high and rising rapidly is nothing new, but the study appearing in the Journal of the American Medical Association identifies the exact components of healthcare that are driving those soaring costs. The data from this study suggests traditional economic forces break down in the US healthcare market.

Different chronic diseases have different patterns of price increases. The biggest increase was seen in diabetes care, as you can see here, driven largely by the rising costs of pharmaceuticals."

The Chart breakdowns reveal the various impacts of healthcare costs moving from left to right and then downward:

• 50% of the increase in healthcare costs was simply due to higher prices.

• Inpatient care or Service Utilization (purple) went down from 1996 – 2013 as outpatient treatment increased; however, the price of the remaining inpatient care went up much more – increasing overall inpatient care spending by around $250 billion.

• Different Chronic Diseases have different patterns of price increases. The biggest increase was seen in diabetes care and driven largely by the rising prices of pharmaceuticals.

The takeaway drawn by Dr Perry Wilson: "Regardless of the disease, it is clear, the price of what we're buying – whether a drug, an ED visit, or a hospital stay – not the amount of what we're buying is the major driver of cost increases . Efforts to reduce the consumption of healthcare may not bend the cost curve as much as efforts to reduce its price."

You can not make an argument about the regulation of costs "not" being one of the dynamic components of a healthcare plan given the continuous unhindered industry driven rising cost of healthcare. Yet, every healthcare plan I have read fails to mention cost regulation specifically, provide remedy for it, and many assume a natural occurrence of control.

Tags: run75441 Comments (9) Digg Facebook Twitter Comments (9)

Longtooth , November 26, 2017 12:59 am

Run thanks for this, but in my opinion you're avoiding the central problem , though you briefly touched upon it without being more explicit:

"This has nothing to do with R&D and has more to do with pharmaceutical companies controlling the market regardless of supply and restricted manufacturing throughput. "

The market can't be controlled by the pharmaceutical companies unless the government lets them. So this is a government sourced and caused problem unless you believe laissez-fair is the gov'ts job to promote and endorse.

You can't blame the pharmaceutical companies for doing precisely what the gov't lets them do by law.. the pharmaceuticals company's owners are in this to be philanthropic are they?

What you are essentially not coming to grips with is that our government is not designed to be democratic but designed by it's concept to be a system to ingratiate those who pay the most to keep the gov't in power which is to say those that represent them are paid to do their bidding in other words a gov't controlled by the sources of wealth to maintain it. if it were anywhere near a democratic system, how could 1% control it?

Longtooth , November 26, 2017 1:08 am

Run, sorry I forgot that there's never been a democratic system from the Spartan through the Athenian to the present that hasn't been controlled by the wealth. There have only been moments brought about by extreme deprivation that have had to deal with that deprivation to avoid revolution.

When we want to fix U.S. healthcare costs and quality we know how to do it, but you have to fix the system of government we employ to do it. Address the source of the problem rather than effects of it.

Longtooth , November 26, 2017 1:36 am

Run, let me only add that I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system at the same time. That is the actual dilemma since they are mutually exclusive.

If you think about how to "comprise" one with the other then you have to decide how such compromise is made and sustained (sustained being key word) and I can't see or find any evidence in U.S. history that suggests such compromise has ever worked to provide for the greater good on a sustained basis.

Perhaps its not even possible among human systems of civilized government .. but then why the charade as if it is? If the public wants to improve the healthcare system then why does it elect Presidents and representatives who don't want to improve it? If the public want's to improve the healthcare system why do Supreme Court interpret the Constitutional "law" to prevent it? Or if the 200+ year old constitutional law is so outdated as to be irrelevant than why doesn't the pubic demand to change it?

Or does the pubic want it's cake and eat it too? The public may be confused (I'm sure of this in fact) because they want simultaneously mutually exclusive conditions.

Denis Drew , November 26, 2017 9:29 am

Run, great major post.

Long, " I don't know how we can have a free market based and biased system of government and anything even approximating a democratic system "

No? Look at continental Europe -- look at across the board labor union density -- look at sector-wide labor agreements. Come to think look at our northern neighbor.

Mostly all other problems from health care to student debt to everything are just symptomatic of the same economic/political-union free pathology. Bernie and Eliz don't spend a lot of time looking abroad either -- or even looking at 1973 stateside.

Come a Dem Congress I think the best idea is:
Why Not Hold Union Representation Elections on a Regular Schedule?
Published November 1st, 2017 – Andrew Strom

https://onlabor.org/why-not-hold-union-representation-elections-on-a-regular-schedule/

This can be sold as taking a page from Repub govs (e.g., Walker) who force government employee unions to re-certify every year -- with majority of union members, not just those who vote, required to retain.

I'm playing with the idea of proposing (via spam mail*) re-certification for every union in the country every year -- oh, of course, that would include certification elections for every nonunion workplace: that's the Trojan Horse .

We really want to certify/recertify every three or five years (three at first while we are trying to build density -- maybe five later on). Once we organize enough we can write the rules any way we want. By proposing re-certification every year (from my spider hole in Chicago) maybe I can get union members dander up and thereby at least wake them up to the issue. Cab driver political drama.

(* I have about 2000 email addresses, journalists, union, academic, politicians -- in WA, OR, CA, NV -- that I like to hit with new ideas.)

run75441 , November 26, 2017 11:40 am

Denis:

You may want to look at this again. A portion of it was blocked due to an error in linking to an article on Pharma costs which was kind of important. I have another article coming out which will discuss Pharmaceutical companies pulling advertising from medical news sites and mags if they are critical of pharma. As I read each of these articles, I could see a similar thread in them.

in 2015, AARP broke ties with MetLife over LTC insurance which MetLife discontinued in 2011 (no new applications). No big deal except AARP never told its membership of the AARP sponsored insurance break with MetLife. AARP now has a new LTC insurer New York Life announced as of 2015 and no letter to its members holding MetLife policies. Those who had AARP sponsored MetLife are now left with MetLife who is requesting a 21.75% increase just for cost over 3 years in addition to the normal inflation factor which was ~10% for 2018. AARP refers all inquiries to MetLife even though documents from MetLife still has AARP logos on it. Another interesting post of companies and Organizations screwing people.

Longtooth , November 26, 2017 5:48 pm

Dennis,

FWIW I come from a long line of union activists, members, and in one case a major union leader in the western U.S. and California in particular -- Building & Construction Trades Council.

I've been and remain a hugely strong union supporter. However my uncle (the Western US major union leader) was a realist and well understood the nature of economics viz-a-viz unions and capital owners.

In a series of discussions while I resided with he and his wife during one summer college break, he made me understand those trade-offs, and what drove them. At the time the college educated workforce in the US was 10% (4 year or better degree). He said a major factor in union's was the level of the college educated workforce and he said in 1966, that if the rate of college degree growth reached the then unprecedented rate of ~ 0.5%/year than in a few decades 1/3rd of the workforce would have college degrees -- the upshot of which is that they would very unlikely be persuaded to join unions or create new ones. His prognosis in 1966 turns out to be pretty close to reality even though he had little historic information to go on., .. he was not a pie in sky type, but a practical and major proponent of the general working class an working poor.

He also told me in 1966 that if unions demanded too much of the capital owners profits, they would resort to capital invested in automated methods -- his primary example of which was the hift to lath & plaster skilled union members to wall board which required no skill per-se and that forced union wages for interior "plasterers" down as lower skill and more efficient "sheetrock" hangers too over.

He cited other examples of automation replacing skilled union labor and without elaborating it was an eye-opener for me to see that unions were on their way down He not only knew the economics of building and construction business and labor, but of mining and manufacturing.

This was all long before Reagan's anti-unionism push (which in reality was Reagan using what was already well underway as a means of pumping up is conservative credentials).

My uncle's wisest advice was that if unions demanded more than capital owners were able to profit, they would simply use their capital in other enterprises where profits were greater -- this included not only investing in automated methods in mfg'ing and the building and construction trades (remember "sheetrock") , but in foreign low wage labor regions where especially mfg'ed goods could be produced at lower costs IF(the big IF in 1966) transportation and import duties made it more profitable to do so. He cited Mexico as the primary source of low transport cost low wage labor at the time, and at that time import duties from the few mfg'ed goods produced in Mexio were excessive which was the only reason mfg'ing hadn't shifted to use Mexican labor in Mexico for production and also why mfg'ing was investing more and more capital in automation. BUT, he said sooner or later it would become clear that capital owners would push to chane US import policies from Mexican roduced goods and the this would reduce mfg'ing's need for U.S. labor, thus Union's would have far less leverage to take a share of capital profits.

So he was a few decades off in his estimates, but he was right in 1966.. My uncle was among those in the U.S. union leaders who all understood all this very well what they said in public was different that what they saw occurring and would continue to occur they just didn't know then the rate of occurrence -- the computer age hadn't started . semi-conductors were being invented and barely developed for example. China's opening up hadn't occurred yet either. Clinton's NAFTA was still far in the future.

Through al the years since 1966 I've watched the progression of what my Uncle told me during our discussions in the summer of 1966. take place, for precisely the reasons he (and other major union leaders) knew they would.

In hindsight what fails in the U.S. relative to Europe is Germany's constitutional protections of labor unions. which by osmosis transfers to the other major European nations just as U.S. union wages and benefits transferred by the same osmosis to non-union wages and benefits rising to keep pace.

Keep up the good fight, Dennis, but you're forgetting about the economic realities in the US and it's individualism worship and constitution that protects it. .

JackD , November 26, 2017 9:22 pm

Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge. With Democrats in charge, it's tough enough. Witness the ACA's development and the impact of the blue dogs.

JimH , November 27, 2017 10:28 am

JackD wrote "Run, as you know, nothing substantive on controlling medical costs can possibly occur with Republicans in charge."

I could not agree with you more.

The Republicans' implementation of Medicare Part D which forbids negotiation of drug prices was asinine. Where was their concern for the national deficits and debt?

On heath care President Obama was negotiating with the duplicitous. His opposition had only one concern, their oath to Grover Norquist.

Daniel Becker , November 27, 2017 5:22 pm

It's not just that pharma has some say on what gets published, but in the health literature world, the trend was to only publish positive results.

As you can imagine, this has left a major void in truly understanding what happens in the body when a treatment is applied. There is a push to change this. Additionally, there is the push toward the idea of "numbers to treat". That is, how many have to receive the treatment to create one positive results. Outcomes can look a lot more different when looking at numbers to treat.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] Looks like the rot in the US healthcare system is terminal

Nov 30, 2017 | marknesop.wordpress.com

kirill , November 27, 2017 at 8:38 pm

Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

[Nov 30, 2017] The most interesting insight into healcare in the USA: The cost is shocking

Nov 30, 2017 | marknesop.wordpress.com

James lake , November 28, 2017 at 12:21 am

This is s very interesting insight into healcare in the USA. The cost is shocking.
I live in the UK and the healthcare system is paid for from taxation.
When it was established over 70 years ago it's
The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means.
It was the best thing in my view that government has ever done.
Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.
Which many people do not mind.
-Elderly care was also privatised as it's the most expensive
-care for the disabled also is a issue for local councils
-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.
And yet still more and more taxation is needed for the NHS!
The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.

[Nov 30, 2017] The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system)

Nov 30, 2017 | marknesop.wordpress.com

Ryan Ward , November 28, 2017 at 3:40 am

With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 30, 2017] I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties.

Nov 30, 2017 | marknesop.wordpress.com

anon@gmail.com , November 27, 2017 at 6:02 pm

I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.

[Nov 30, 2017] A comprehensive health care program for social services recipients can be provided for about 3-4% of the cost of services. Private medical insurance providers rake 20%. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

Nov 30, 2017 | marknesop.wordpress.com

Patient Observer , November 27, 2017 at 5:12 pm

Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.

[Nov 29, 2017] The Best Health Care You Can Afford by marknesop

Notable quotes:
"... "No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick ..."
"... "Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems." ..."
"... The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments ..."
"... "The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity. ..."
"... Interesting article. Looks like the rot in the US is terminal. ..."
"... This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay. ..."
"... Privatisation has meant profits for businesses, poor services to vulnerable groups. ..."
Nov 27, 2017 | marknesop.wordpress.com

"The art of medicine consists of amusing the patient while nature cures the disease."

"No, I mean I'm sorry that you've inherited such a miserable, collapsing Old Country. A place where rich Bankers own everything, where you've got to be grateful for a part-time job with no benefits and no retirement plan, where the most health insurance you can afford is being careful and hoping you don't get sick

Cory Doctorow; Homeland

"Until fairly recently, every family had a cornucopia of favorite home remedies–plants and household items that could be prepared to treat minor medical emergencies, or to prevent a common ailment becoming something much more serious. Most households had someone with a little understanding of home cures, and when knowledge fell short, or more serious illness took hold, the family physician or village healer would be called in for a consultation, and a treatment would be agreed upon. In those days we took personal responsibility for our health–we took steps to prevent illness and were more aware of our bodies and of changes in them. And when illness struck, we frequently had the personal means to remedy it. More often than not, the treatment could be found in the garden or the larder. In the middle of the twentieth century we began to change our outlook. The advent of modern medicine, together with its many miracles, also led to a much greater dependency on our physicians and to an increasingly stretched healthcare system. The growth of the pharmaceutical industry has meant that there are indeed "cures" for most symptoms, and we have become accustomed to putting our health in the hands of someone else, and to purchasing products that make us feel good. Somewhere along the line we began to believe that technology was in some way superior to what was natural, and so we willingly gave up control of even minor health problems."

Karen Sullivan; The Complete Family Guide to Natural Home Remedies: Safe and Effective Treatments for Common Ailments

No, I haven't abandoned Uncle Volodya, or shifted my focus to American administration; what follows is a guest post on the American healthcare system, by our friend UCG. As I've mentioned before – on the occasion of his previous guest post, in fact – he is an ethnic Russian living in the Golden State.

As an American in America, naturally his immediate concern is going to be healthcare in America; but there are lessons within for everyone. Don't get me wrong – doctors have done a tremendous amount of good, and medical researchers and many others from the world of medicine have made tremendous advances to which many of us owe their lives. Sadly, though, once a field goes commercial, the main focus of attention eventually becomes profit, and there are few endeavors in which the customer base will be so desperate. While there are obvious benefits to 'socialized medicine' such as Canada enjoys and American politicians scorn as 'Commie' – enough to earn the admiration of many – it results in such a backlog for major operations that those who don't like their chances of dying first, and have the money or can somehow get it, often flee to America, where you can get a good standard of medical care without running out of time waiting for it.

Without further ado, take it away, UCG!!

Healthcare in America

This article is my opinion. My hope is that others will do their own research on America's Healthcare Industry, because this is an issue that needs to be addressed, and for this article to be a mere starting point in this research. The reason for my citations is so that you, the reader, can verify them. Once again, this is my opinion. I write this in the first paragraph, so that I can avoid stating "in my opinion" before every sentence.

Let's start with Owen Davis who was charged $14,018 for going to a hospital because he sliced his hand, and they fixed it . A study published by Johns Hopkins showed that for $100 of ER treatment, some hospitals were charging patients up to $1,260 . A redditor claimed that :

I tore my ab wall a month ago and didn't think much of it until my pain kept worsening. I went to an immediate care facility to rule out a hernia (I had all the symptoms) and they told me to get to ER ASAP. I go to the ER and they give me a CT scan and one x-ray and say it's not a hernia and let me go. Fast forward to today and I got a bill for $9,200 and $3,900 of it is out of pocket. $9,200 for two tests???? No pain meds were administered; it was literally those two tests. What should I do to contest it? I will be calling tomorrow to demand an itemized bill, but is there anything else I should do in the meantime?

All of these took me a few minutes on Google to find, and another few minutes to post. The reason I chose that reddit, is because one of the readers offered an ingenious solution: Next time you hurt yourself – book a return ticket to NZ – go to accident and emergency, say you're a tourist and you hurt yourself surfing, pay nothing – fly home and pocket $8,000 in spare change. If that was me, I'd spend at least $2,000 on tourism in New Zealand. You guys have that system, so you clearly deserve the money! Anyone interested in a startup?

But I am not done with examples just yet. Shana Sweney described her experience in the emergency room : I delivered in 15 minutes. During that time, the anesthesiologist put a heart rate monitor on my finger and played on his phone. My bill for his services was $3,000. $200/minute. I talked to the insurance company about it – and since I ran my company's benefit plans, I got a little further than most people, but ultimately, that was what their contract with the hospital said so that's what they had to pay. Regardless of if he worked 15 minutes or 3 hours. Similarly, my twins were born prematurely and ended up in the NICU for 2 weeks. While the NICU was in-network for my insurance, for some mysterious reason, the neonatologists that attended the NICU were out of network. I think that bill was $16k and they stopped by to see each kid for an average of about 30 min/day.

Almost done with the examples, just please bear with me. How would you like a hospital billing you $83,046 for treating a scorpion sting , if a Mexican ER might have treated you for the same type of sting for $200? Perhaps being charged $546 for six liters of saltwater is more to your liking? $1,420 for two hours of babysitting ? $55,000 for an appendicitis operation ? $144,000 to deliver a perfectly healthy, albeit quite impatient baby? According to my interpretation of the sources linked, all of these actually happened. I encourage you to do your own research.

The World's Biggest Legalized Corruption (IMHO)

$984.157 billion. That's $984,157,000,000. That is how much money I believe the United States wastes on Healthcare. Not spends; wastes. As in money down the drain. The astute reader figured out that equates to five percent of America's 2016 GDP . Said reader is absolutely correct. How did I estimate such a gargantuan amount? According to the OECD data , in 2013 the United States spent 16.4 percent of its GDP on Healthcare; the two next biggest spenders, Switzerland and the Netherlands spent 11.1 percent. Even if one was to give the United States the benefit of doubt, and claim that the United States healthcare is just as efficient as that of Switzerland or the Netherlands – which is most likely not true according to an article from Business Insider , but even if it was – that meant that the United States wastes 5.3% of its GDP on healthcare. Wastes. I just want to make sure that the amount of this alleged legalized corruption, which will most likely reach a trillion dollars by 2020, is noted.

Let me place those funds into perspective: it's almost as much as the amount that the rest of the World spends on the military, combined . The SCO member states, including China, Russia, India, and Pakistan spent roughly $360 billion on the military . The wasted amount is equivalent to the GDP of Indonesia, and greater than the GDP of Turkey or Switzerland . In 2016, the US Federal Government spent $362 billion, or 36.8% of the wasted amount, to run all Federal Programs , including the Department of Education and NASA, with the exception of Social Security, Medicare/Medicaid, Veteran's Affairs, the military, and net interest on the US debt. All other Federal Programs were covered with the $362 billion. The US Federal Debt stands at $20.4 trillion , meaning that the debt can be paid off in 30 years, merely if the Healthcare Waste is eliminated.

But why stop there? The US Housing Crisis started partly because loans were allowed to be taken out without the 20% down payment. Could this funding, if applied directly to the housing market, stop the 2008 Great Recession? Absolutely, and all the Federal Government had to do was to gear these funds towards down payment on subprime mortgage loans to meet the 20 percent barrier. I can go on and on about what can be accomplished, like making collegiate attendance free, or at least very inexpensive, or drastically improving the quality of education, paying off the national debt, reinvesting into the economy, reinvigorating the rural sector, and so on, and so forth. A trillion dollars is a lot of money.

Lobbyists, the Media and the Waste

Any guess how much was spent on lobbying by the Healthcare, Insurance, Hospitals, Health Professionals, and HMOs? How about 10.5 billion dollars? I knew that was your guess! That's a lot of money, and that does not include "speaking fees", or when a politician who constantly made calls beneficial to the Healthcare Lobby gets $150,000 to speak in front of an audience after they retire from politics. Obama made a speech in front of Wall Street, netting $400,000 . And by pure coincidence, only one Wall Street Broker was jailed as a result of the scandal. That $10.5 billion is just a tip of the iceberg, because "speaking fees" are notoriously hard to track, and not included in said amount.

Obama genuinely tried to reform US Healthcare to the Swiss Model. He was going to let Wall Street slide, he was going to let Neocons conduct foreign policy, just please, let him have healthcare! First, the lobbyists laughed in his face. Second, they utilized the Blue Dog Coalition to block Obama's attempt at Healthcare Reform, until it was phenomenally nerfed, and we have the disaster that we have today. As a result, Obama's Legacy, Obamacare is having major issues, including the rise of racism.

Obamacare helped the poor, (mostly minorities,) at the expense of the middle class, (mostly whites,) thus transferring funding from whites to minorities. While the intent was not racial, it is being called out as racial by the mainstream media . This probably suits the lobbyists, because if the debate is about racism, one cannot have a genuine discussion about Healthcare Reform.

Racism strikes both ways. Samantha Bee came out with a "fuck you white people" message right after the election. Jon Stewart, without whom she probably wouldn't have her own show, pointed out that it was simply economics, like the healthcare insurance premium increase , that brought Donald Trump to power. Interestingly enough, James Carville made the same argument when Bill Clinton beat George Bush, but when Hillary Clinton lost, Carville was quick to blame Russia. These delusions on the Left are letting the Right mobilize stronger than ever before. And all of this takes away from the Healthcare Debate.

In an attempt to blame Trump's Election on white racism, rather than basic economics, numerous outlets simply fell flat. For instance, Eric Sasson writes : white men went 63 percent for Trump versus 31 percent for Clinton, and white women went 53-43 percent. Among college-educated whites, only 39 percent of men and 51 percent of women voted for Clinton What's more, these people hadn't suffered under Obama; they'd thrived. The kind of change Trump was espousing wasn't supposed to connect with this group.

Did this group thrive? The collegiate debt went from $600 billion to $1.4 trillion under Obama's Administration, while the health insurance increased from $13,000 to $18,000 per family . This is thriving? Was the author experimenting with medical marijuana when said article was written? Nevertheless, the parade of insanity continued, with Salon assuring us that it was blatant racism that gave us Trump . The Root, which also claimed that Russians attempted to hack election machines, pointed out that Russia exploited America's racism , and thus Trump won the election. Washington Post claimed that racism motivated white people more than authoritarianism . Comedian Bill Maher tried to sway the discussion back to economics, by pointing out that outrage over Pocahontas or Halloween should not stop the Democrats from working for the working man . Sadly, Maher and Stewart are in the minority, and instead of a Healthcare Debate, the US is now stuck in a debate over racism, which isn't even three-fifths as effective. Meanwhile the US continues to waste almost a trillion dollars on healthcare .

Who Benefits?

Let's start with the banks. Medical students graduate with an average of $416,216 in student debt . The average interest rate on said loan is seven percent. Roughly 20,055 students go through this program, per year . Presuming a twenty year loan, the banks are looking at about $7.185 billion in interest payments. It really is a small fraction of the cost. Prescription drug prices are another story. In 2014, Medicare spent $112 billion on medicine for the elderly . Oh la la! Cha-ching. I would not be surprised if at least half of that was wasted on drug price inflation. You know the health insurance companies? It's a great time to be one, since profits are booming – to the tune of $18 billion in projected revenue for 2017.

Of course the system itself is quite wasteful, with needless hours spent on paperwork, claim verification, contractual review, etc, etc, etc. Humana's revenue was $54.4 billion , Aetna's was $63.2 billion , Anthem's was $85 billion , Cigna's was $39.7 billion , and UnitedHealth's was $184.8 billion . Those are just the top five companies. None of them ia a mom-and-pop shop or small business store. Do any of these insurers support Obamacare? Even if they do, it is without much enthusiasm . They are leaving, and leaving quite quickly. Thirty-one percent of American counties will have just one healthcare insurer . Welcome to a monopoly that is artificially creating itself. And despite the waste, 28.2 million Americans remain uninsured . Mission accomplished!

Who else benefits? Those who hire illegal immigrants instead of American workers, since illegal immigrants cost the United States roughly $25 billion in Healthcare spending . Meanwhile those who hire them can avoid certain types of taxes and not have to cover their Healthcare; communism for the rich, capitalism for the rest of us. Of course that is just a rough estimate, since this spending is also quite hard to track.

The Future

The problem with changing Healthcare is that too many people have their hands in the proverbial pie. There is not a single lever of power that isn't affected by Healthcare, and most of the levers that are affected, benefit quite a bit. Insurance companies will fight to the death, because Universal Healthcare will be their death knell. Banks will defend it, because who doesn't want to make billions from student loans? Medical schools too – since it lets them charge higher and higher tuition. Pharmaceutical companies can use the increase in Healthcare expenditure to justify their own price hikes, even though a major reason for those price hikes is artificial patent based monopoly.

What is an artificial monopoly? In my opinion, it's when a patent is utilized to prevent competitors from manufacturing the same exact drug. In less than a decade, the price of Epi-Pen soared from $103.50 to $608.61. When asked the justify said increase, one of the reasons provided by the CEO was that the price went up because we were making investment; as I said, about $1 billion over the last decade that we invested in the product that we could reach physicians and educate legislatures. "Reaching" doctors and legislators; I wonder, how was said "education funding" spent? According to US News, a website that is extremely credible when it comes to internal decision making within the United States, drug companies have long courted doctors with gifts , from speaking and consulting fees to educational materials to food and drink. But while most doctors do not believe these gifts influence their decisions about which drugs to prescribe, a new study found the gifts actually can make a difference – something patient advocates have voiced concern about in the past. Do you feel educated? Would you feel more educated if I paid you a $150,000 consulting fee? What about $400,000? What? It's just consulting; no corruption here!

Everyone knows that this is going on. But there is not going to be change. Why not? The same reason that there was not change with Harvey Weinstein, until Taylor Swift came along. Remember how I said that almost everyone has their hands in the Healthcare Pie? It was not much different with Weinstein. Scott Rosenberg explained why it took so long for people to speak out against Harvey , and the reasons were numerous. First, Harvey gave many people their start in Hollywood, and treated all of his friends like royalty. That drastically increased their loyalty. Second, he ushered the Golden Age of the 1990s, with movies like Pulp Fiction, Shakespeare in Love, Clerks, Swingers, Scream, Good Will Hunting, English Patient, Life is Beautiful – the man could make phenomenal movies. Third, even if one was willing to go against his own friends, workers, mass media, and so on, there was no one to tell. There was no place to speak out. Fourth, some of the victims took hefty settlements.

That fourth reason enabled mass media to portray rape victims as gold diggers. Rape Culture is alive and well. In California, a Judge gave minimal sentencing to a convicted rapist , because he was afraid a harsher sentence would damage the rapist's mental psyche for life. Uh dude, from one Californian to another, he, uh, raped. His mental psyche is already damaged; for life. That's the kind of pressure that Rose McGowan had to deal with. She had a little kerfuffle with Amazon , and she thinks it was partially because of Harvey Weinstein. How many times had the word "socialism" been thrown around to describe Universal Healthcare? Switzerland has it – are they Socialist?

Enter Taylor Swift . In order to destroy allegations that women are filing sexual harassment claims as gold diggers, she sued her alleged sexual assaulter for a buck; one dollar. She won. Swift stated that the lawsuit was to serve as an example to other women who may resist publicly reliving similar outrageous and humiliating acts. On top of that, Weinstein was no longer as popular as he used to be, and an avenue to tell the story, an outlet was created. The additional prevalence of the internet caused the stories of Weinstein's sexual abuse to leak. Within a month, the giant fell.

Something similar is needed to change Healthcare in America. But until that comes along, racism will increase, the cost of Healthcare will rise, emergency room costs will most likely double every ten years, and the future remains bleak. As if that was not enough, more and more upper class Americans, (like yours truly,) are seeking treatment abroad. It cost me less money to lose five weeks of wages, spend three weeks partying in Eastern Europe, (Prague to be more specific,) after my two weeks of treatment, buy a roundtrip plane ticket, and stay in a five star, all-inclusive hotel, than the cost of the same treatment in the US. If anyone wants to utilize this as a startup – let me know!

Of course its effects on Healthcare will hurt, since it is a huge chunk of business that will be traveling across the Atlantic. But what can be done to stop it? One cannot stop Americans from traveling to other countries. One cannot force the poor to work for free. Perhaps this is the change that is needed to make those who benefit from the Healthcare Waste realize that this cannot continue. Perhaps not. What we do know, is that Obamacare insured the poor, at the expense of the middle class . And that is regarded as a failure in America.

Northern Star , November 27, 2017 at 3:12 pm
As for Obongo Care ??:

"In trying to show that he was successfully managing the Obamacare rollout, the president last week staged a high-profile White House meeting with private health insurance executives -- aka Obamacare's middlemen. The spectacle of a president begging these middlemen for help was a reminder that Obamacare did not limit the power of the insurance companies as a single-payer system would.
****The new law instead cemented the industry's profit-extracting role in the larger health system -- and it still leaves millions without insurance."*** (THAT is the Achille's lower torso of the ACA)

https://www.healthcare-now.org/blog/single-payer-healthcare-vs-obamacare/

https://www.dailykos.com/stories/2016/2/11/1483523/-Single-Payer-Healthcare-vs-The-Affordable-Care-Act-A-Simple-Comparison

ucgsblog , November 28, 2017 at 3:58 pm
Exactly! That's why I stated that they're now oligapolizing the market, and will slowly start to increase their insurance rates and profits once again.
Northern Star , November 27, 2017 at 3:23 pm
"Prince Harry..Do you take this American mulatto negress -aka raghead untermensch-as your lawfully wedded royal wife?*
http://www.newsweek.com/prince-harrys-worst-moments-meghan-markle-rogue-723177
https://www.sbs.com.au/guide/sites/sbs.com.au.guide/files/styles/body_image/public/nazi.jpg?itok=q1oxMi44&mtime=1503879842

Ummm Advice to Meghan .make sure the honeymoon motorcade stays clear of tunnels in Paris
or elsewhere!!!

Northern Star , November 27, 2017 at 3:52 pm
Appurtenant to many of the issues raised in Mark's post:

http://www.wsws.org/en/articles/2017/11/27/pers-n27.html

(Socialist or not..the WSWS writers continue to state that which NEEDS to be hammered home)

"The vast wealth of the financial oligarchy, expressed in their ownership of massive corporations, must be seized and expropriated, while the complex technologies, supply chains, and advanced transportation systems must be integrated in an organized, planned manner to harness the anarchic force of the world economy and eliminate material scarcity.

Amazon is a prime example. Its supply lines and delivery systems could distribute goods across the world, bringing water, food, and medicine from each producer according to his or her ability, to each consumer according to his or her need.

The massively sophisticated computational power used by the technology companies to censor and blacklist political opposition could instead be used for logistical analysis to conduct rescue and rebuilding missions in disaster zones like Houston and Puerto Rico. Drones used in the battlefield could be scrapped and rebuilt to distribute supplies for building schools, museums, libraries, and theaters, and for making Internet service available at no cost for the entire world.

The ruling class and all of the institutions of the political establishment stand inexorably in the way of efforts to expropriate their wealth. What is required is to mobilize the working class in a political struggle against the state and the socio-economic system on which it is based, through the fight for socialism.
Eric London "

Particularly for American Stooges:

Patient Observer , November 27, 2017 at 5:17 pm
Advanced technology is helpful but not essential for a humane and just society. Its what we believe and feel that matters. FWIW, I like socialism on a national/international level and individual accountability on a personal level.
saskydisc , November 27, 2017 at 4:04 pm
While general medical care is single payer in Canada, dental services are not. For major work on teeth, it is cheaper to fly to Mexico. The downside is for Mexicans -- such practices will drive the costs up in Mexico.
Patient Observer , November 27, 2017 at 5:12 pm
Mark, today's posting provided is a nice change of pace to a topic of local impact (for me at least). UGC presented a good overview peppered with supporting data.

In an earlier career incarnation, I worked as a systems analyst involved with development of online systems for state social services. Data showed that our systems were able to administer a comprehensive health care program for social services recipients for about 3-4% of the cost of services. Private medical insurance providers required approximately 20% of the cost of services to provide similar services. Yet, private providers were supposedly driven by invisible market forces to maximum efficiency. BS. In fact, they are driven by greed and they found it much easier to maximize profits by colluding with politicians and health care providers. That is the trouble with free markets – its just so damn easy to cheat and cheaters are never in short supply.

One more thing, prescription drugs costs may exceed $600 billion in the US by 2021:

https://www.reuters.com/article/us-usa-drugspending-quintilesims/u-s-prescription-drug-spending-as-high-as-610-billion-by-2021-report-idUSKBN1800BU

That would be nearly $2,000 per year for every American!

If a tiny fraction of that amount were spent on prevention, education, improved diets and other similar initiatives, the population ought to be healthier and richer. But, greed overpowers the public good every time. The US health care system is a criminal enterprise in my opinion. The good that it does is grossly outweighed by greed and exploitation of human suffering.

marknesop , November 28, 2017 at 12:10 am
I believe the author is also a systems analyst, so you are thinking along similar lines.
ucgsblog , November 28, 2017 at 4:05 pm
I agree with that. Plus, it seems like they have an entire staff dedicated to giving their "customer" the run around. A friend of mine had to deal with several different departments regarding his healthcare bill. The billing office told him that they only deal with billing questions, and that for explanations for the bill, he should call the doctor's office. The doctor's office told him to call the hospital, since that's where the service took place. The hospital told him to call his primary doctor, who sent him there, and his primary doctor referred him back to the specialist, where he was referred back to the billing department, which promptly told him that they're closing for the day, since he spent 6 hours being transferred from one department to the next.
anon@gmail.com , November 27, 2017 at 6:02 pm
I find it terribly silly that we should even consider med student's debt as an excuse. First, American doctors are the best paid professionals in the country. Internists make a median 190 thousand a year, and they are among the worst paid specialties. I cannot possibly see the problem with paying your income for 5 years, knowing that you get access to a caste that will allow you make good money into your eighties.

Second, the debt is not that high as you claim. Harvard Medical School tuition is 64 thousand. You can rent across the street with 20 thousand a year – I currently live there.

Third, med students know all this. The reason why they borrow far more is because they know they can afford it. I went to med school somewhere in a developing world. We shared toilets in the dorm. As a matter of fact, most under-30s in Boston live in shared accommodation. The outliers? Med students. Even the lowly Tufts and BU students that I met own cars and live by themselves, mainly in new buildings across the street from their hospitals.

Every time I go to the doctors, I am thinking how I am going to sue their asses if they make a mistake.

ucgsblog , November 28, 2017 at 4:08 pm
It's not an excuse. It's a bill. When you rent an apartment, did you know that most landlords also factor in the property tax when figuring out what your rent payment should be? Similarly, the interest payments on the doctoral students' loans are passed off to the consumer, and that is yet another reason why Healthcare is so expensive. That's why I think that medical school should be free for those students who promise to charge their patients no more than x amount of money.
kirill , November 27, 2017 at 8:38 pm
Interesting article. Looks like the rot in the US is terminal. But Canada and its "socialized" medicine is not far behind. Operating an emergency ward with only one doctor doing the rounds at the rest of the hospital during the night is absurd. But that is what major Canadian hospitals do. Don't bother going to emergency at 2 am unless you are literally dying. Wait until 7 am when the day day crew arrives and you can actually receive treatment.

The problem in Canada, as in the USA, is overpaid doctors and not enough of them (because they are overpaid). Instead of paying a doctor $300,000 per year or more, the system needs to have 3 or more doctors earning $100,000 per year. Then there is no excuse about being overworked and "requiring" a high compensation. Big incomes attract crooks and not talent. If you want to be a doctor then you should do 5 years of low income work abroad or at home. That would weed out a lot of the $$$ in the eyeballs leeches. A nasty side effect of having overpaid doctors and living adjacent to the US, is that they act like a mafia and extort the government by threatening to leave to the USA. I say that the Canadian provinces should make all medical students sign binding contracts to pay the cost difference between their Canadian medical education and the equivalent in the USA if they decide to run off to America.

At the undergraduate level, the physics courses with the highest enrollment are aimed at streams going into medicine. There are hordes of money maker wannabes trying to make it big in medicine. But they are all nearly weeded out and never graduate from medical school. So the system maintains the fake doctor shortage and racket level salaries. On top of this, hospitals pay a 300% markup for basic supplies (gauze, syringes, etc). It is actually possible for private individuals to pay the nominal price so this is not just a theory. Clearly, there is no effort to control costs by hospital administrations since basic economics would imply that hospitals would pay less than individuals for these items due to the volume of sales involved. At the end of the day North American public medicine is a non-market bloating itself into oblivion since the taxpayer will always pay whatever is desired. That is, the spineless politicians will never crack the whip.

Ryan Ward , November 28, 2017 at 3:19 am
This is part of the problem in Canada. One way to help deal with it in my view, beyond simply cutting doctors' fees (which any government with the political will to do so can do) is to simply make it easier for International Medical Graduates to get licensed in Canada. Canada has legions of immigrants (and could have pretty much however many more it likes) with full medical qualifications who would be thrilled to work for much less than the current pay rates. It's a scandal how many qualified doctors we have in Canada driving taxis rather than practicing medicine. If we just took advantage of the human resources we already have, we could easily say to doctors who threaten to leave for the US, "Fine, go. We've got 10 guys from India lined up to do your job." This isn't to say that doctors shouldn't be very well-paid. Anyone who has ever known someone in med school knows it's hell. But doctors would be very well-paid at half the rates they're getting now.

Another part of the problem is an over-reliance on hospitals. There are a lot of people in the hospitals more in "holding" than anything else, because there's no space in the proper facilities for them (The book "Chronic Condition" talks about this). The problem with this is that the cost per day to keep someone in the hospital is much higher than in other kinds of facilities. This is an entirely unnecessary loss.

For all that though, the Canadian system is leaps and bounds better than the American. We spend a vastly smaller percentage of our GDP on health care, and in return achieve higher health outcomes, as measured by the WHO. If we were willing to spend the kind of money the Americans do on health care, we could have patients sleeping in golden beds even with the structural flaws of our current system. That's worth constantly remembering, because some of the proposals for health reform floating around now lean in the direction of privatization, and we've seen where that road leads.

marknesop , November 28, 2017 at 10:32 am
Before he retired from politics, Keith Martin was my MLA, and he was also a qualified MD. He used to rail against the convoluted process for certification in medicine in Canada, while others complained that we were subject to an influx of doctor-immigrants from India because Canada required less time spent in medical school than India does. I never checked the veracity of that, although we do have quite a few Indian doctors. My own doctor – in the military, and still now since he is in private practice – is a South African, and he explained that he had gone in for the military (although he was always a civilian, some military doctors are military members as well but most are not) because the hoop-jumping process to be certified for private practice in Canada with foreign qualifications was just too onerous.

Unsurprisingly, I completely agree on the subject of privatization, because it always leads to an emphasis on profit and cost-cutting. I don't know why some people can't see that.

Jen , November 27, 2017 at 11:15 pm
Thanks very much UCG, for your article. Very interesting reading for us Australians as the Federal Government eventually wants to shove us kicking and screaming into a US-style privatised healthcare insurance model.

Funnily enough I'm currently considering changing my private health insurer. I'm with Medibank Private at present but considering maybe going with a smaller non-profit health fund like Australian Unity or Phoenix Health Fund.

Fern , November 28, 2017 at 7:02 am
I was just about to post along the lines of "I don't know if Jen has experienced this in Australia but here in the UK ." so I'll finish the thought. In the UK, successive governments, not just Conservative ones, have been trying to dismantle the NHS and move us to the American system. It is pure ideology – no amount of the very abundant evidence of the inefficiencies of the US system, its waste etc makes any dint in the enthusiasm of those pressing for change.
ucgsblog , November 28, 2017 at 4:17 pm
Thank you Jen! My advice: don't let the Government cajole you into wasting your money on Corporate Greed. Share the article with your fellow Australians, if you must, but don't let our wasteful system be replicated. Interestingly enough, one of my friends, Lytburger, send me a meme right after Ukraine adopted America's Healthcare System, it said: "ISIS refused to take responsibility for Ukraine's Healthcare Reform!" I'd be happy to provide other data or answer questions about the Healthcare System here.

As for insurance, I'm not sure if Australia has the in-network and out-of-network rules. Does it? Whatever insurance you get, make sure that it has good coverage. If you own a home in the US, and you end up in a hospital's emergency room that's not covered by your insurance, the hospital can take your house under certain circumstances. Ironically, even the Government cannot. All of my real property is in various Trust Accounts, just in case, and I make sure that I have insurance where all major hospitals are in-network and that's the best I can do.

James lake , November 28, 2017 at 12:21 am
This is s very interesting insight into healcare in the USA. The cost is shocking. I live in the UK and the healthcare system is paid for from taxation. When it was established over 70 years ago it's. The health service would be available to all and financed entirely from taxation, which meant that people paid into it according to their means. It was the best thing in my view that government has ever done. Good healthcare should be available to all and not dependent on peoples ability to pay.

However there always a private healthcare system that ran alongside it

And over the years it had been unpicked as successive governments have tried to privatise it. Claiming they will save the taxpayer money

– opticians and dentistry have become part private after 18 if you are employed.

Which many people do not mind.

-Elderly care was also privatised as it's the most expensive

-care for the disabled also is a issue for local councils

-Mental health became care in the community – society's problem!

Privatisation has meant profits for businesses, poor services to vulnerable groups.

And yet still more and more taxation is needed for the NHS!

The issue of more money was even part of the Brexit debate as it was stated that leaving the EU would mean more money for the NHS which people are proud of.

marknesop , November 28, 2017 at 10:25 am
There was a quote I was thinking of using in the lead-in, but decided in the end not to since I didn't want to have too many and it might have become confusing. It related that you would get the best medical care of your lifetime – after you died, when they were rushing to save your organs, for transplant. Obviously this would not be true if you were not an organ donor (at least in this country) or died as the result of general wasting away so that you had nothing left which would be particularly coveted. But this is a major issue in medicine in some countries and there have been various lurid tales of bodies being robbed of their organs without family permission, bodies of Ukrainian soldiers harvested of their organs and rackets in third-world countries where the poor or helpless are robbed of organs while they are alive. From my standpoint, since I haven't done much research on it, I have seen little proof of any of them despite plenty of allegation, but it is easy to understand that traffic in organs to those who will pay anything to live a little longer would be tremendously profitable, and the potential for disproportionate profit seldom fails to draw the unscrupulous.

As I alluded in the lead-in, Canada has what is sometimes described as 'socialized medicine' and alternatively as 'two-tier healthcare' although I have never seen any real substantiation for the latter charge. My mom had an operation for colon cancer some time back, and she paid nothing for the hospitalization or the operation. My father-in-law is scheduled for the same operation as soon as he gets his blood-sugar low enough, and he already had one for a hernia and removal of internal scar tissue from an old injury – again, we paid nothing. He had a nurse come here for a couple of months, once a week, to change his dressing (because the incision would was very slow to heal because he is diabetic – nothing. That's all great, from my point of view, and I've paid into it all my life without ever using it because I was covered by the government under federal guidelines while I served in the military, although I was a cheap patient because I never had to be hospitalized for anything and was almost never even sick enough not to come to work. But the great drawback to it, as I said, is the backlog which might mean you have to wait too long for an operation. And in my small practical experience – the two cases I have just mentioned – both were scheduled for surgery within a month of diagnosis. So perhaps the long wait is for particular operations such as heart or brain surgery.

Patient Observer , November 28, 2017 at 12:49 pm
The Albanian Kosovo Liberation Army harvested organs from captured Serb civilians and soldiers:

https://thebloodyellowhouse.wordpress.com/

In December 14th 2010, Dick Marty, Rapporteur of EU Commission pass for adoption to the Council of Europe a report on allegations of inhuman treatment of people and illicit trafficking in human organs in Kosovo organized by KLA leader and Kosovo Prime minister Hashim Thaçi . An official report accusing Kosovo's prime minister of links to a "mafia-like" network that killed captives in order to sell their organs on the black market was yesterday endorsed by a Council of Europe committee.

Bold text emphasis added.

Nothing came of the charges that I am aware of and it is business as usual with Kosovo and Albania.

Per Wikipedia:

The Washington Times reported that the KLA was financing its activities by trafficking the illegal drugs of heroin and cocaine into western Europe.[16]

A report to the Council of Europe, written by Dick Marty, issued on 15 December 2010[23] states that Hacim Thaçi was the leader of the "Drenica Group" in charge of trafficking organs taken from Serbian prisoners.

On 17 February 2008, Kosovo declared its independence from Serbia. Thaçi became Prime Minister of the newly independent state.

So, there you have it – the war criminal, drug runner, murderer and organ thief/butcher became the PM of Kosovo, a nation created and nurtured by NATO with a nod and a wink from the EU. Simply disgusting but typical treatment for Serbia by the fascist/racist and genocidally inclined West.

et Al , November 28, 2017 at 1:32 am
Thank you very much for a very interesting article UCG! Quite the horror story. I've heard quite a few about the US over the years from people I know too. I think one of the BBC's former America correspondent gave an interview to the Beeb as he was leaving America a few years back (MAtt Frei?) and was asked what were the best and worst things about living there. The worst was certainly healthcare.

I've also read that healthcare costs for the self-employed, independents, freelancers can also be crushing in the land of the free where everyone can become rich. Has this changed? I would have thought that those were the ideal Americans, making it off their own back, but apparently not.

There's also another issue that is not addressed: an ageing population. This is a very current theme and it is now not at all unusual for people to live another 30 odd years after retirement. Now how on earth will such people manage their healthcare for such a period? Will they have to hock absolutely everything they have? America is already at war with itself (hence the utmost need to for foreign enemies), but nothing is getting done. Just more of the same. Meanwhile the Brits are trying to copy the US through stealth privatization of their health system. It might work as well as privatizing its rail service

yalensis , November 28, 2017 at 3:21 am
Thanks for an interesting post, UCG. Hopefully this will stimulate some ideas on how to fix the American healthcare system, which seems to be badly broken.
Patient Observer , November 28, 2017 at 4:34 am
Broken for us but working perfectly for Big Pharma and insurance companies. That is a fundamental reason why it will be extremely difficult to "fix" because it ain't broken as a money making machine.
yalensis , November 28, 2017 at 1:25 pm
True. And the insurance companies, in particular, have been really raking it in, especially with Obamacare and the various Medicare Advantage options.
Ryan Ward , November 28, 2017 at 3:40 am
With health care in general, there's a bit of a trade-off. The most cost-efficient systems, like the system in Sweden for example, are fairly regimented and don't leave much room for individual choice (unless someone pays out of pocket for treatment completely outside the public system). On the other hand, systems that give people a little more choice, like the system in Germany, tend to be a little on the pricey side. I think, given American political culture, something along the lines of the German model is much more likely to attract widespread public support. In any case, it's still cheaper than the American system, and achieves some of the best results in the world. https://en.wikipedia.org/wiki/Healthcare_in_Germany

[Nov 15, 2017] Alex Azar Can There Be Uglier Scenarios than the Revolving Door naked capitalism

Notable quotes:
"... By Lambert Strether ..."
"... So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy. ..."
"... In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real ..."
Nov 15, 2017 | www.nakedcapitalism.com

Alex Azar: Can There Be Uglier Scenarios than the Revolving Door? Posted on November 15, 2017 by Lambert Strether By Lambert Strether

Clearly, Alex Azar, nominated yesterday for the position of Secretary of Health and Human Services by the Trump Administration, exemplifies the case of the "revolving door," through which Flexians slither on their way to (or from) positions of public trust. Roy Poses ( cross-posted at NC ) wrote, when Azar was only Acting Secretary:

Last week we noted that Mr Trump famously promised to “drain the swamp” in Washington. Last week, despite his previous pledges to not appoint lobbyists to powerful positions, he appointed a lobbyist to be acting DHHS Secretary. This week he is apparently strongly considering Mr Alex Azar, a pharmaceutical executive to be permanent DHHS Secretary, even though the FDA, part of DHHS, has direct regulatory authority over the pharmaceutical industry, and many other DHHS policies strongly affect the pharmaceutical industry. (By the way, Mr Azar was also in charge of one lobbying effort.)

So should Mr Azar be confirmed as Secretary of DHHS, the fox guarding the hen house appears to be a reasonable analogy.

Moreover, several serious legal cases involving bad behavior by his company, and multiple other instances of apparently unethical behavior occurred on Mr Azar’s watch at Eli Lilly. So the fox might be not the most reputable member of the species.

So you know the drill…. The revolving door is a species of conflict of interest . Worse, some experts have suggested that the revolving door is in fact corruption. As we noted here , the experts from the distinguished European anti-corruption group U4 wrote ,

The literature makes clear that the revolving door process is a source of valuable political connections for private firms. But it generates corruption risks and has strong distortionary effects on the economy , especially when this power is concentrated within a few firms.

The ongoing parade of people transiting the revolving door from industry to the Trump administration once again suggests how the revolving door may enable certain of those with private vested interests to have excess influence, way beyond that of ordinary citizens, on how the government works, and that the country is still increasingly being run by a cozy group of insiders with ties to both government and industry. This has been termed crony capitalism.

Poses is, of course, correct. (Personally, I've contained my aghastitude on Azar, because I remember quite well how Liz Fowler transitioned from Wellpoint to being Max Baucus's chief of staff when ObamaCare was being drafted to a job in Big Pharma , and I remember quite well the deal with Big Pharma Obama cut, which eliminated the public option , not that the public option was anything other than a decreasingly gaudy "progressive" bauble in the first place.)

In this post, I'd like to add two additional factors to our consideration of Azar. The first: Democrat credentialism makes it hard for them to oppose Azar. The second: The real damage Azar could do is on the regulatory side.[1]

First, Democrat credentialism. Here is one effusive encomium on Azar. From USA Today, "Who is Alex Azar? Former drugmaker CEO and HHS official nominated to head agency" :

"I am glad to hear that you have worked hard, and brought fair-minded legal analysis to the department," Democratic Sen. Max Baucus said at Azar's last confirmation hearing.

And:

Andy Slavitt, who ran the Affordable Care Act and the Centers for Medicare & Medicaid Services during the Obama administration, said he has reason to hope Azar would be a good secretary.

"He is familiar with the high quality of the HHS staff, has real-world experience enough to be pragmatic, and will hopefully avoid repeating the mistakes of his predecessor," Slavitt said.

So, if Democrats are saying Azar is "fair-minded" and "pragmatic" -- and heaven forfend that the word "corruption"[2] even be mentioned -- how do they oppose him, even he's viscerally opposed to everything Democrats supposedly stand for? (Democrats do this with judicial nominations, too.) Azar may be a fox, alright, but the chickens he's supposedly guarding are all clucking about how impeccable his qualifications are!

Second, let's briefly look at Azar's bio. Let me excerpt salient detail from USA Today :

1. Azar clerked for Supreme Court Justice Antonin Scalia .

2. Azar went to work for his mentor, Ken Starr , who was heading the independent counsel investigation into Bill and Hillary Clinton's Whitewater land deal.

3. Azar had a significant role in another major political controversy when the outcome of the 2000 presidential election hinged on a recount in Florida . Azar was on the Bush team of lawyers whose side ultimately prevailed [3]

For any Democrat with a memory, that bio provokes one of those "You shall know them by the trail of the dead" moments. And then there's this:

When Leavitt replaced Thompson in 2005 and Azar became his deputy, Leavitt delegated a lot of the rule-making process to Azar.

So, a liberal Democrat might classify Azar as a smooth-talking reactionary thug with a terrible record and the most vile mentors imaginable, and on top of it all, he's an effective bureaucratic fixer. What could the Trump Administration possibly see in such a person? Former (Republican) HHS Secretary Mike Leavitt explains:

"Understanding the administrative rule process in the circumstance we're in today could be extraordinarily important because a lot of the change in the health care system, given the fact that they've not succeeded legislatively, could come administratively."

We outlined the administration strategy on health care in "Trump Adminstration Doubles Down on Efforts to Crapify the Entire Health Care System (Unless You're Rich, of Course)" . There are three prongs:

1) Administratively, send ObamaCare into a death spiral by sabotaging it

2) Legislatively, gut Medicaid as part of the "tax refom" package in Congress

3) Through executive order, eliminate "essential health benefits" through "association health plans"

As a sidebar, it's interesting to see that although this do-list is strategically and ideologically coherent -- basically, your ability to access health care will be directly dependent on your ability to pay -- it's institutionally incoherent, a bizarre contraption screwed together out of legislation, regulations, and an Executive order. Of course, this incoherence mirrors to Rube Goldberg structure of ObamaCare itself, itself a bizarre contraption, especially when compared to the simple, rugged, and proven single payer system. ( Everything Obama did with regulations and executive orders, Trump can undo, with new regulations and new executive orders . We might compare ObamaCare to a child born with no immune system, that could only have survived within the liberal bubble within which it was created; in the real world, it's not surprising that it's succumbing to opportunistic infections.[2])

On #1, The administration has, despite its best efforts, not achieved a controlled flight into terrain with ObamaCare; enrollment is up. On #2, the administration and its Congressional allies are still dickering with tax reform. And on #3 . That looks looks like a job for Alex Azar, since both essential health benefits and association health plans are significantly affected by regulation.

So, yes, there are worse scenarios than the revolving door; it's what you leave behind you as the door revolves that matters. It would be lovely if there were a good old-fashioned confirmation battle over Azar, but, as I've pointed out, the Democrats have tied their own hands. Ideally, the Democrats would junk the Rube Goldberg device that is ObamaCare, rendering all of Azar's regulatory expertise null and void, but that doesn't seem likely, given that they seem to be doing everything possible to avoid serious discussion of policy in 2018 and 2020.

NOTES

[1] I'm leaving aside what will no doubt be the 2018 or even 2020 issue of drug prices, since for me that's subsumed under the issue of single payer. If we look only at Azar's history in business, real price decreases seem unlikely. Business Insider :

Over the 10-year period when Azar was at Lilly, the price of insulin notched a three-fold increase. It wasn't just Lilly's insulin product, called Humalog. The price of a rival made by Novo Nordisk has also climbed, with the two rising in such lockstep that you can barely see both trend lines below.

The gains came despite the fact that the insulin, which as a medication has an almost-century-long history, hasn't really changed since it was first approved.

Nice business to be in, eh? Here's that chart:

It's almost like Lilly (Azar's firm) and Novo Nordisk are working together, isn't it?

[2] Anyhow, as of the 2016 Clinton campaign , the Democrat standard -- not that of Poses, nor mine -- is that if there's no quid pro quo, there's no corruption.

[3] And, curiously, "[HHS head Tommy] Thompson said HHS was in the eye of the storm after the 2001 terrorist attacks, and Azar had an important role in responding to the resulting public health challenges, as well as the subsequent anthrax attacks "

MedicalQuack , November 15, 2017 at 10:31 am

Oh please, stop quoting Andy Slavitt, the United Healthcare Ingenix algo man. That guy is the biggest crook that made his money early on with RX discounts with his company that he and Senator Warren's daughter, Amelia sold to United Healthcare. He's out there trying to do his own reputation restore routine. Go back to 2009 and read about the short paying of MDs by Ingenix, which is now Optum Insights, he was the CEO and remember it was just around 3 years ago or so he sat there quarterly with United CEO Hemsley at those quarterly meetings. Look him up, wants 40k to speak and he puts the perception out there he does this for free, not so.

diptherio , November 15, 2017 at 11:25 am

I think you're missing the context. Lambert is quoting him by way of showing that the sleazy establishment types are just fine with him. Thanks for the extra background on that particular swamp-dweller, though.

a different chris , November 15, 2017 at 2:01 pm

Not just the context, it's a quote in a quote. Does make me think Slavitt must be a real piece of work to send MQ so far off his rails

petal , November 15, 2017 at 12:52 pm

Alex Azar is a Dartmouth grad (Gov't & Economics '88) just like Jeff Immelt (Applied Math & Economics '78). So much damage to society from such a small department!

sgt_doom , November 15, 2017 at 1:21 pm

Nice one, petal !!!

Really, all I need to know about the Trumpster Administration:

From Rothschild to . . . .

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

Since 2014, Ross has been the vice-chairman of the board of Bank of Cyprus PCL, the largest bank in Cyprus.

He served under U.S. President Bill Clinton on the board of the U.S.-Russia Investment Fund. Later, under New York City Mayor Rudy Giuliani, Ross served as the Mayor's privatization advisor.

Jen , November 15, 2017 at 7:56 pm

Or from a "small liberal arts college" (which is a university in all but name, because alumni).

Tim Geitner ('82 – Goverment)
Hank Paulson ('68 – English)

jo6pac , November 15, 2017 at 2:13 pm

Well it's never ending game in the beltway and we serfs aren't in it.

https://consortiumnews.com/2017/11/15/trump-adds-to-washingtons-swamp/

Alfred , November 15, 2017 at 2:53 pm

I don't believe that the President's "swamp" ever consisted of crooked officials, lobbyists, and cronies I think it has always consisted of those regulators who tried sincerely to defend public interests.

It was in the sticky work of those good bureaucrats that the projects of capitalists and speculators bogged down. It is against their efforts that the pickup-driving cohort of Trumpism (with their Gadsden flag decals) relentlessly rails.

Trump has made much progress in draining the regulatory swamp (if indeed that is the right way to identify it), and no doubt will make considerably more as time wears on, leaving America high and dry. The kind of prevaricator Trump is may simply be the one who fails to define his terms.

Henry Moon Pie , November 15, 2017 at 4:13 pm

I think we've moved past the revolving door. We hear members of the United States Senate publicly voice their concerns about what will happen if they fail to do their employers' bidding (and I'm not talking about "the public" here). In the bureaucracy, political appointees keep accruing more and more power even as they make it clearer and clearer that they work for "the donors" and not the people. Nowhere is this more true than the locus through which passes most of the money: the Pentagon. The fact that these beribboned heroes are, in fact, setting war policy on their own makes the knowledge that they serve Raytheon and Exxon rather than Americans very, very troubling.

I suspect Azar's perception is that he is just moving from one post to another within the same company.

Watt4Bob , November 15, 2017 at 5:28 pm

Perfect cartoon over at Truthout

I'm amazed there is enough private security available on this planet to keep these guys safe.

Larry , November 15, 2017 at 8:01 pm

Big pharma indeed has so much defense from the supposed left. It combines their faith in technological progress, elite institutions, and tugs on the heart strings with technology that can save people from a fate of ill health or premature death. Of course, the aspect of the laws being written to line the pockets of corrupt executives is glossed over. While drug prices and medical costs spiral ever higher, our overall longevity and national health in the US declines. That speaks volumes about what Democrats really care about.

[Oct 27, 2017] Prime case of crapification in medicine is that many doctors bowled over by the drug companies

Notable quotes:
"... One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session). ..."
"... I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight. ..."
"... Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy ..."
"... Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes." ..."
"... Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. ..."
"... ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines: ..."
"... Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea. ..."
"... Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system. ..."
"... EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies" ..."
"... I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child ..."
"... And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on. ..."
"... And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's ..."
"... I think, what this article alludes to is that medicine is complex and not easily algorithmic ..."
"... The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency. ..."
"... My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience. ..."
"... Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized. ..."
"... My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care ..."
Oct 27, 2017 | www.nakedcapitalism.com

el_tel , October 27, 2017 at 7:24 am

Interesting article and a couple of clarifications:

Psychologists have studied the accuracy of risk assessments made by statistical predictors and by clinicians, but they have not done similar studies of the accuracy of evaluations of patient preferences over health outcomes.

True but health economists have done so . And they got so scared by the results that some (Dolan) left the field to do something else. This particular example is that whilst the general population reckons "extreme pain" to be worse than "extreme depression/anxiety", those members of the population who'd experienced them both put them the other way round. Which has profound implications for the UK values assigned to health outcomes. Of course other countries might do things in different ways and this is NOT some veiled attack on what the US might do if single payer gets onto the playing field. It's merely adding to the warning in the paper about how to do it. Which leads to a second warning I'd make – averages. They conceal a lot.

Mental health is the archetypal example and, again, maybe the paper is right that something like maximin is warranted, given that "living by averages" means some groups automatically lose out. Just some thoughts, which hopefully are constructive this time round and expand on points made.

PlutoniumKun , October 27, 2017 at 8:19 am

One thing this article doesn't distinguish between are hospital doctors and solo practitioners (i.e. family doctors, or occasionally doctors in small hospitals). There is a huge issue with doctors simply not keeping up with current research if they don't have the peer pressure and oversight that you would expect in a well run hospital. I was a victim of this as for years as a child I was repeatedly given antibiotics by my family doctor for 'chest infections'. In fact, I had asthma triggered by a cold air sensitivity, and was only diagnosed in my late teens (after I'd been carted to hospital after a school outdoors sport session).

I talked much later to a family member who is a specialist in prescribing practice who said that this was by far the most common misdiagnosis/treatment and as late as the 1990's in the UK (where he did research on the subject), he found that 25% of GP's (family doctors) were not identifying asthma correctly. Very often, pharmacists are the only gatekeepers to identify bad prescribing practices.

I've also heard numerous stories about terrible practices by specialists in small hospitals, who can become mini-emperors with nobody to contradict their professional opinions. This is one reason why all doctors will generally advise that the best place when you are ill is a large teaching hospital (definitely not a small private hospital). Bad diagnostic practice is much more likely to be stamped out in the biggest hospitals where there is greater peer oversight.

JTMcPhee , October 27, 2017 at 10:04 am

I'd ask what the author assumes is the best model for doctor-patient interaction, what "patient care" means. To me it should be two or maybe more (including nurses and family members and other caregivers) people, ones with more knowledge of physiology and systems, others with more knowledge and experience of whatever the "presenting condition" happens to be, interacting to increase longevity, reduce pain, repair damaged structures, correct physiological malfunctions and problems with homeostatic functions and so forth, to maximize function, independence and comfort -- an incomplete definition of a very complex notion.

Physicians aren't bots. There are different reasons people go into medicine, not all of them about "patient care" and altruism -- "unselfish regard for or devotion to the welfare of others behavior by not beneficial to or may be harmful to itself but that benefits others of its species." Sometimes quite the opposite, thanks to greed and pleasure-seeking and the burdens of "debt" assumed by so many "providers," or even rare psych phenomena like von Muchausen's by proxy

Always, the smart kids in the room want to systematize and organize every kind of function, and in the neoliberal universe, reduce complexity to profit-generating, "management"-centric forms. Sometimes that application of rationalization is a good thing, it can help focus attention wisely and lead to those often undefined "good outcomes."

But there's almost an infinite number of ways humans can get injured, sickened and die. Human physiology is vastly complex. The interaction pathways are likewise near infinite. Medicine is an art of observation compounded over time, and a lot of the knowledge base (I personally hate that term) is just wrong, from a wide variety of causes including bias, sample size, things like referred pain, atypical "presentations," "normal variation" and so forth. When what to me is a semi-mystical interaction between practitioner and person works well, it is a thing of beauty and kindness. As with anything human-created and -mediated, too often the result is far worse -- most of us can insert one or more anecdotes here, on either extreme.

Constant mechanization of medicine results in stuff like the ICD-10 classification thing, which is mostly about Big Data and payments. "Billable" medicine has been "reduced" to about 70,000 "diagnosis codes" and a whole lot of treatment and procedure codes, up from about 13,000 diagnosis codes in ICD-9. It's a "whole new way of doing business:"

ICD-9 is widely considered to be based on outdated technology, with codes unable to reflect the use of new equipment. ICD-10 offers far more integration with modern technology, with an emphasis on devices that are actually being used for various procedures. The additional spaces available are partly designed to allow for new technology to be seamlessly integrated into codes, which means fewer concerns about the ability to accurately report information as time goes on. In Conclusion, ICD-10 is not a simple update to ICD-9. The structural changes throughout the entire coding system are very significant, and the increased level of complexity requires coders to be even more thoroughly trained than before. However, it is possible to prepare for the changes by remembering a few simple guidelines:

Train early- The more familiar your staff are with ICD-10, the better. While currently scheduled to begin Oct. 1, 2014, beginning the training now is not a bad idea.

Understand the ICD-10- The structural changes require a change in the way people think about coding, and understanding it will help to break current coding habits. Medical professionals used to reporting things a certain way so they can be coded may need to change what they say in order to work well with the new system.

EBM is just another management buzz(kill)word, like "total quality management" and "zero defects" and "zero-based budgeting." All supported by proponents who rationalize and argue in the language of squishy "disciplines" like psychology and economics, using "specialized" lexicons that often are cloudy restatements of commonplaces in arcane terminologies, and the creation of intellectual artifacts that have tenuous or little relationship to the reality most "uneducated" observers perceive -- yes, sometimes incorrectly as more acute observations might show, but more often accurately than the modeling and force-fitting that "experts" soar off on. How many of the articles cited as authoritative on various points have anything other than presence in peer-reviewed land as proof of the claimed "findings" both of the original researchers and authors, or acuteness and accuracy of the proposition for which they are offered subsequently? And how much fraud and selectiveness (like medication trials that exclude likely non-responders to the therapies) and purblindness fills the vast swath of "published studies"

I've personally experienced and seen lots of misdiagnoses and clinician blindness and tunnel vision, starting as a child when the family doctor, a partisan of allergies as the most common source of disease, and who patch-tested me and my sisters unmercifully, supposedly told my mom that my broken right forearm was the result of an allergy. And our favored subsequent family doctor, who mis-diagnosed my mother's fatal ovarian cancer (a common failing given vagueness of symptoms) for a year or more after her original office visit, as a gall bladder problem needing bile salts. (Said doctor, seeking alpha, had moved largely into "industrial medicine," doing workers comp and employment physicals -- a wonderfully nice guy, but clinical skills atrophy or lose focus or get too sharpened into narrow channels– totally understandable, given human nature -- channels that get reinforced by "economic" forces, stuff like HMOs and corporate bottom lines, and stuff like the vast and geometrically growing pile of "medical knowledge" of more or less validity, on and on.

These observations only touch on an enormously complex and painfully meaningful subject. Seems to me that the best "we" patients and patients-to-be can expect is that we connect with clinicians that still start from "Do no harm" and aspire to better the lives of we who seek and depend on their expertise -- a notably, and inevitably, ever smaller fraction of the available "knowledge base." And "we" can hope that AI and EBM and the horrors wrought by the other false gods of "modern medical practice" like "Electronic Medical Records" don't intermediate and leverage their way into the care we mopes need and hope for. EBM from what I have seen can be a useful approach in some ways, but then Smith's Law of Crapification is as universal as Murphy's

el_tel , October 27, 2017 at 10:15 am

Yeah I agree entirely . But more holistic approaches (judging medicine by overall quality of life) get into areas that have got a little Shall we say Controversial So I'm keeping my comments focused to stay within site guidelines.

cojo , October 27, 2017 at 12:08 pm

There are two reasons why patient care adhering to guidelines may differ from the care that clinicians provide:
Guideline developers may differ from clinicians in their ability to predict how decisions affect patient outcomes; or
Guideline developers and clinicians may differ in how they evaluate patient outcomes.

I think, what this article alludes to is that medicine is complex and not easily algorithmic. The concerns in medical decision making as noted by Yves and others is that if your data/knowledge you base your treatment choices on is outdated, or flat out wrong, you will be doing your patient's a disservice at best and harm at worse. In these situations evidence based medicine should be used as a guide. Where evidence based medicine runs into trouble, is two fold. One, when the guidelines are based on flawed evidence/data, and two, when they are no longer used as a guide, but as the law.

So in that case you may statistically help the population at large, based on the data at hand, but at the cost of doing preventable harm to a large cohort that could have been picked up by rational clinical decision making. This is where the "Art of Medicine" should theoretically be superior. The problem with the art of medicine, is that it takes time as it comes with experience. Much more experience that one can learn in medical school or residency.

My suspicion is that those early in their careers would benefit from practicing a high level of guideline based medicine until they gain experience.

With experience, the guidelines should still be understood but there is more flexibility to stray from the guidelines for individual patients based on patient preference and physician experience.

For those in the late stages of their careers, it is again important to understand and try to follow the guidelines so as to not become outdated in your practice knowledge.

At all three stages, one must understand the rational and methodology of the guidelines figure out which guidelines are to be used for most cases and which guidelines are just that, a guide.

Above, I speak of how to practice medicine without consideration of how to pay for it. Now when you start adding payments, reimbursements, and insurance claims, you add another level of complexity, bias, and incentive. It appears the free market insurance model is not working, as well as the fee for service model. Here the trick is to change the way medicine is reimbursed and incentivized.

Jason , October 27, 2017 at 12:14 pm

I am a practicing internal medicine hospitalist in a major US city. While in the past, there were large delays in physicians taking evidence-based practice and turning it into new habit and too much unwanted variation in clinical practice -- I feel like in the US, the pendulum is swinging too far the other way -- and in unintelligent ways, forcing clinicians into care protocols without regard for individual circumstance. Now there are clinical care guidelines from Medicare, the American Heart Association, the CDC, and others around major disease states (like stroke, heart failure, sepsis) that hospitals must follow for reimbursement -- yet the guidelines do not keep pace with current peer-reviewed evidence.

My point is that there are mandates and financial incentive for hospitals to pressure physicians into adhering to guidelines which are not universally good for patients or for cost of care (sepsis guidelines now are a good example of this). Often these expectations are negotiated by bureaucrats, not clinicians. The healthcare industry needs a better way of giving physicians real-time feedback about their clinical practice habits in relation to their peers -- - and having some common-sense expectations around unwanted variations in practice.

financial matters , October 27, 2017 at 12:50 pm

Hopefully you can get yourself on some committees dealing with these issues. Very important to have physician input.

Economics is definitely important, not only for improving the hospitals bottom line but for making medicine economically responsible generally.

Single payer, I think would be great but we still need to watch what we are paying for. No need for pharmaceutical companies to make outrageous profits.

One interesting area now is that many very expensive tests are becoming available for cancer testing. These need to be ordered responsibly and that takes physician, social and admin input. And at a deeper level needs to examine why the tests, drugs etc are so expensive.

el_tel , October 27, 2017 at 1:01 pm

Tranylcypromine – first generation antidepressant and still the gold standard for effectiveness (the "cheese effect" side effect has been overblown as numerous studies have more recently shown – I'm on it and can confirm this) costs the NHS over £1000 per month for me. It's been off patent for 50 years. However there is a monopoly supplier (price gouger). Why don't generic suppliers move in? Because the market is too small. Two generations of doctors have been taught that this class (MAOIs) are akin to leech therapy. Thus the assumption is that most people on them will be old and will die off. Scandalous, as any psychiatrist worth their salt will tell you (never mind the health economist like me).

el_tel , October 27, 2017 at 1:36 pm

Prime case of cr*pification in medicine if you ask me. Doctors bowled over by the drug companies selling SSRIs/SNRIs which let's not forget don't even work as the pharmacology says they should – they should show benefits at day 4/5 like MAOIs if their original pharmacological justification is paid attention to. Now does that mean they don't work? No I'm not saying that. But their method of action is clearly odd and not in line with the original pharmacological data and models.

Health economics 102 is derived demand – patients rely on doctors to enunciate their demand function. But when doctors have effectively undergone the medical equivalent of regulatory capture then Houston we have a problem.

financial matters , October 27, 2017 at 1:54 pm

Yes indeed. These pharmacologic profits can be perniciously spread around. It can be difficult to find a true patient advocate.

el_tel , October 27, 2017 at 2:17 pm

Thanks for the reply. The problem here is that patient advocacy requires systemic change: change in the medical curriculum along with a concerted effort to tell GPs about the new data on "old" drugs And they are already overburdened with stuff "coming at them from on high".

Plus even if (say) they learn the real data concerning MAOIs they still can't prescribe them straight off A psychiatrist must initiate it (then GP can carry on) And mental health services are close to breaking point. My local service is at critical levels. Austerity yet again .

Bill , October 27, 2017 at 1:48 pm

I was going to a physical therapist practice for spasticity and weakness and pain related to a pretty radical cervical laminectomy and progressive spine problems. I was a Medicare patient and they insisted on using the guidelines for rehabilitation after operation, even though my operation took place 12 years earlier. This consisted of exercises which only made my spasticity worse and aggravated my arthritis. What I needed was to have my chest and arms worked on to counteract the contraction of muscles caused by spasticity, which the therapist knew how to do. But she refused and told me that If I did not do the exercises, she would no longer treat me as I was violating the "guidelines", which did not apply to my circumstance. There was apparently nothing to allow treatment for chronic problems (except opiods, which I refused).

el_tel , October 27, 2017 at 2:00 pm

Sorry to hear that. I had reason to look at the UK guidelines on a range of conditions (from NICE). I was actually pleasantly surprised: although they do in many cases follow "stepped care" functions from medicine, there were a surprising number of "get outs" regarding if the patient cannot tolerate /has good reason to reject the official guidance. Patient preferences have begun to get recognised in the UK.

Of course whether austerity allows the doctors to *afford* differences is another sad story .

Bill , October 27, 2017 at 2:59 pm

I guess that what I need now is what amounts to palliative care (non-pharmaceutical). I find now that I have discovered high-CBD hemp (Otto II strain) which I can grow myself, I can actually slow down the progressive effects of my condition. Ironically, though I qualify for the medical marijuana card, I can't afford to buy from the dispensaries, and they mainly offer high THC strains anyway. I am lucky to have found a way to treat myself!

[Oct 25, 2017] Overtreatment in the United States Health Care System

American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "
Over-treatment involves actual procedures performed on a patient, often surgically. Unnecessary cardiac stents is one example and is a real epidemic due to excessive green and pervert incentives.
Notable quotes:
"... By Lambert Strether of Corrente. ..."
"... Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments. ..."
"... The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast. ..."
"... It's clear that one ..."
Oct 25, 2017 | www.nakedcapitalism.com

Posted on October 24, 2017 by Lambert Strether By Lambert Strether of Corrente.

Over the past, oh, decade or so I've been so consumed with the battle to get everybody into the heatlh care system -- "Everybody in, nobody out," as Quentin Young puts it -- that I haven't put much energy into thinking about the heatlh care itself. After all, just because a house is energy inefficient doesn't mean that it's OK to leave people out in the cold. Now that single payer is no longer "never, ever," but a program that could actually be achieved with (an enormous) level of effort, KHN's new series, "Treatment Overkill," which starts with Liz Szabo's "So Much Care It Hurts: Unneeded Scans, Therapy, Surgery Only Add To Patients' Ills," provides me with a change to broaden my scope a bit, with a survey post like this one.

So I'm going to look at two issues: (1) Is overtreatment a real problem? and (2) What are the causes of overtreatment? Spoilers: Yes, and it's complicated.

Confession time: I'm the sort of person who doesn't get the idea of deductibles at all; I can't understand why anyone would seek out medical treatment unless they were absolutely sure they needed it. And the reason I fear the health care system is, in fact, the prospect (painful) overtreatment; the dental clinic that was going to give me full anesthesia to remove a wisdom tooth; or my nightmare of "end of life care" hooked up to a machine in a nursing home in a room with a television I can't turn off.

Overtreatment Is Real Problem

Evidence for overtreatment[1] falls into two categories: Anecdotes, and studies and surveys. I'll look at anecdotes first.

"Anecdotes" isn't really a fair word, though; most of the stories are more about entire vertical markets (for example, stents, as we shall see). Szabo starts out with this example:

When Annie Dennison was diagnosed with breast cancer last year, she readily followed advice from her medical team, agreeing to harsh treatments in the hope of curing her disease.

"In addition to lumpectomy surgery, chemotherapy and other medications, Dennison underwent six weeks of daily radiation treatments. She agreed to the lengthy radiation regimen, she said, because she had no idea there was another option.

Medical research published in The New England Journal of Medicine in 2010 -- six years before her diagnosis -- showed that a condensed, three-week radiation course works just as well as the longer regimen. A year later, the American Society for Radiation Oncology , which writes medical guidelines, endorsed the shorter course.

In 2013 , the society went further and specifically told doctors not to begin radiation on women like Dennison -- who was over 50, with a small cancer that hadn't spread -- without considering the shorter therapy.

"It's disturbing to think that I might have been overtreated," Dennison said. "I would like to make sure that other women and men know this is an option."

(Note, sadly, that Dennison immediately puts the onus on the consumer patient to be informed; an obvious tax on time, to be paid with the patient has the least time or energy to spare, instead of looking for the systemic solution she vaguely hints at with "would like to make sure." This impulse is a topic for another post.)

Nobel Prize Winner Bernard Lowns gives a second example in this interview (after demolishing "bed rest" for heart attack patients as "a form of medieval torture" as well):

[DR. LOWN]: At the Peter Bent Brigham Hospital [now Brigham and Women's Hospital in Boston] in 1960, I was asked to see a patient who was in her late 70s, demented, and had burns over 60 percent of her body. She had been smoking in bed. They asked me to consult about putting in a pacemaker, which she did not need. Furthermore, she was clearly dying, and implanting a pacemaker would only have increased her suffering without prolonging her life. I was mortified. I wrote a note urging against a pacemaker. It created quite a rumpus. If that were an isolated episode, it would be tragic. But that kind of thing happened daily.

Here is a third, and egregious example, from Health Beat :

Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn't need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Midei's story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report..

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company's cardiac stents into trusting patients in a single day: "Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei's home." Employees from St. Joseph's attended the feast.

(It may seem that I'm stacking the deck on causality here, but I'm really not, although it would be foolish to deny that such cases exist.)

Note again that these examples all involve treatment : Radiation treatment, a pacemaker, and stents. We're not talking about ordering a few two many tests. ( The American Family Physican supplies numerous classes of overtreatment, not just anecdotes. See Table I.) Now to the studies and surveys.

"Overtreatment in the United States," by Heather Lyu, et al (from the Public Library of Science, and thus peer-reviewed) has induced a good deal of discusson since its publication in September 2017. From the Findings:

The response rate was 70.1%. Physicians reported that an interpolated median of 20.6% of overall medical care was unnecessary, including 22.0% of prescription medications, 24.9% of tests, and 11.1% of procedures.

Dear me. If one-fifth of all medical care is unnecessary, that does seem like rather a lot of stress and fear induced for no reason. And if one out of every ten treatments is unncessary, that's rather a lot of people going to Pain City because their number came up, and not for any medical reason. Those odds aren't quite as bad as Russian roulette, but they'e in the ballpark! I haven't (yet) been able to find figures on the costs of overtreatment, but there have been studies done on the costs of unnecessay care. Health Affairs :

Current estimates for unnecessary expenditures on overuse range from 10 to 30 percent of total health care spending. Even the lower estimate, from the Institute of Medicine , amounts to nearly $300 billion a year. No specialty is immune from practices that lead to overuse, as a recent spate of papers in medical journals can attest. In cardiology, even using criteria that are relatively permissive, an estimated 11 percent of stents are delivered to " inappropriate patients ." At some hospitals, that rate is closer to 20 percent.

(Note that the figure of 11% unnecessary stents jibes well with Lyu's figure of 11.1% of all procedures being unnecessary.)

I'm sure none of this is new to any medical professionals in the NC readership, but it was new to me, and may well be new to NC readers -- especially those who received treatments that they retrospectively, or just now, understood to be unnecessary.

The Causes of Overtreatment

It's clear that one cause for overtreatment is the profit motive. (I would speculate that individuals like Midei, the stent dude, are edge cases, and that the real causes are more subtle and systemic.) Quoting again from Lyu, et al. :

The top three cited reasons for overtreatment were "fear of malpractice" (84.7%), "patient pressure/request" (59.0%), and "difficulty accessing prior medical records" (38.2%) Seventy-one percent of respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them. The interpolated median response for the percentage of physicians who perform unnecessary procedures with a profit motive was 16.7%; 28.1% of respondents believed that at least 30–45% of physicians do so (Fig 2). Respondents who were attending physicians with at least 10 years of experience (OR 1.89 (1.43–2.50) vs trainees) and specialists (OR 1.29 (1.06–1.57)) were more likely to believe that physicians perform unnecessary procedures when they profit from them Respondents' compensation method and hospital characteristics were not associated with differences in perceptions on the profit motive associated with unnecessary care.

So, the more experienced the doctor is, the more likely the doctor is to believe that profit drives unnecessary procedures. However, the profit motive imputed to individuals cannot be the sole driver (see "DICE: Nonclinical Causes of Overtreatment" for a model that includes "Economics" without being reductive) as this letter in the British Medical Journal shows :

As a person who follows the evolution of health care policy from the vantage point of the United States, I found BMJ's May 12 article on "Choosing Wisely in the UK" [see here ; CW is an "informed consumer" model] very interesting. The authors ascribe the phenomenon of medical overtreatment in the UK to a culture of "more is better" fostered by such factors as "defensive medicine," "patient pressures," "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance."

Many critics of the American health care scene ascribe the problem of irrational overtreatment unsupported by available evidence in the U.S. to precisely the same causes, and argue that the key to rationalizing American medical practice lies in adoption of the UK's single payer, universal coverage health care system and the UK's system of civil justice. The fact that a Choosing Wisely program is necessary in the UK, and for most of the same underlying reasons as apply in the U.S., proves that the UK has not found the panacea to achieving rational medical practice and that emulation of the UK methods of health insurance, physician payment, and civil justice will not work as a panacea in the U.S. either.

So, sadly, single payer as such is unlikely to solve overtreatment (although I can't think of an advocate who ever said it would).

Conclusion

If there were one kind of doctor-patient relationship that I would like to see incentivized when single payer comes to pass, it's this one. Again Dr. Lown :

U.S. News: Problems with America's health care system are economic, but they are also human. What's been lost in modern medicine?

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Call me Polyanna, but I think if the health care system started treating patients like human beings, that a good deal of overtreatment would be avoided.

NOTES

[1] Overtreatment is not the same as overtesting, or overdiagnosis. Over-treatment involves actual procedures performed on a patient, often surgically. In other words, lots of pain and suffering imposed to no good purpose. (Szabo's article considers all three, but I am focusing only on overtreatment.) American Family Physicians defines overtreatment as follows: "Treatment initiated when there is little or no reliable evidence of a clinically meaningful net benefit, where net benefit equals benefit minus harm. "

taunger , October 24, 2017 at 1:41 pm

I worked as a disability advocate for years, which is a high volume practice. I read literally tens of thousands of medical records during that time. I can say, unequivocally, overtreatment is an issue.

Causes are far more difficult to deal with. The high cost of medical care is a reflection of the low quality of life many USAians are living. Listening is a good start, but far from the answer. Getting everyone in the system, so that more preventative medicine can work, avoiding patient demanded surgeries with low-probabilities of success would help as well. But even these two are just the tip of the iceberg.

In disability, chronic physical ailments mix with unemployment to form a deep pool of depressed individuals. Even with access to great healthcare (which few have), the advice to exercise, stretch, and eat healthy that would improve many conditions (spinal stenosis, other arthritis and orthopedic issues, obesity, heart disease) is worth very little. In a depressed state, changing long term habits into healthy ones is very difficult, and the prevalence of patients seeing a professional to make behavioral adjustments in concert with their disease treatment is few, not counting those that show up to the psychiatrist for medication regularly.

This is why single payer, jobs guarantee, and redistribution tax policy are necessary together.

Anon , October 24, 2017 at 2:28 pm

Excellent comment. The last sentence is a comprehensive statement of actions needed to heal us (U.S.)

Certainly, some will not respond to these actions, but many will and the attempt is magnanimous for a consciously sick nation.

Arizona Slim , October 24, 2017 at 2:03 pm

Experienced this a couple of years ago.

After a car wreck, both of my parents were hospitalized for a week. During that time, I got a lot of phone calls from the hospital, and many of them related to getting my permission for this, that, and the other test on my mother. Dad had Alzheimers, and, lucky for him, he evaded the endless tests. I guess the doctors figured that he wasn't going to live much longer, so what was the point? (He died nine months later.)

One of the phone calls really stood out. Mom was anemic, and the doctors wanted to do a colonoscopy to find out why. "Malnutrition!" I said. Loudly.

This had been a problem for years. Mom and Dad simply weren't eating enough. I'll get back to that point in a minute. But let me say that I refused the colonoscopy for my mother. In addition to being very invasive, I thought it was unnecessary.

Anyway, Mom got sent home and Dad was discharged to a nursing home. Once he was separated from my mother, he started eating like a horse. Gained 15 pounds in less than three months. Then he started losing weight and the nursing home sent him to hospice. In his case, that was the correct call.

Let's just say that my mother still has issues with food. Not a new problem. I remember it from my childhood. But she does have caregivers who insist on proper nutrition. And she complies.

Last time I spoke with Mom's doctor, he didn't say anything about anemia. Sounds like that's no longer a problem.

Rojo , October 24, 2017 at 2:04 pm

I think specialists are more likely to zero in on the "problem" -- the heart or lung or throat, while GP's are more likely to treat the whole person.

But GP's are often referral gateways to specialists.

Anon , October 24, 2017 at 2:47 pm

General Practice doctors are hugely important in the healthcare system. They are the traffic cops that direct patients to the appropriate specialist. They do most of the listening.

Nilavar, M. D. , October 24, 2017 at 4:58 pm

I think specialists are more likely to zero in on the "problem"

Call me skeptic after being a practioner of Medicine over 40 years! I was a GP before got trained as Diagnostic Radiologist after nearly 5 years of residency. I also worked as ER Physician in early years. I am also licensed to practice in Ontario(Canada) but practiced only in USA after the residency training!
A Diagnostic Radiologist is called ' a doctor's doctor" since the myriad of imaging exists to help the clinical diagnosis. I came across virtually all kind of specialists, medical and surgical kind! Ifound out to whom I wouldn't even send my 'dog' for treatment!

There are ethical and morally conscious docs, but they are in the minority!VERY FEW!

A specialist is like a HAMMER, s/he sees everything as if it is just problem of NAIL! Surgeon thinks through SCALPEL. Go to Pulmonologist, more likely you get bronchoscoped (needed or not), Gastroenterologist – gastro or colonoscopy, so on!

So buyer beware!

S.Nilavar. M.D.

Anonymous , October 24, 2017 at 2:07 pm

Imagine going to a restaurant where the waiter got to order for you.

"You want the steak? OK better start off with these two appetizers I think you'll like.
You'll need some wine too. There's a 1994 Cabernet that will pair great with this. I'll mark
that down. The cost? Oh don't worry about that, your dining insurance will cover it.
Now for dessert. They're all so good, I have picked out three for you. You don't need
to finish them. Now I'll just add in my customary 25% tip (I am highly trained) and we'll
call it a meal."

Vikas Saini , October 24, 2017 at 2:34 pm

As a regular lurker here, it's great to see you on this beat Lambert. We've been on this for awhile now at the Lown Institute. I refer you and the rest of the commentariat to a series we did in the Lancet which is here:

The Drivers paper is pertinent as a description of the ecosystem of bad care.

FYI it's a deep problem of modern medicine, part of the reductionism of the Flexner paradigm that needs to change. Over treatment exists in Canada and the UK as well as in an utterly profit driven system like the US.
Single Payer will be necessary but not sufficient for this problem. Monopsony will only go so far without a revolutionary shift in culture and consciousness.

oh , October 24, 2017 at 2:50 pm

If the patient is the one who controls the payment, things may improve. Right now with insurance, there is no one to one relationship between the patient and the health provider. Insurance companies stand between the patient and payment. Even in the case of single payer, if the patient is given incentives to get second opinions and refuse unnecessary treatment, things may work better.

Lyle , October 24, 2017 at 9:38 pm

Single payer is likley to require second and if need be third opinions for non emergency surgery. Most insurance pays for a second opinion if you want one (and would be a fool not to get) and if need be a third opinion if the first and second don't agree.

kb , October 24, 2017 at 3:03 pm

Kip Sullivan unequivocally disputes the "overtreatment" meme To the contrary, we are under treated in the US ..
Please read:
"The Health Care Mess: How we got into it and how we'll get out of it" by Kip Sullivan ..

hreikd , October 24, 2017 at 3:08 pm

Over treatment: My mom's story. From several years ago.

So I was the guardian for my very (VERY) demented mom whom we kept at home, at great cost but also great benefit to her. She had a basal cell tumor on her forehead. About the size of a nickel. She was 90 at the time. I live in one state, she the next state over about 2 hours away. She had full time help at home.

So one of my innumerable trips to help out and oversee, involved taking her to her md appointment at Brigham and Women's. She had a wonderful gerontologist, who referred me to a dermatologist affiliated with B &W. Her care giver took her a few weeks later and I got a call from the dermatologist, a young woman. Now I'm an old woman but a trained m.d. in Internal Medicine. I also knew (by then ) a great deal about dementia. And especially dementia in my particular mother.

So when the dermatologist called me she said "your mom needs a MOHS procedure". Well, a Mohs procedure is an 8 hour stop and go procedure. They keep cutting until the margins are clean. They cut, send the specimen to the lab, wait for the result and cut again. Patient is awake the whole time so there's no anesthesia risk, but 8 hours on a table for a woman with advanced Alzheimer's was not going to work. I told the dermatologist that there's no way my mom could tolerate that. The dermatologist got irate. Tried to scare me by saying, "the tumor could grow into her brain!". I said, "mom's 90, she'll be dead b/f the tumor goes anywhere!"

They were so intent on this procedure and challenged my right to speak on mom's behalf. so .. I had to fax PROOF of my guardianship for them to let me have the last say. I was pretty discharged. And complained bitterly to the referring doc when we saw him next . and he mentioned that my complaint wasn't the first.

Then I found out that the MOHS surgeons get a ton of money at the places they work, like $700,000.00 / year.

Nemo , October 24, 2017 at 3:57 pm

Thank you for sharing. It helps to know I am not alone in such experiences.

I often wonder how epidemic stories like yours are. I feel like I could write a whole book based on personal experiences along with those of family and friends. A person really has to educate oneself just to avoid being robbed blind or worse yet harmed, and you at least have the fortune of a medical education. To have to education oneself (trying to filter all the misleading 'marketing' information and quacks out there) on complex medical procedures on top of everything else is exasperating beyond words.

How long do we, and those we care about, have to continue suffering the indignities and malfeasance of a broken and corrupt (not worth using euphemisms to debate the issues at this point anymore) healthcare system?

McWoot , October 24, 2017 at 3:52 pm

I'd be surprised if a significant contributor to the "overtreatment" pie wasn't Pharma advertising

clarky90 , October 24, 2017 at 4:17 pm

The underlying premise of "modern medicine" is flawed. It dumber than Medieval bloodletting.

Allopathic medicine is brilliant for catastrophic events. In the case of paraplegic injuries, over the last 50 years, their survival rate, in the first two years after the injury, has increased dramatically. However their long term life expectancy is about the same as it was 50 years ago.

Trends in Life Expectancy After Spinal Cord Injury
"Results
Other factors being equal, over the last 3 decades there has been a 40% decline in mortality during the critical first 2 years after injury. However, the decline in mortality over time in the post–2-year period is small and not statistically significant ."

http://www.sciencedirect.com/science/article/pii/S0003999306004060

We are bamboozled by the "complexity" of the modern medicine model, BUT, "it" is stupidly simple. They define a "normal" range of numbers. This range is arbitrary and always changing. What is normal cholesterol? PSA? Blood sugar? ferritin? vitamin D?

Then they subject the patient to an array of blood tests, x rays, scans, urine tests

Then, the allopatic doctors use drugs or surgery in order to get your test numbers in the normal range.

Before you know it, the patient is on 15 drugs. They cannot sleep so they are prescribed sleeping pills. Then they are depressed, so anti-psychotics- Finally Oxycontin for the constant unbearable pain.

Allopathic care in NZ is cheap, readily available, but a death trap for the trusting (except for catastrophic events). USAians pays hundreds of thousands of dollars for misery and drug induced ill-health.

If cat poop (feces) were cheap and available in one place (NZ), but outrageously expensive and rationed in another (USA), it is still, basically, just cat shite.

VietnamVet , October 24, 2017 at 4:40 pm

The problem is for profit healthcare. The more tests and treatments, the higher the managers bonuses. There is no regulation except for the insurance companies who are only interested in their own bottom line. The patient is not in a position to rationally oversee their care by themselves. All that matters today is profits; no matter how they are achieved. That is why American life expectancy is decreasing. Besides giving everyone healthcare; a system of primary physicians, government oversight of hospitals and care facilities plus jail time for criminals are also needed.

kareninca , October 24, 2017 at 4:43 pm

I have relatives by marriage who live in southern Indiana near the Kentucky border. They are "respectable working class," and I guess they must have good health insurance. I have never known anyone to have so many surgeries. It is astounding. Cardiac surgeries and orthopedic surgeries, for the most part. The ones I have in mind are 58 and 62 years old; they have never smoked; they go to Mass every Sunday, they have been happily married since they were young and while they don't eat health food they don't eat every meal at McDonald's. But it is surgery after surgery after surgery. They never question the doctors; they never hesitate. And now, unfortunately, some consequences of the surgeries are coming due; the guy is in the hospital with infections both in his pacemaker and in his heart valve (they just replaced both; he'll probably be okay). No-one else I know has surgeries like this. I think it is a regional scam. It's true that my dad in CT has had a number of vascular surgeries, but he smoked for decades and the dire need for them has been very apparent.

Here in northern CA, I have a friend whose girlfriend's son went to the emergency room a number of years ago for a bad finger cut. He was told he needed amputation. Then they found out he had no insurance. He was told to use a salve, and in fact it worked fine. I also have a friend here in Silicon Valley who recently had digestive problems. The MRIs, CAT scans, lab tests and probings under sedation were endless. Finally she was told to stop eating acidic food.

nihil obstet , October 24, 2017 at 4:54 pm

Reducing the profit motive as much as possible is why I would prefer a National Health Service (call it VA for all). Insurance, even if it's single payer, is still open to fraud and overtreatment. Let's try to think of medical practitioners as professionals rather than entrepreneurs, and get them to think of themselves that way. I also see it as a possible way to reduce the very high premium given to specialists, so that more would go into primary care.

Nilavar, M. D. , October 24, 2017 at 5:09 pm

In modern Medical practice, PROCEDURALISTS ( Surgeons of all kind, Cardiologists, orthopods, Pulmonologists, gastro enterologists anfd of course, invasive and diagnostic Radiologists etc ) always get compensated more than the primary care providers!

There are more CPT codes to charge for specialists than the GPs or FPs

Medicine is business run by 3rd parties! Vested interests won't allow any challenges to status quo, just the banking system and the FIRE Economy!

Wade Riddick , October 24, 2017 at 4:59 pm

With all due respect, if the UK system has embraced, "commercial conflicts of interest," "payment by activity," and the demands of "pay for performance" then that means they have a substantial set of profit incentives already in place, rendering their medical system *more*, not *less*, similar to America's. They may have single payer but that just captures the monopoly rents by regulating the cartel/monopoly/utility or whatever you want to call the medical establisment (it's per se difficult to even talk about market competition when there's only one drug or treatment that will save a patient).

The unregulated private provision of public goods like medical care always leads to extortion for profit. If you privatize fire-fighting, entire cities will burn to the ground. If you privatize schools, you get ignorance. If you privatize prisons, you get kidnapping-for-profit and the highest incarceration rate in the civilized world.

If you privatize the military, you get endless war. Why would a for-profit business ever win a war? For that matter, why would they ever lose? The war's over and they'd be out of money. You think it's just a coincidence that in the age of corporate personhood (Citizens United) and unlimited bribery of public officials, you've had two of the longest, most expensive and least determinative conflicts in our history in Iraq and Afghanistan?

You think it's a coincidence that the more unregulated "markets" we through at medicine, the more expensive our medical care becomes and the sicker we all get?

Cures don't make money. Repeat customers do.

Show me a for-profit business that's in business to go out of business and I'll show you the perfect company for insuring against social hazards.

It's simple middle-manager fraud. Politicians love privatizing government because they get to pocket the public budget. When the marines or public school principals hand tax dollars back to politicians and their cronies, everybody goes to prison. Privatize it and then you can have the contractor or charter school give you "campaign donations" – no doubt celebrating your economic genius in the process. They can hire your spouse and cousins. The contractor can even bid up the real estate and then rent it back to themselves at exorbitant prices. There are a million ways to launder the money.

Why do you think there is no transparent public accounting on most of this stuff? The budget disappears into a black hole – which, incidentally, you'll discover the minute you're in a hospital, dealing with a pharmacy benefit manager (PBM) or health insurer. That was the true purpose of MERS – to make good mortgage information disappear so CDO purchasers would never know what was in the mystery meat.

This is the great unraveling of Progressive Era controls on public corruption.

If you pay a dotor for every surgical screw he installs, is it any surprise then that a diabetic winds up getting several in his spine he never needed?

This is also how we have set up the aluminum and copper markets, letting speculators buy and horde commodities to drive up the price. It's also how we run drug distribution under the PBMs. PBMs provide a kickback in the form of a "stocking fee" to pharmacies which would get people sent to prison in other industries. When derivatives traders are not end consumers or producers of a commodity, they bid up prices the same way. We actually give pharmacies a profit incentive to drive cheap, effective, public domain chemicals off the market in favor of expensive, privately patented medicines. Because they are expensive, they pay a greater kickback so the pharmacy has greater incentives to stock and push it.

When railroads charged both farmers and consumers shipping and receiving food, it bankrupted both sides of the transaction by creating incentives to reduce supply in the monopoly transportation network. Reducing rail capacity bid up transportation prices and saved the company on investment. That's how you raise profits: raise prices, lower expenses. They had no rival to compete. That's why these kickbacks were outlawed. Imagine if the post office made you buy a stamp for every letter you receive. Oh, wait. We have that with the end of net neutrality. The ISPs get paid both by the service supplier (e.g., Netflix) and by their "customer" (you and I).

You this same "rationing" take place now with drugs. Since legalizing PBM kickbacks, drug prices have soared and we've lived through some of the greatest drug shortages since the Soviet Union went bankrupt. Hundreds of chemotherapy patients per year have died because cartels control supply and they don't like patients getting cheap, efective, public domain treatments. Go look at the availability of methotrexate over the last ten years or your platinum-based compounds. No one tells you this. It's a blip on the back page of a newspaper (and pretty soon we won't even have those). Do you think TV "news" – making its profits off drug ads – will ever talk about this?

It's a new war of enclosure – and it's far more extensive than simply drug markets. The privatizers are confiscating clean air, potable water, healthy food, public education, public policing and a host of other "general welfare" functions of the government promised us in the preamble. It all traces back to the ideology of for-profit government – which, in technical political science terms, is called fascism – when businesses own and operate the government for private gain.

By the way, we don't need less testing in medicine. We need more. I don't know a single idiot in Silicon Valley who ever said we need less data collection. The simple fact is we need to test everything in a patient and compare everything we collect across thousands of diseases. The cost of sensors and DNA sequencing, imaging and protein detection – not to mention data processing – has been falling dramatically and yet "reformers" always stress "rationing" as the cure for health care prices. It's partly because we ration preventative medicine and diagnostics that we're in this situation.

Another great place to start would be separating diagnostics (evaluation) and treatment. Would you let the bank's chief loan officer also serve as the chief auditor? Yet we let the same doctor diagnose, treat and evaluate his own work.

As someone with serious chronic illness from these frauds, listen to me when I tell you we should be practicing medicine thousands of patients at a time with transparent public auditing and big data model building. Building my own private model of genetics from public research saved my life. Nobody does that for you in medicine. Nobody is paid anywhere in the system based on whether you get the cheapest, most effective and safest treatment; in fact, I've heard of people getting fired for exactly that.

nilavar, MD , October 24, 2017 at 5:37 pm

'By the way, we don't need less testing in medicine. We need more. '

ah?

No test is 100% accurate! Every test has a potential for a FALSE positive or FALSE negative result.

False + may lead to unnecessary more testing and probably unneeded surgery! False negative gives false sense of relief!

Every test has to stand alone for specificity, sensitivity and accuracy, by statistics!

Wade Riddick , October 24, 2017 at 7:48 pm

You've answered your own question. No single measurement, in isolation, is 100% accurate. That's why we need thousands.

We need a cheap gene array chip that measures 10,000 markers in the blood and we need a big data project to match those measurements against a baseline. We need cheap, safe whole body scans. We need measurements of what every cell is up to and how they deviate from the norm.

Nobody's very angry that cell phone cameras keep getting better, yet somehow we're always upset that doctors want plenty of tests. That camera is a sensor that measures our environment and the chip gets better and cheaper each year. We need the same attitude in medicine. But then cardiologists might get upset that an immuno-assay shows you're at risk for atherosclerosis. These guys still don't want to accept that clogged arteries are an immune system problem and the immune specialists don't want to accept that it mostly gets started in the gut. And the gut guys don't want to have anything to do with immunology or cardiology.

Round and round we go

Oregoncharles , October 24, 2017 at 5:09 pm

I'll have to read the post this evening, but I have something to add to the theme:

I was in a meeting where a prominent local single-payer advocate, an emergency room doctor, told us, passionately, that administrative costs were only half the problem,. or less. Overtreatment and overtesting were the bigger part. He blamed the doctors, but of course their billing practices are a big factor.

A big advantage of single-payer is that it creates an institution with the power and motive to change medical practice. Iatrogenic illness is a big factor; overtreatment can kill.

Mayo One , October 24, 2017 at 5:13 pm

My wife has some chronic health issues and is a regular visitor at–and occasional guest of– the Mayo Clinic, traditionally seen as the home of "integrated medicine" (i.e. the various specialties speak with each other). We count ourselves ridiculously, ridiculously fortunate to be able to so often and easily rely on the oft-named best hospital system in the world. That said, it's amazing to both of us, even there, how silo-ed medicine has become. This silo-ing HAS to create an inordinate amount of overtreatment. The generalists, however, are left far behind in the community practices, often not able to do much beyond prescribing antibiotics and making referrals. There is a LOT of need for more holistic thinking about the patient that modern western medicine has lost, likely inadvertently, as greater knowledge leads to the need for greater specialization. The gap of some type of "master generalist" (which would of course be another layer of expense in the healthcare system) is filled either by the patient (of patient's family) or left void. As a result, there's either a huge tax of time, stress, frustration spent searching internet chat boards and medical reference sites to understand topics because it seems like no single doctor "gets it", or a hugely inefficient and potentially quite harmful medical treatment experience as each specialty chips away at their corner of the patient. I'm not sure what the answer is, but if this is the experience of a frequent Mayo Clinic patient, I'd wager that the question posed is a pretty fundamental one to the entire practice of modern medicine.

PlutoniumKun , October 24, 2017 at 5:21 pm

I would add an extra 'over' to your list – overdiagnosis.

One of the the few bright spots in published stats for the US compared to other countries is an apparent higher survival rate from cancers. I mentioned this to a relative who is a medical specialist and he just laughed. 'its not surprising' he said 'since an amazing number of those treated in the US for cancer don't actually have cancer'. Quite simply, overuse of dubious 'tests' results in a huge number of false positives for cancer. This leads to 'successful' treatments. There are many tests in the US which are simply not permitted in countries with public systems because they produce far too many false positives to justify their use, either because the cancer doesn't exist, or it is not sufficiently malignant to justify treatment (apparently there are cancers that lie dormant without ever threatening life). I'm not aware, however, if this has ever been quantified, but its certainly true that there are many testing protocols commonly used in the US which are actively recommended against in most European health systems as they are considered not just a waste of money, but actively harmful.

A relative of mine who is a very highly regarded specialist in drug prescribing practice in Europe is currently doing a one year study on practice in the US (focusing on opiates, as it happens). He said that one of the initial findings is that there is a different culture around prescribing in the US to what he is familiar with. Quite simply, US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.

Someone mentioned overuse of heart operations above. In Ireland, they developed what are called ' Sli na Slainte ' walks, which have spread worldwide. These were developed by the Irish Heart Association following complains that patients were asking for too many drugs and treatments, and not doing the simple thing which was shown to help in the aftermath of heart attacks – exercise. They are way marked walks of set distance – doctors simply prescribe the walk instead of drugs. They are hugely successful. But there is no money in it, so guess where they haven't been adopted?

*disclaimer* I should say I'm not a medical professional, but I do have an interest in the topic.

nilavar, MD , October 24, 2017 at 5:44 pm

'US doctors are not taught how to say 'no' to patients in a way which doesn't upset them or feeling they've been given a brush off.'

But there is always another doctor 'willing' to say YES! Shopping for 'yes' doctors is NOT usual! They are called 'DR. Feel good' ;-)

Remember, Medicine is a business in America!

Chris , October 24, 2017 at 5:44 pm

Thank you, PK. Very interesting, and follows from a thoughtful and insightful post from Lambert, but I guess it makes common sense to strengthen heart muscle and accelerate the body's natural ability to heal itself through exercise. Pity about the commonness of common sense though, but I digress.

We all know we can live longer and avoid or postpone chronic ailments by maintaining a healthy weight and doing some exercise, particularly cardio. And our arms and legs may look the same over our declining years, but if you don't use them, you will lose them, those muscles that is.

I post. that such an ideal is too far when you are time and money poor, constantly worried and depressed

Poverty and sickness and lower mortality – they're all linked to one another. Designed and baked into the dying system

JBird , October 24, 2017 at 6:54 pm

None or too little, or too much, and very occasionally just the right amount of medical care for the lucky few. What a mess.

I'll add that the elderly, and the poor's, opinions seem to be discounted by caretakers as if you are lucky enough to be old or unlucky enough to be destitute means you're soft in the head. So if a patient can understand and communicate what they want and realistically need they have to fight to be listened too.

Steve , October 24, 2017 at 7:25 pm

Four years ago my father who was 78 at the time began having difficulty eating. He had been diagnosed with parkinson's a couple years earlier but the meds he was on were acceptable and effective for him. He was a brilliant physicist. Well they did a colonoscopy and found tiny tumors. One couldn't be taken care of at the time and the process to his death began. No one knew how long the tumor had been there or at what speed it would grow but chemo and radiation were prescribed to make it easier to remove. This became a very long sad story which I will not go into detail on right now. The chemo made my Dad horribly sick. The radiation to pin point a tiny area less than the size of a quarter ended damaging all his organs. He died in pain on Thanksgiving morning 2 years ago. The radiation had done too much damage. When he asked questions about treatment he was shuffled to diffident doctors or just not answered. These were very high end NE Medical facilities. The reason he went in for digestive problems never were fixed. Had the tumors never been addressed he could very well be alive today. To date I have over 5 friends who have had a parent die not from the condition they sought help for but the radiation treatment.

mirjonray , October 24, 2017 at 8:09 pm

For me the problems start with the routine physicals which are "free" courtesy of Obamacare. The doctors run tests and find problems with this and that, and after ultrasounds and CT scans and little surgeries to get rid of benign little thingies, before you know it you've spent thousands of dollars (courtesy of high deductibles ) for basically nothing. This last time around my GP didn't like a few things in my lab results and I ended up with a specialist. He started off with "why are you here to see me today?" After questioning me for a little while about my (lack of) symptoms, I finally told him, "I never would have come here on my own if my doctor hadn't have sent me here."

cojo , October 24, 2017 at 9:04 pm

Dr. Lown is on to something:

[DR. LOWN: In my view the lost art of listening is a quintessential failure of our health care system. I think that you cannot heal the health care system without restoring the art of listening and of compassion. You cannot ignore the patient as a human being. A doctor must be a good listener. A doctor must be cultured in order to understand where the patient lives, why he lives like that, and also realize that the leading cause of disease in the world is poverty.

Medicine is becoming more dehumanizing. This is not only structural due to shorter patient visits, less face to face interaction, fewer family physicians treating the whole family, visiting the patient at their home, to see what their environment/neighborhood is like. It is also the way physicians practice medicine, treating patient's as mere data sets. I'm not trying to minimize data in medical decision making, but taken out of context from the human element, treating data may be misleading and may not be treating the patient's ills.

In my experience, when I see a patient coming in over and over for the same complaints, it is likley due to one of three main reasons. One, they are either being misdiagnosed and mistreated, two, they are seeking a special test or drug, or three, their symptoms are not due to an organic medical cause, but due to some sort of somatization secondary to life stressors. Trying to figure out which it is requires the clinician to listen to the patient and understand where they are coming from. Unfortunately, when a primary care physician only has 10 minutes per visit, it is much easier to order a battery of tests to not miss any important diagnoses, or to just capitulate to patient demands than to listen, and in many cases take the time to give the patient some much needed reassurance.

That being said, the patient is not always an innocent bystander in this. There are also many times that the clinician will pick up on the dynamics mentioned above, but reassurance will not satisfy the patient. The patient will demand more be done for a number of reasons. These are mostly anecdotal, such as I read an article and think I need such and such a test, or my friend/family member had this procedure done and I need it two. It sometimes takes me twice as long to explain to a patient why they don't need something done as it does as to why they do. This is a societal thing and this is linked to the problem of defensive medicine. I like to joke, that physicians always get sued for not ordering a test that may have been indicated, but rarely if ever get sued for over treating someone and then causing harm. Perhaps it has something to do with the ethos that it's better to do something and look like you're trying that to do nothing, even though that may be the best course for the patient.

In the end, I think physicians need to be better trained to listen, remember the mantra of "first do no harm", and treat each patient as if they were their close family member. The incentive structure in medicine has to also change, including the way physicians are reimbursed, as well as the way information and clinical data is sourced and distributed to avoid excess industry bias. And finally, patient's have to understand that more is not necessarily better, they or their relative do not have a god given right to every experimental, and outrageously expensive treatment available if it does not apply to them clinically and if the chances of it prolonging life are minimal.

GERMO , October 24, 2017 at 9:27 pm

Overtreatment can't possibly be as big a problem as undertreatment, at least certainly not in the world of crappy insurance or subsidized care our experience was definitely a solid reluctance to order expensive tests or to consider that the problem might be complicated and costly. Which it turned out to be, and the eventual surgery was scheduled as late as possible, as a last resort, and we had to insist on more thorough testing to get a proper diagnosis. They just wanted to save money. The tumor grew all the while this organization was hoping it was something minor. I don't want to hear about overtreatment, thanks -- it seems to always get distorted into blaming the patients for greedily consuming too much healthcare!

[Sep 17, 2017] Obamacare is a symptom of a bigger American health care cost problem. If How much larger portion of the US economy can healthcare take before the entire system collapses? Its currently 17% heading for 20%, while competitor nations spend half that. Obamacare, was a hail mary to continue the party for the health insurance and overall industry at tax payer expense, and it was so poorly conceived that as you note, it is falling apart.

Sep 17, 2017 | vascript:void 0

There are two real question facing the US as to what sort of president will Trump be.

1. Thus far he looks to me to be a man who will run a tight ship deciding major issues himself and will make deals with whomever has the power to enable him to reach his goals.

IMO that means that the Republicans in Congress will either go along with Trump's legislative proposals or see Trump go across the aisle to seek votes.

A good example would be whatever it is that Trump decides that he wants to do about the obvious failure that is the ACA, presently sinking under the weight of far higher costs than expected and smaller enrollments. Democrats understand that the law must be modified to survive and to preserve the increase in health care coverage that it has brought. The hardline Republicans in both Houses of Congress want to destroy Obamacare and they have no realistic alternative other than the usual blather about private health accounts. Trump will not want to alienate his working class followers. Why would Trump not make a deal with the Democrats to get what he wants and needs?

ISL said... Dear Colonel,

Obamacare is a symptom of a bigger American health care cost problem. If How much larger portion of the US economy can healthcare take before the entire system collapses? Its currently 17% heading for 20%, while competitor nations spend half that. Obamacare, was a hail mary to continue the party for the health insurance and overall industry at tax payer expense, and it was so poorly conceived that as you note, it is falling apart.

I am hopeful that Pres Trump, who is not beholden to the insurance industry, unlike Obama, will take the side of the US (non-health care) business community and pull our costs to be more in line with those of the rest of the world.

I predict twitter storms against recalcitrant Repubs and Dems that mobilize via social media Trump's constituency to =scare the bejeezus of them for the mid terms. Reply 10 November 2016 at 11:08 AM Pete Deer said... "Why would Trump not make a deal with the Democrats to get what he wants and needs?"

He doesn't care about health insurance for anyone other than himself or his family. He is on record as supporting repeal and replace. And he is an incompetent person who is not a very good negotiator. In fact, he won't do any negotiating at all, leaving that to his staff as that would imply doing the hard work of governing, which is something he is really not all that interested in doing. I say that after having watched him over the past 30 years as he has bankrupted several business, stiffed his contractors and investors and cheated on his various wives. Why should he be any different now?

Pete Reply 10 November 2016 at 11:13 AM Anna said... Medicare for all would solve the crushing ACA problem at once - and this would endear Trump to the working class, progressives, small-business owners... to the absolute majority of the US citizenry. A process of reorganization from the current mess of viciously-profiteering middlemen (insurance companies) toward the Medicare for all could be achieved in one year. The reorganization must be approached as a nationwide emergency that demands a swift, drastic solution. There can be no restoration of the middle class and its purchasing power without first solving the scandalous healthcare crisis. The current system of penalties for not buying a health insurance is in fact a clear case of taxation without representation. Moving to a Single-payer system is perhaps the most urgent task for the US government Reply 10 November 2016 at 12:40 PM shaun said in reply to Anna... we don't do solutions this is the USA./ Reply 10 November 2016 at 02:13 PM Edward Amame said in reply to Anna... Anna

Do you remember why there was no banking reform in the aftermath of the 2008 crash? A very frustrated Sen. Dick Durbin admitted on the radio, "And the banks, hard to believe in a time when we're facing a banking crisis that many of the banks created, are still the most powerful lobby on Capitol Hill. And they frankly own the place."

Likewise with health insurance reform. HRC ran into an insurance industry/health care industry firestorm when she tried to reform the system in the early 1990s.

That's how we got Obamacare. Democrats had the full support of most of the base because the other side and the the insurance industry/healthcare industry were not willing to even entertain the idea of Medicare for all. We thought Obamacare was something that could get passed in a bi-partisan way because it was a "market-based" solution birthed in the Heritage Foundation that the insurance industry/healthcare industry got sort-of behind.

http://www.forbes.com/sites/theapothecary/2011/10/20/how-a-conservative-think-tank-invented-the-individual-mandate/#7380f885621b

Obamacare got passed without the public option because the insurance industry, the GOP, and some Blue Dog Dems demanded it be gone and yet the final version of Obamacare did not get a single GOP vote.

Based on what do you think Trump and the GOP House/Senate would even consider a major new entitlement like Medicare for all? Reply 10 November 2016 at 02:49 PM Anna said in reply to Edward Amame... If the only sensible solution to the healthcare crisis - the Single payer system - were not implemented, then Trump's other important projects will be destined for failure. Reply 10 November 2016 at 05:51 PM FourthAndLong said in reply to Anna... That it is. But medical care has always been for the priveleged historically. Emergency care and first aid excepted. Believing politicians actually care about the public is sort of like thinking parents will be around forever to look out for you, or worse. Egotist desire for a legacy is the best bet. Reply 10 November 2016 at 08:52 PM r whitman said... The individuals speaking out against the ACA do not have insurance under that program. They are medically secure under Medicare, Tricare, Corporate care, etc. The 6 people I know personally that have ACA insurance are happy with it within limits compared to their choices if any before the program.

The excuse that the finances are out of whack is a nonstarter. Every government program that subsidizes an area loses money--Medicare, Medicaid, the Military commissary system, the Farm program, AFDC, food stamps. All these were supposed o be self sustaining but as usual politicians lied about them. The ACA deficit is just more of the same. I am sure that it will evolve into a better system in time. In the meantime 20 million US citizens have some health insurance, same as the rest of us. Reply 10 November 2016 at 02:16 PM ISL said in reply to r whitman... r whitman,

Oh come on, do you really think that poorly of Americans that we are incapable of doing as poorly as the vast majority of European countries (if not sabotaged by crony capitalism), which have better health outcomes that the US? If we could do as well as Belgium (forget Denmark) costs would be half and people would live years longer.

Its not rocket science. Its that Obama was the single largest receiver of donations of any senator by a factor of TWO from the health insurance industry. Deplorable USA sent a message - the pay to play corruption of the establishment sucks. Expect the same message again in two years if their voice is ignored.
Reply 10 November 2016 at 04:29 PM r whitman said in reply to ISL... You miss my point. These people have health insurance. They did not have it before. They are reasonably happy with it. Do not confuse it with the cost. The USA always has the highest cost of government programs, health care or otherwise. Reply 10 November 2016 at 05:20 PM Anna said in reply to r whitman... "The individuals speaking out against the ACA do not have insurance under that program. They are medically secure under Medicare, Tricare, Corporate care, etc."
Could you conceive an idea that the majority of people that are against the ACA are very unhappy with paying the racket money to insurance companions while, at the same time, having no real coverage because of the exorbitant deductibles? The ACA is going to be more expensive next year - up at least 25% and to the whooping 144% - with zero (0) improvement in the coverage. But the most insulting aspect of the program is the penalty for not buying an insurance from the national racketeers; in some states the federal penalty has an additional state penalty. Instead of imposing an honest tax and providing the citizenry with universal health care (at least on the basic level), the racketeering class managed to tax the populace without representation. This is an act of murder of small businesses in the US. Reply 10 November 2016 at 06:09 PM r whitman said in reply to Anna... Are you an ACA participant?? There you go with the cost again. Forget the crooked government costs. The ACA people have health care which they did not have before. Several small businesses that I know have sent their employees to the ACA for health insurance and subsidize their premiums instead of screwing with insurance companies.

You need to divorce actual health care from the cost of health care. Health care is beneficial and in some cases curative. The cost is a racket like most government subsidy programs Reply 11 November 2016 at 10:45 AM

[Jul 25, 2017] Congress is obviously determined to replace Obamacare this year, without a viable alternative, and I think lobbying from hedge funds may be one of their motivations

Notable quotes:
"... Congress is obviously determined to replace Obamacare this year, without a viable alternative, and I think lobbying from hedge funds may be one of their motivations. ..."
"... All this comes back to the mystifying need in congress to enact a new healthcare bill this year that basically just removes a few key components of Obamacare. One of those key components is the Net Investment Income Surtax, which is a 3.8% tax on investment income that is used to increase Medicaid's coverage of people with low incomes. Is it possible that the urgency to pass a new healthcare bill this year is primarily related to its removal of a tax which helps calculate the $25-$100 billion that hedge funds will owe the government next year? If so, my guess is this will also have some influence on any tax cuts included in next years budget. ..."
"... "When asked if they would feel safe using a self-driving car, just 34% said they would while 67% said they would not." Huh? ..."
"... in the form of an amendment to the Republican bill ..."
"... even Republicans ..."
"... unless you give them your personal information. ..."
"... a high-risk investment in undeveloped and unproven ..."
Jul 25, 2017 | www.nakedcapitalism.com

JimTan , , July 25, 2017 at 3:16 pm

"And a majority doubt that President Trump .has a clear plan to replace Obamacare if Congress manages to repeal it."

Congress is obviously determined to replace Obamacare this year, without a viable alternative, and I think lobbying from hedge funds may be one of their motivations.

Hedge funds are compensated for their investment services using the standard 2 an 20 model, which means a management fee of 2% of all assets under management, and a performance fee of 20% of profits over a predetermined benchmark. Annual performance fees depend on how well the fund invests; low or no performance means no performance fee. This performance fee is classified by hedge funds as Carried Interest , which is a tax loophole that allows them to pay a low tax rate on these profits.

Annual management fees are independent of performance, and are always large numbers calculated as 2% of their multi-billion dollar assets under management. This management fee is commonly used to fund an offshore 'reinsurance company', because another tax loophole allows profits invested in these offshore insurance companies to be deferred indefinitely.

Apparently the 2008 bank bailout ( Emergency Economic Stabilization Act of 2008 ) closed this loophole and gave hedge funds until April 2018 to pay taxes on all these management fees they have been deferring in these offshore companies. On July 20th, the Wall Street Journal and CNBC estimated hedge fund managers collectively owe between $25-$100 billion in taxes on this money.

According to the article some hedge-fund managers face personal tax bills of over $100 million including Steven Cohen ( formerly SAC Capital ), David Einhorn ( Greenlight Capital ), and Daniel Loeb ( Third Point LLC ).

The article also says these deferred fees lower a hedge funds compensation costs, which suggests that many high level employees have past bonuses tied up in these offshore entities which are about to be taxed. To avoid some of these impending taxes, there is apparently an exodus of hedge funds moving to Florida which has no state income tax.

All this comes back to the mystifying need in congress to enact a new healthcare bill this year that basically just removes a few key components of Obamacare. One of those key components is the Net Investment Income Surtax, which is a 3.8% tax on investment income that is used to increase Medicaid's coverage of people with low incomes. Is it possible that the urgency to pass a new healthcare bill this year is primarily related to its removal of a tax which helps calculate the $25-$100 billion that hedge funds will owe the government next year? If so, my guess is this will also have some influence on any tax cuts included in next years budget.

IowanX , , July 25, 2017 at 7:08 pm

Hmmm. Tim Kaine was gushing on NPR yesterday about if the D's and R's worked together, what are the "fixes" and he's got a bill for "re-insurance"–but I don't know the details. Favorable tax treatment (I would guess) is almost certainly part of the bill.

Tim , , July 25, 2017 at 3:16 pm

"When asked if they would feel safe using a self-driving car, just 34% said they would while 67% said they would not." Huh?

Lambert, I think what is going on is driving used to be fun when there weren't very many cars on the road, now driving is so congested and commutes are so long that it is not only not fun, it is extremely stressful, so people are willing to take a hear no evil see no evil approach to driving just so they don't have the stress of doing the driving themselves.

The move to self driving cars is about safety at a society and government level, but at the individual level it is just about de-stressing and saving your concentration for other tasks.

I live 5 miles from work in a fully built out part of San Diego with good road infrastructure, so driving is still fun for me and I drive a stick shift, but I can see the guy stuck in LA traffic for 2-3 hours every day wanting to disconnect from that driving experience as soon as possible even if it may be less safe.

ChrisPacific , , July 25, 2017 at 7:30 pm

What's going on is that the poll is completely useless. I would like my next car to be autonomous. If it can fly, run without fuel, and transform into a magic fairy that cooks dinner and does the dishes, I'd like that too. Am I willing to entrust my safety to the current models on offer from the likes of Google and Uber (or their near term evolutions) knowing what I know about them and about their respective attitudes to regulatory and safety compliance? That's a totally different question.

What was the methodology for the survey? Who funded it? Where is the raw data? Providing disclosure on these points is standard surveying best practice. None of them are answered. The embedded links go to reportlinker.com which is a for-profit organization that produces business analytics. Who was their client in this case? I couldn't find that answer either.

I would file this one under advertising if I'm being kind, or propaganda otherwise.

River , , July 25, 2017 at 7:54 pm

If the car was like Ahmed from Count Zero , then sure I'd take one.

https://books.google.ca/books?id=dFX1xN7q-AgC&pg=PA113&lpg=PA113&dq=count+zero+ahmed&source=bl&ots=UwuJ_cxJpN&sig=Djqvols6Uu39bkQjnm2fOaocExY&hl=en&sa=X&ved=0ahUKEwim1NK20KXVAhWBzIMKHQGyDe8Q6AEIOTAC#v=onepage&q=count%20zero%20ahmed&f=false

page 112-113.

Mo's Bike Shop , , July 25, 2017 at 8:46 pm

Will our self driving cars be powered by the hydrogen economy?

Is SDC all unicorn feed, or is there some real tech being spun? I find everything bewildering about SDC evaporates when, like a fortune cookie, you add "on a battlefield" to the end.

Lambert Strether Post author , , July 25, 2017 at 3:21 pm

And :

Vice President Mike Pence cast the tie-breaking vote, clearing the procedural motion and allowing the Senate to begin debating an ObamaCare repeal.

On to the skinny bill, and then to the conference? But wait! Under reconciliation, there's the vote-o-rama to come:e

Those rules, defined by law, include allowing only 20 hours for debate but it also includes a process called "vote-a-rama," in which amendments may be proposed and must be voted on before the final passage of the bill. That's where Levin's idea comes in: He proposed introducing tens of thousands of amendments that would need to be voted on before the Senate's bill could be passed. In theory, Levin figured, Democrats could introduce enough amendments to shut down the Senate for a year.

It would be hilarious if Sanders introduced his single payer bill in the form of an amendment to the Republican bill . I don't know if that's possible under the rules, but why putz around with 1000s of little amendments?

mary , , July 25, 2017 at 3:26 pm

It would even more hilarious if the Senate Dems then all voted for it.

IowanX , , July 25, 2017 at 7:12 pm

+++++++100! Perfect. I think such an amendment would entirely be "in order". Lambert, you are a genius, and also a funny, funny man.

Cujo359 , , July 25, 2017 at 8:14 pm

I don't know what the rules allow, either, but you'd think that re-writing the House Medicare for All bill (HR 676) to be an amendment wouldn't take long. Neither the OC Repeal bill nor M4All is all that complex..

MikeW_CA , , July 25, 2017 at 3:31 pm

"Why Republicans should keep doing nothing" is a brilliant recommendation as far as I'm concerned, but at some point, don't even Republicans have to do something to deliver the goods their clients are paying for? What's the point of holding out for 2018 when you already have what should be the power to do whatever you want?

jo6pac , , July 25, 2017 at 3:39 pm

http://start.att.net/news/read/article/the_associated_press-the_latest_trump_keeps_up_twitter_pressure_on_heal-ap

Done and now part 2

Jim Haygood , , July 25, 2017 at 4:06 pm

Record closes today for the S&P 500 (at 2,477) and Nasdaq Composite.

This puts the "round number strange attractor" into effect: 2,500 or bust.

Dead Dog , , July 25, 2017 at 4:12 pm

Thank you, Lambert. Haven't posted a comment for a few days. Timing thing

Lots of news and links, but it feels less suspenseful at the mo – ie after the last 18 months or so – elections (US, UK, France), Brexit, Trump, Sanders, Corbyn, North Korean, the Russians, Yemen, Qatar and on, and on

Probably a good thing, I get more things done.

My home town of Cairns ticks along, same as. Well, as long as those pesky tourists keep coming (damn you Barrier Reef).

And, at least in my pub, the locals pay no attention whatsoever to anything happening south of Gordonvale (about 20k away). No, we are sophisticated. No politics, geo, neo, or whatever, or you have no friends. So, we sit there and take the piss out of everyone and we focus on footy, golf, the price of beer, cars, bikes, boats, fishing, camping and gossip.

I mean, why be curious like me? Nothing they can do to change things. And, as my partner says, I just don't want to know about that stuff (eg climate change, politics).

!!

One of the hidden news stories here in Oz is that a growing number of politicians (two Greens Senators, incl the QLD leader) have had to resign because of dual citizenship. ie you must be an Australian, and only an Australian (in our Constitution). (For example, I never renounced my UK citizenship (Anfield Boy) and would need to if I were to nominate to enter an election (not gonna happen).

The latest is our Resources Minister, Matt Canavan – who has resigned from the Parliament, after being told by his mother he was Italian, as well as Australian. See https://www.macrobusiness.com.au/2017/07/dual-citizenship-claims-canavan/

You can't make this up, eh? Hope they make him pay back the salary he has received during the years since he was elected.

To use the local venacular, Gold, pure Gold

6 am, still dark, cold, like about 17 degrees

Have a great day everyone

The Rev Kev , , July 25, 2017 at 7:11 pm

This story is hilarious. The ruling conservatives tore the Greens a new one last week over how they showed "extraordinary negligence" and "incredible sloppiness" over not checking that if their people had dual citizenship. Now it has come back to bite them hard and I heard that there may be about two dozen others from both major parties in the same boat.
Most people here say if you don't want to give up your other citizenship to serve another country in government, then don't bother putting your name in.The local 'intelligentsia'(?) are making noises that this is wrong and we should abolish that clause in our constitution. This clause does stop a country from flying in a bunch of carpetbaggers, err, technocrats and making them citizens on the spot to serve in government (I'm looking at you Ukraine).
Apparently countries like the US have no real problem with dual citizens serving in government ( http://thehill.com/blogs/congress-blog/homeland-security/240572-when-dual-citizenship-becomes-conflict-of-interest ) but at the end of the day, you have to wonder who they are actually serving at time. Could you imagine how it would look if, on CNN, if the members of the Senate and House of Reps were asked to put their hands up in the air if they were also citizens of another country? Not a good look I would imagine.

Dead Dog , , July 25, 2017 at 7:19 pm

Thank you, Kev, as you say, hilarious.

Now that the LNP have been caught being as sloppy as the greens, they've tried to argue that Canavan knew nothing, it was a staffer's fault, so he should be fine.

If you are right and this is start of a few more, then the make up of the Senate and the power therein could change in a bielection. Australians unlikely to vote in a party's replacement candidate – just the way we see things.

I didn't know the law officer ha ha

And, pay the family blog money back. Have to sell a few IPs?

Too sad

The Rev Kev , , July 25, 2017 at 8:12 pm

Sounds like he tried the Sergeant Schultz defense ( https://www.youtube.com/watch?v=UmzsWxPLIOo )
Come to think of it, didn't Shane Warne blame his mother too when accused of performance-enhancing drug taking?

Synoia , , July 25, 2017 at 10:06 pm

So, we sit there and take the piss out of everyone and we focus on footy, golf, the price of beer, cars, bikes, boats, fishing, camping and gossip.

All male group? No discussion of women? Or by women?

clarky90 , , July 25, 2017 at 4:40 pm

"The Democrats' 'Better Deal' is a box-office dud"

The cute, sad eyed puppy (The Democrats), that we brought home has grown up to be a thuggish Pit Bull Terrier. If it would only stop mauling the local children! So embarrassing. We must stare intensely at this dog with love- using positive affirmations. Then our Pit Bull will magically turn into a Labrador? (I don't think so.)

IMO, the democrats are hopeless. It is better to start a new party, or join the Republicans and influence that party? (Can I say this?)

The Dems are no longer the party of FDR. The Dems were pro slavery in the 1800s. Lincoln's Party was the Republicans.

"Anitya, anitya, anitya" (Impermanence). Everything changes. IMO, the Democrats are "a dead horse". Horse whispering will not work. Whipping will not work. Stand back and let time turn the carcass back into soil.

diptherio , , July 25, 2017 at 4:42 pm

Venezuela Constituent Assembly YES! Interference NO!

The U.S. State Department, the oligarchy and the Venezuelan right, together with the regional and European right have not let up in their attempt to destroy the enormous achievements accomplished by the Bolivarian Revolution of Venezuela and the Government of Nicolas Maduro.

The main objective that drives them, constantly and permanently, is to put into practice various methods of war in order to take control of the vast natural resources of the country, especially oil. Since Chavez, all those resources have been put in the hands and stewardship of the Venezuelan people.

It is the first time in two hundred years of history that this has happened, thanks to the emancipatory and anti-imperialist efforts of Commander Hugo Chávez – a direction continued by the Government of Maduro. The oil income is now at the disposal of huge projects aimed at benefiting those who were always forgotten and humiliated; the people, workers, farmers, blacks and native people.

Also for the first time in the history of Venezuela, illiteracy has been eradicated; more than 1,500,000 affordable homes have been built, education, culture and sports now reaches every corner and mountain top of the country and is no longer just a privilege to be enjoyed by the rich. Women have recaptured their dignity and today they occupy important positions at all levels of the life of the country, including the armed forces. Social missions have been multiplied to give a roof, work and land to those who never had anything .

Imperialism just could not stand what was happening.
So they plotted and invented a humanitarian crisis, by urging the Venezuelan right and the oligarchy to hide and destroy food and medicine while the imperialists themselves prevented shipments of these vital items. They gave cover to the cowardly terrorist imperialist right who have systematically refused to engage in dialogue while failing to organize even one "peaceful demonstration" that even remotely matched the size that the legitimate government of Maduro has been able to bring together.
Instead they have resorted to the most inhumane extreme tactics by funding, providing and sponsoring mercenaries that kill in the most horrendous ways any young man who looks like they could be a supporter of Chavez. Many times the color of their skin is enough to be set on fire.

http://theinternationalcommittee.org/venezuela-constituent-assembly-yes-interference-no/

curlydan , , July 25, 2017 at 4:42 pm

Maybe I'm the old hag. Anytime I read a summary of a Twitter fight (e.g. Joan Walsh), I get nauseous.

PKMKII , , July 25, 2017 at 4:56 pm

And tweetstorms. If you have that much to say, take it to a blog or Facebook.

clarky90 , , July 25, 2017 at 4:58 pm

Did South Park invent the alt-right?
http://www.avclub.com/article/south-park-raised-generation-trolls-258253

"South Park turns 20 years old this summer .The show celebrated this existential crisis-inducing fact last year with a tongue-in-cheek ad, depicting South Park as a sort of benevolent guarantor keeping reliable watch over a girl from infancy until her first trip to college. It was a typically self-effacing joke, but it's true: Our world is now filled with people for whom South Park has always been there, a cultural influence that, in some cases, is completely foundational to their point of view. The ad doesn't end with the girl logging onto Twitter to complain that social justice warriors are ruining the world, but otherwise, spot on."

polecat , , July 25, 2017 at 5:19 pm

You could say the same for, say, SNL no?
.. comedy of a different face, but still

MyLessThanPrimeBeef , , July 25, 2017 at 5:48 pm

Should I not have quit watching TV?

The quoted passage sounds quite foreign to me.

Richard , , July 25, 2017 at 9:07 pm

I used to frequent AV Club religiously, until they lost most of their best, veteran writers in what seemed like a purge a few years ago. Whenever I peeked in in '16, it seemed like Team Blue Central, shoehorning every feature into a critique of Trump, stupid conservatives, ignorant deplorables, etc.
That said, Sean O'Neill (a holdover from that earlier period) is an awesome writer, who has always had a penchant for holding elites (mostly cultural elites) up to well deserved ridicule in his news updates. And this is a fine piece. I wouldn't go as far as the title suggests, and neither does O'Neill actually; he backs down a bit in his conclusion.
I have real respect for South Park. Its writers have always understood an essential component of satire that liberal darlings (on the same network!) like the Daily Show and the Colbert Report tended to miss: you have to be merciless, and you can't make nice afterwards. You need to keep your distance.
It's possible the South Park and NC are a match made in heaven even! Co-creator Matt Stone's comment, " I hate conservatives, but I really (family blogging) hate liberals!"

Daryl , , July 25, 2017 at 9:40 pm

I don't think South Park is foundational to anyone's world view.

ewmayer , , July 25, 2017 at 5:49 pm

"At its core, the Times's internal transformation focuses on upending the paper's copy desk blah blah blah" [Vanity Fair] -- VF writer expends much digital ink fretting over the Verwandlung of the NYT, somehow omits the "and it's *still* an elite establishment propaganda rag which for the good of humankind would best be taken out into the alley and shot" bit.

Pat , , July 25, 2017 at 6:09 pm

OMG, the comedy just writes itself. McCain gets up after the vote to proceed and announces he won't vote for the bill itself because it is a shell of a bill. And then begs his fellow senators to work together. While it isn't quite Hillary Clinton giving an impassioned speech noting all the reasons NOT to vote for AUMF before voting for it, it is still pretty high up on the 'have it both ways' thing. And the bargaining begins.

McConnell better have lots left in that slush fund.

https://www.washingtonpost.com/news/the-fix/wp/2017/07/25/were-getting-nothing-done-john-mccains-no-holds-barred-lecture-to-the-senate-annotated/?utm_term=.30aa247203f5

Mad Pear , , July 25, 2017 at 6:25 pm

A better bad deal is still a bad deal. America doesn't need a better bad deal. America needs a good deal.

Steely Glint , , July 25, 2017 at 7:02 pm

2018, what is needed is a full throated roar of money is not speech, except in the "Market" and politics do NOT belong in the market sphere. That is why Bernie's message resonated, and why his list is so important! The 90 percent will be heard. And until the " little" people who are waiting for this to happen get a response, important matters like health insurance, demise of monopolies in agriculture "Red State" fly over country matter a great deal. Want to know why consumer spending on new cars are falling? Look no farther than the gig economy, where today's paycheck may be gone tomorrow, due to H1B visas, or what ever trade agreements have locked us into. Sorry, mic drop.

Oregoncharles , , July 25, 2017 at 7:18 pm

" an out-of-work auto mechanic whose nerve-damaged shoulder makes it impossible to lift his 11-month-old baby. " Or work.

Good luck to him. When my shoulder was damaged (admittedly, by doing something dumb), medical care was considerably worse than useless. Nerve damage? I know of nothing that will help that.

3.14e-9 , , July 25, 2017 at 7:18 pm

OT question for NC readers familiar with auto lending:

I recently got an auto loan from my credit union (awesome deal on a hybrid SUV on eBay, but that's another story). At the signing last month, I had to provide proof of insurance meeting minimum requirements, standard for auto loans: comprehensive and collision, max $1,000 deductible, with credit union listed as lienholder. I had it all set up beforehand, the loan officer approved it, so far, so good.

Then, in yesterday's mail, I received a letter saying that the credit union had received "evidence of insurance," but was "unable to fully accept this policy," because it didn't include comprehensive or collision coverage. I'm like, WTF? My policy actually exceeds the requirements, with $500 deductible C&C, plus an added premium for the balance to be paid to the lender in case something happens to the car before the loan is paid off.

I emailed the loan officer, and here's where it gets interesting. She apologized for the inconvenience and said it likely was because the credit union recently partnered with a third party for their insurance paperwork. She called it Allied Insurance, but a quick search showed that it's actually Allied Solutions LLC, which is a subsidiary of Securian. I'm not exactly sure what they do or why the credit union partnered with them, but alarm bells are going off in my head, starting with what they're doing with my private information.

After a few exchanges with the loan officer, I'm told that the proof-of-insurance form I signed authorized the credit union to provide its "Insurance Service Center" with the necessary information to verify coverage. Why they would need verification when they had the policy right in front of them is beyond me. More to the point, though, it doesn't say "third-party" insurance center. The average borrower/CU member could be excused for thinking this was an internal department.

I looked back over the letter I received last night. Nowhere does it identify the sender as Allied Solutions – not even on the outside of the envelope – and in fact it has my credit union's logo in the upper left-hand corner. It is signed simply, "Insurance Service Center." Further, it said I could have my insurance company forward a copy of my policy or, "for [my] convenience," I could verify the information online by accessing "my account" on myinsuranceinfo.com, or my insurance company could do it. Deafening alarm bell.

The letter not only was threatening ("You don't have the proper insurance on your car!"), but it essentially was accusing me of changing my insurance policy after the fact, since the loan officer had already approved it. Meanwhile, the loan officer is telling me I gave the credit union permission to share my insurance information with this company, even though they aren't named on the insurance paperwork or even identified as a generic "third party," and didn't identify themselves as such on their correspondence. Does this just "border on" fraud, or is it outright fraud?

The loan officer also sent me a copy of the CU's privacy policy saying they can legally share personal information for "everyday business purposes." Is the average bank/CU customer supposed to somehow just assume this means their auto insurance policy can be shared with third parties? And that they don't have to be notified about how that third party will use their private information?

In fact, the "terms of service" page on myinsuranceinfo.com says that any information you give them in feedback, comments, and the like, becomes theirs to use as they please. They collect personal information about visitors to the site only for statistical purposes, blahblah, unless you give them your personal information. Here's the exact language:

Allied Solutions will not obtain personally-identifying information about you when you visit our site, unless you choose to provide such information to us, nor will such information be sold or otherwise transferred to unaffiliated third parties without the approval of the user at the time of collection.

Well, now, how do you sign into "your account" and verify your insurance without providing them your personal information? I don't know, because I didn't even consider signing in.

I did a little more research and found a few credit union sites that link to myinsuranceinfo as a "service" to their members. From what I can tell, Allied offers the same service to banks.

In addition to the above questions, can any NC readers in financial services explain what's really going on here? Or maybe this is normal, and I should hop back on the turnip truck? Of course, that's not all Allied does. It looks to me like maybe they buy and sell auto loans, but I concede that I never understood that whole process, so I could be mistaken. What I do know – well, from what I've read in comments on NC – is that there's some weird activity going on lately with auto loans. Does the situation I describe fit into that in any way?

THANKS!!!

Jean , , July 25, 2017 at 9:17 pm

I wish I could help. Commiseration count? It's almost like a sci-fi plot – the mind-fuck of it.

Altandmain , , July 25, 2017 at 8:04 pm

Chlorinated chicken? Yes, we really can have too much trade
https://www.theguardian.com/commentisfree/2017/jul/25/chlorinated-chicken-trade-britain-us-food-standards-globalisation

Quite alarming if you think about US food standards.

Democrats Don't Know the First Thing About "Chasing" Rural Voters
http://progressivearmy.com/2017/07/25/democrats-dont-know-first-thing-chasing-rural-voters/

More policing, less spent on social programs
https://blavity.com/center-popular-democracy-policing-budget-study

alex morfesis , , July 25, 2017 at 8:30 pm

This day which will live in infamy lost behind the Trumpcare kabuki of john mccain & the declaration of war against russia, iran & 1dumbsun (419-3 ww3 here we come ) as the queen bee has previously pointed out litigation futures of darkoynz bit and ether and lite et al

sec comes out with report suggesting ico nonsense is actionable

https://www.sec.gov/litigation/investreport/34-81207.pdf

although "no action" for some reason on this german firm they go beyond just the indiviual
coynz themselves and insist the "exchanges" must also register as a National Securities Exchange

wow know a handful of securities attorneys who could probably clean up and fix the ico messes

but how many firms have actually worked on the being registered as an exchange side of things heck how many tall building law firms can even suggest they can do it

https://www.sec.gov/news/press-release/2017-131

and in all the risk factors suspect not even one ICO had the sec favored language of:

a high-risk investment in undeveloped and unproven

although this could get somewhat interesting if the sec allows a flood of these ico national security exchanges, it will possibly open up the scenario of local stock exchanges or "angel" exchanges much like in the days prior to the "big bang"

but the queen bee was spot on

most of these ico things will probably need to do roll ups and merge just to sustain the costs involved even if they go ahead and have a nice healthy carl icahn "end of the world" 2 inch thick litigation proof set of potential risk disclosures it will be interesting

sorry about the bold here .tried to cut and paste and redo and could not figure out how to make it go away..

[Jul 25, 2017] Dont underestimate how personally piqued McCain is over President Obama, taking McCains turn, when it comes time for a vote. McCain is a nasty man

Notable quotes:
"... One of my neighbors has this to say about McCain: "I worked for American Continental. So I know what kind of a crook he is!" Said neighbor is also of the "McCain was a traitor while in North Vietnamese custody!" school. ..."
"... As to your neighbor's opinion of McCain as a collaborator, this post from Ron Unz of the Unz Review is rather eye-opening . ..."
"... McCain comes back from getting health care to help make sure others don't get health care. That's nice. ..."
"... One would have though McCain's incessant pounding on the war drums would have been enough to turn people off. I can't understand how he is so eager to send people off to repeat what happened to him. ..."
"... It probably doesn't matter whether Arizonans notice or not. McCain isn't up for reelection until 2022, so even if he survives longer than the average person with his type of cancer, in 2022 he'll still probably be dead or too weak to campaign for another term. ..."
Jul 25, 2017 | www.nakedcapitalism.com

NotTimothyGeithner , July 25, 2017 at 2:31 pm

Don't underestimate how personally piqued McCain is over President Obama, taking McCain's turn, when it comes time for a vote. McCain is a nasty man. Now that Herr Trump beat Hillary, even McCain might have done it.

Pat , July 25, 2017 at 5:11 pm

Which only proves that McCain truly is an idiot, or doesn't expect to live for another two or so years. Having a signature 'achievement' fail outright to be far more embarrassing than repealing it and having your version of healthcare, whatever it is, fail as badly or worse than ACA would, Especially since delusional folk will still think we would be in the best shape ever if only the big bad Republicans hadn't repealed Barack Obama's health reform plan. There is no such glittery unicorn if ACA continues and dies of its own weight.

(I should note that for those us not under the media induced delusion of McCain as mavericky upstanding moral leader McCain being a vindicative idiot is very old news.)

Arizona Slim , July 25, 2017 at 6:19 pm

One of my neighbors has this to say about McCain: "I worked for American Continental. So I know what kind of a crook he is!" Said neighbor is also of the "McCain was a traitor while in North Vietnamese custody!" school.

JerseyJeffersonian , July 25, 2017 at 6:51 pm

As to your neighbor's opinion of McCain as a collaborator, this post from Ron Unz of the Unz Review is rather eye-opening .

Worthy of a read, particularly for the links to researchers' posts on the matter.

JohnnyGL , July 25, 2017 at 3:09 pm

McCain comes back from getting health care to help make sure others don't get health care. That's nice.

Tim , July 25, 2017 at 3:21 pm

I noticed that irony too, I don't see how anybody in the public would NOT notice that irony, since it is a well known fact that congress gets their own health care guaranteed.

Roger Smith , July 25, 2017 at 3:40 pm

Maybe if they have brain cancer they wouldn't notice . oh.

One would have though McCain's incessant pounding on the war drums would have been enough to turn people off. I can't understand how he is so eager to send people off to repeat what happened to him.

Vatch , July 25, 2017 at 5:33 pm

It probably doesn't matter whether Arizonans notice or not. McCain isn't up for reelection until 2022, so even if he survives longer than the average person with his type of cancer, in 2022 he'll still probably be dead or too weak to campaign for another term.

Arizona Slim , July 25, 2017 at 6:22 pm

And he keeps getting weak opponents on the D side of the ballot. In 2016, it was Ann Kirkpatrick. To this day, I can't figure out why she was so compelling to the Arizona Democratic Party establishment. Oh, in 2010, you're gonna love this: Rodney Glassman. Guy didn't even complete a single term on the Tucson City Council, but he thinks he can go up against one of the best-known names in American politics. Epic fail.

[Jun 28, 2017] Follow the Money: Non-Profit Hospital CEOs Quietly Collect Their Millions While US Health Care Reform Battle Rages by Roy M. Poses MD

Jun 28, 2017 | hcrenewal.blogspot.com
June 22, 2017 In Washington, DC the health care policy wars continue, with a few Republican senators working behind closed doors on a bill to "repeal and replace" Obamacare, aka the Affordable Care Act, and Democrats decrying their secrecy. Just as during the era in which Obamacare was enacted, there is constant discusison of how US health care costs continually rise, driving up insurance premiums, and how access to health insurance is continually in peril.

However, while the current Republican process to write new legislation seems strikingly opaque, in neither era has there been a frank discussion of why US health care costs are so amazingly high, and disproportionate to our mediocre health care outcomes. In particular, there has hardly been any discussion of just who benefits from the rising costs, and how their growing wealth may impede any real cost-cutting measures.

An obvious example is the gravity defying pay given to top health care managers, particularly the top managers of non-profit hospital systems.

Such systems provide much of the hospital care to Americans, and most have declared their missions to be providing the best possible care to all patients, or words to that effect. Many explicitly include care of the poor, unfortunate and vulnerable as a major part of their missions. As non-profit organizations, their devotion of mission provides some rationale to their freedom from responsibility for federal taxes.

As we last discussed in detail in May, 2016 , we have suggested that the ability of top managers to command ever increasing pay uncorrelated with their organizations' contributions to patients' or the public's health, and often despite major organizational shortcomings indicates fundamental structural problems with US health, and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.

In particular, we have written a series of posts about the lack of logical justification for huge executive compensation by non-profit hospitals and hospital systems. When journalists inquire why the pay of a particular leader is so high, the leader, his or her public relations spokespeople, or hospital trustees can be relied on to cite the same now hackneyed talking points.

As I wrote in 2015, and in May, 2016 ,

It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy. We first listed the talking points here, and then provided additional examples of their use. here , here here, here , here, and here , here and here .

They are:

Yet as we discussed recently , these talking points are easily debunked. Additionally, rarely do those who mouth the talking points in support of a particular leader provide any evidence to support their applicability to that leader.

Boston, Massachusetts area, August, 2016 ( Per the Boston Business Journal )

West New York State, August, 2016 ( Per the Buffalo News

New Jersey, September, 2016 NJ Advance Media)

Top 10 hospital CEOs received total compensation from $1.94 million to $4.7 million

New Orleans, Lousisiana, September, 2016 (Per the Times-Picayune)

Gastonia, North Carolina, February, 2017 (Per the Gaston Gazette )

York County, Pennsylvania, April, 2017 (Per the York Daily Record)

Tri-Cities region, Tennessee and Virginia, June, 2017 (Per WJHL )

Connecticut, June, 2017 ( Per the Connecticut Post)

Summary and Conclusions

The current inflamed discussion of "Obamacare" and Republican attempts to "repeal and replace" it focuses on the costs of care and how they affect individual patients. Examples include concerns about health insurance premiums that are or could be unaffordable for the typical person; insurance that fails to cover many costs, and thus may leave patients at risk of bankruptcy due to severe illness; poor people unable to or who might become unable to obtain any insurance, and perhaps any health care. Yet there is little discussion of what really drives high and ever increasing health care costs (while quality of health care remains mediocre).

That may be because those who are benefiting the most from the status quo want to prevent discussion of their role. There are many such people, but top management of non-profit hospitals provide a ready example. Their institutions' mission is to provide care to sick patients. Many such hospitals specifically pledge to provide care to the poor, vulnerable, and disadvantaged. Non-profit hospitals have no owners or stockholders to whom they owe revenue.

Yet these days the top executives of non-profit hospitals receive enough money to become rich.

See the examples above.

The justification for such compensation is pretty thin. Consider the talking points above. Apparently hospitals are extremely concerned about paying top management enough to recruit and retain them. Yet there is much less evident concern about paying a lot of money to recruit and retain the health care professionals who actually take care of patients to fulfil the hospitals' mission. Hospital CEOs are frequently proclaimed to be brilliant, visionaries, or at least incredibly hard workers with very complex jobs. I wonder if those who make such proclamations have any idea what it takes to be a good physician or a good nurse. Yet such health care professionals' hard work, long training, devotion to duty, and ability to deal with trying situations and make hard decisions rarely inspire hospitals to shower them with money.

Furthermore, hospital CEO compensation is almost never justified in terms of their ability to uphold and advance the fundamental hospital mission, taking care of sick people. The articles above do not contain any justifications of generous CEO compensation based on hospitals' clinical performance or health care outcomes. At best, hospital executive pay seems to be justified by the hospitals' financial, not clinical performance.

As we discussed here , there is a strong argument that huge executive compensation is more a function of executives' political influence within the organization than their brilliance or the likelihood they are likely to be fickle and jump ship for even bigger pay. This influence is partially generated by their control over their institutions' marketers, public relations flacks, and lawyers. It is partially generated by their control over the make up of the boards of trustees who are supposed to exert governance, especially when these boards are subject to conflicts of interest and are stacked with hired managers of other organizations.

Furthermore, such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat. As an op-ed

Outrageous pay gives top executives an incentive to behave outrageously. To hit the pay jackpot, they'll do most anything. They'll outsource and downsize and make all sorts of reckless decisions that pump up the short-term corporate bottom line at the expense of long-term prosperity and stability.

So I get to recycle my conclusions from many previous posts....

We will not make any progress reducing current health care dysfunction if we cannot have an honest conversation about what causes it and who profits from it. In a democracy, we depend on journalists and the news media to provide the information needed to inform such a discussion. When the news media becomes an outlet for propaganda in support of the status quo, the anechoic effect is magnified, honest discussion is inhibited, and out democracy is further damaged.

True health care reform requires publicizing who benefits most from the current dysfunction, and how and why. But it is painfully obvious that the people who have gotten so rich from the current status quo will use every tool at their disposal, paying for them with the money they have extracted from patients and taxpayers, to defend their position. It will take grit, persistence, and courage to persevere in the cause of better health for patients and the public.

And for our musical interlude, the beginning of "For the Love of Money," sung by the O'Jays, used in the official intro of season 2 of guess what show?

https://www.youtube.com/embed/rgr6EuG6zBw

[Jun 28, 2017] Trump betrayed all three his election time promises about changes to Obamacare: everybody got to be covered, no cuts to Medicaid, and Every bit as good on pre-existing conditions as Obamacare

Jun 28, 2017 | economistsview.typepad.com

im1dc June 25, 2017 at 09:27 AM

Here is a 5 day old article on Trump deregulating Big Pharma that directly impacts the skyrocketing costs of American Health Care to go with the above posts re the Republican Party's AHCA cutting of coverage and transfer of wealth to the wealthiest in America

Trump is the #1 problem with American Health Care today, he works for the interests of the corporations not the people's

https://www.nytimes.com/2017/06/20/health/draft-order-on-drug-prices-proposes-easing-regulations.html

"Draft Order on Drug Prices Proposes Easing Regulations"

By SHEILA KAPLAN and KATIE THOMAS...JUNE 20, 2017

"In the early days of his administration, President Trump did not hesitate to bash the drug industry. But a draft of an executive order on drug prices appears to give the pharmaceutical industry much of what it has asked for - and no guarantee that costs to consumers will drop.

The draft, which The New York Times obtained on Tuesday, is light on specifics but clear on philosophy: Easing regulatory hurdles for the drug industry is the best way to get prices down.

The proposals identify some issues that have stoked public outrage - such as the high out-of-pocket costs for medicines - but it largely leaves the drug industry unscathed. In fact, the four-page document contains several proposals that have long been championed by the industry, including strengthening drugmakers' monopoly power overseas and scaling back a federal program that requires pharmaceutical companies to give discounts to hospitals and clinics that serve low-income patients.

Mr. Trump has often excoriated the drug industry for high prices, seizing on an issue that stirs the anger of Republicans and Democrats alike. He has accused the industry of "getting away with murder," and said that he wanted to allow the federal government to negotiate directly with drug companies over the price of drugs covered by Medicare.

But the proposed order does little to specifically call out the drug industry and instead focuses on rolling back regulations, a favorite target of the administration..."

im1dc -> im1dc... , June 25, 2017 at 09:37 AM
Additional evidence of Trump lying about his and the Republican AHCA repeal of Obamacare

https://www.usatoday.com/story/news/politics/2017/06/24/promises-trump-made-health-care-repeal-plans/426089001/

"3 promises Trump made about health care that repeal plans haven't kept"

Eliza Collins , USA TODAY ...June 24, 2017

"...Here are three promises Trump made that will not come true under the current bills moving through Congress:

  1. 'Everybody's got to be covered.'...
  2. 'No cuts' to Medicaid"...
  3. 'Every bit as good on pre-existing conditions as Obamacare.'...
im1dc -> pgl... , June 25, 2017 at 11:53 AM
Cuts, cuts, and more cuts to reimbursement that's the Trump Republican AHCA in a nutshell.

All it will accomplish is to transfer $Billions to 'Trump's People', his fellow $Billionaires and MegaMillionaires.

It will not deliver on any Promise Trump made on Health Care and when he and the Republicans say it does they are lying, pure and simple.

More care does not come from far less money spent especially as the need increases due to population and need.

im1dc -> im1dc... , June 25, 2017 at 09:45 AM
I don't know the reason for persistence at attempts to understand the Economics of Trump's and the Republican various remake of the American Economy from an academic Economics perspective by this blog.

It is not possible to do any such rational analysis, b/c as Paul Krugman has pointed out recently and pointedly, there is no rhythm or reason to what they are doing except to obtain the sole single outcome of a major transfer of wealth to the wealthiest Americans in the form of a huge tax cut for most of America's Billionaires and Mega-Millionaires by eliminating as much as possible of the American Safety Net and other protections from the 99%.

[Jun 28, 2017] We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, tha we canaffort single payer helathcare system

Jun 28, 2017 | economistsview.typepad.com

Christopher H. , June 28, 2017 at 08:10 AM

We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, but PGL and the weak tea centrists demand "how are we going to pay for it???" now that single-payer is becoming a real possibility. Every other advanced nation does it better with massive savings for their taxpayers.

http://www.latimes.com/opinion/op-ed/la-oe-pollin-single-payer-healthcare-healthy-california-20170621-story.html

Op-Ed Single-payer healthcare for California is, in fact, very doable

by Robert Pollin

June 21, 2017

The California Senate recently voted to pass a bill that would establish a single-payer healthcare system for the entire state. The proposal, called the Healthy California Act, will now be taken up by the state Assembly. [not]

The plan enjoys widespread support - a recent poll commissioned by the California Nurses Assn. found that 70% of all Californians are in favor of a single-payer plan - and with good reason. Under Healthy California, all residents would be entitled to decent healthcare without having to pay premiums, deductibles or copays.

But as critics of the bill have pointed out, a crucial question remains: Is Healthy California economically viable? According to research I conducted with three colleagues at the University of Massachusetts, Amherst, the answer is yes.

Enacting Healthy California would entail an overhaul of the state's existing healthcare system, which now constitutes about 14% of California's GDP. In particular, it would mean replacing the state's private health insurance industry with government-managed insurance. Our study - which was also commissioned by the California Nurses Assn. - concludes not only that the proposal is financially sound, but that it will produce greater equity in the healthcare sector for families and businesses of all sizes.

California will spend about $370 billion on healthcare in 2017. Assuming the state's existing system stayed intact, the cost of extending coverage to all California residents, including the nearly 15 million people who are currently uninsured or underinsured, would increase healthcare spending by about 10%, to roughly $400 billion.

That's not the full story, though. Enacting a single-payer system would yield considerable savings overall by lowering administrative costs, controlling the prices of pharmaceuticals and fees for physicians and hospitals, reducing unnecessary treatments and expanding preventive care. We found that Healthy California could ultimately result in savings of about 18%, bringing healthcare spending to about $331 billion, or 8% less than the current $370 billion.

How would California cover this $331-billion bill? For the most part, much the same way it covers healthcare spending right now. Roughly 70% of the state's current spending is paid for through public programs, including Medicare and MediCal. This funding - totaling about $225 billion - would continue, as is required by law. It would simply flow through Healthy California rather than existing programs.

The state would still need to raise about $106 billion a year to cover the cost of replacing private insurance. This could be done with two new taxes.

First, California could impose a gross receipts tax of 2.3% on businesses, but with an exemption for the first $2 million of revenue. Through such an exemption, about 80% of all businesses in California - small firms - would pay nothing in gross receipts tax, and medium-sized businesses would pay an effective tax rate of less than 1%.

Second, the state could institute a sales tax increase of 2.3%. The tax would not apply to housing, utilities, food purchased for the home or a range of services, and it could be offset for low-income families with a 2% income tax credit.

Relative to their current healthcare costs, most Californian families will end up spending less, even with these new taxes, and some will even enjoy large gains. Net healthcare spending for middle-income families would fall by between 2.6% and 9.1% of income. Most businesses would also see a drop in spending. Small firms that have been providing health insurance for their workers will see costs fall by 22% as a share of payroll. For medium-sized firms, costs will fall by an average of between 6.8% and 13.4% as a share of payroll. Even most large firms will see costs fall, by an average of between 0.6% and 5% of payroll.

At the moment, about 2.7 million of California's residents, or about 8% of the population, have no health insurance. Another 12 million residents, or about 33% of the population, are underinsured. A large proportion of the remaining 60% of the population who are adequately insured still face high costs, as well as anxiety over President Trump's proposal to repeal and replace Obamacare.

Healthy California is capable of generating substantial savings for families at most income levels and businesses of most sizes. These savings are in addition to the benefits that the residents of California will gain through universal access to healthcare.

[Jun 28, 2017] how many people know, understand or even care what an "individual mandate" is

Jun 28, 2017 | economistsview.typepad.com

JohnH , June 28, 2017 at 08:17 AM

The message matters...something that eludes comprehension by Democrats... Question is are they really this stupid, or are they paid to be this stupid?

"How did [the healthcare debate] get to this point? A point where Harvard researchers are warning of 217,000 additional deaths over the next decade from a loss of health coverage? Part of the blame has to lie with the Democrats, who failed to heed Luntz's advice to the Republicans...

First, in defending Obamacare, they lacked "words that work." For instance, how many people know, understand or even care what an "individual mandate" is? How about insurance "exchanges"? Or the "public option"? These technical terms and phrases have obscured more than they have clarified. They have also played into the hands of the Republicans, who have worked hard to ensure that the public view health care only through a partisan lens.

Remember: around one in three Americans is unaware of the fact that there is no difference between Obamacare and the Affordable Care Act (ACA) - they are one and the same. Many of these people tell pollsters that they like the ACA but dislike Obamacare. (Isn't it odd how so many Americans' view of a health care system changes when you put the foreign-sounding name of a black man in front of it?)

Second, Democrats have turned down opportunity after opportunity to offer a comprehensive health care alternative that guarantees coverage to all Americans (unlike Obamacare, which leaves around 27 million Americans uninsured.) During the Democratic primaries, Hillary Clinton said a single-payer "health care for all" system would "never, ever come to pass." Inspiring, huh?

As for those on the left like Bernie Sanders and - belatedly - Elizabeth Warren, who are keen to offer a progressive alternative to both Trumpcare and Obamacare in the form of guaranteed, government-funded health care for all, they may have a clear and inspiring policy alternative but whether they have a clear and inspiring message for it remains to be seen. For example, according to a February 2016 poll by the Kaiser Family Foundation, "nearly two thirds (64%) of Americans say they have a positive reaction to the term 'Medicare-for-all,' and most (57%) say the same about 'guaranteed universal health coverage.' Fewer have a positive reaction to 'single payer health insurance system' (44%) or 'socialized medicine' (38%)."

The words don't work and, as a result, ignorance abounds.
"About half (53%) of Democrats say they have a very positive reaction to 'Medicare-for-all' compared with 21 percent who say the same for 'single payer health insurance system,'" according to the Kaiser poll. But to be clear: "Medicare-for-all" and "single payer" refer to the same exact thing.
So then "Medicare-for-all" must be the way to go, right? Rather than the bureaucratic-sounding and yawn-inducing "single payer"? Perhaps. Invoking Medicare to make the case for a system in which the government covers the cost of all health care claims, however, may not be the silver bullet that some on the left seem to think it is. Not everyone associates Medicare with the government. Remember the anti-Obamacare town halls in the summer of 2009, where attendees carried placards that read "Keep government out of my Medicare"? An August 2009 poll found that 39% of Americans said they wanted government to "stay out of Medicare" - which is, of course, impossible.

Why don't progressives go with the simpler option of calling their single-payer proposal "universal health care"? Or "health care for all"? In San Francisco, a single payer system called "Healthy San Francisco" was launched a decade ago and has had very high approval ratings. How about Sanders, Warren et al push for a federal version called "Healthy America"?"
https://theintercept.com/2017/06/28/memo-to-democrats-you-need-a-clear-message-for-universal-healthcare/

[Jun 28, 2017] Prescription Drug Spending is Consuming a Bigger Share of Wages

Notable quotes:
"... The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024. ..."
Jun 28, 2017 | economistsview.typepad.com

anne

, June 27, 2017 at 05:19 PM
http://cepr.net/blogs/cepr-blog/prescription-drug-spending-is-consuming-a-bigger-share-of-wages

June 27, 2017

Prescription Drug Spending is Consuming a Bigger Share of Wages
By Brian Dew and Dean Baker

Prescription drugs are a large and growing share of national income. While it is generally recognized that drugs are expensive, many people are unaware of how large a share of their income goes to paying for drugs because much of it goes through third party payers, specifically insurance companies and the government.

The Centers for Medicare & Medicaid Services (CMS) produce projections of national expenditures on prescription drugs through 2025, along with historical estimates dating back to 1960. As shown below, prescription drug spending from 1960 to 1980 was equivalent to about one percent of total wage and salary income. In the years leading up to the passage of the Bayh-Dole act in 1980, wage income was rising faster than spending on prescription drugs. As a result, the share of wages spent on prescription drugs was actually falling, reaching a low in 1979 of 0.86%.

[Graph]

However, after 1980, prescription drug spending rose rapidly relative to wage income. The ratio of drug spending to wages rose each year from 1980 to 2007. In 2007 wage growth finally outpaced drug expenditures, with the ratio again increasing in the Great Recession. By 2010, prescription drug spending had climbed above four percent of wage income.

The three percent of annual wage income lost to higher drug spending over the past 40 years makes a big difference to working individuals and families. This increase in annual spending averages out to roughly $2,400 per household. CMS projections, combined with projections on wage income growth from the Congressional Budget Office, suggest that spending on prescription drugs will increase further through 2025. This ratio is expected to exceed five percent by 2024.

While an aging population has been a factor increasing spending on drugs, demographics alone cannot explain the sharp increase in prescription drug spending. Inflation-adjusted prescription drug spending per household has increased more than eightfold since 1980, far outpacing any demographic trend surrounding age. The share of people over age 65 in the population has increased from 9.2% in 1960 to 14.8% in 2015. This can at most explain a small part of the increase in spending on drugs over this period.

[Graph]

It is important to recognize that the high cost of drugs is the result of a conscious policy decision to give drug companies monopolies in the form of patents and other forms of exclusive marketing rights. Without these protections drugs would almost invariably be cheap, likely costing on average less than one fifth as much as they do now. Even worse, the perverse incentives resulting from patent monopolies distort the research process and can lead drug companies to misrepresent evidence on the safety and effectiveness of their drugs.

[Jun 25, 2017] Obama basically decided against marketing his healthcare plan.

www.unz.com

JohnH -> kurt... , June 23, 2017 at 07:05 PM

Jun 25, 2017 | economistsview.typepad.com
Obama basically decided against marketing his healthcare plan. In February, 2009 the Obama campaign contacted campaign workers and asked them to convene neighborhood groups to make suggestions for the plan. My wife and eye convened such a group. We believed it was to be part of a national grass roots push to overwhelm the naysayers.

We sent in the neighborhood's suggestions. We were told they would get back to us. They never did. Grassroots organizing was eliminated. There was no grassroots push. Obama hardly marketed his plan, letting Republicans define it for him.

That was when I began to smell a rat...

JohnH -> sanjait... , June 23, 2017 at 07:48 PM
"It's the Message, Stupid"
http://inthesetimes.com/article/5030/its_the_message_stupid

Back in 2009, Greenberg, Carville and Bauman developed a strategy for selling healthcare reform to the public...most of which Democrats just ignored. http://www.democracycorps.com/wp-content/files/dcorps-healthcare-062509.pdf

Much of it still applies today, but Democrats are clueless...they fear their big donors would revolt if they actually stated what the American people want and need.

JohnH -> mulp ... , June 23, 2017 at 08:06 PM
"actually works" is in the eye of the beholder.

Numbers of economists defended Bernie's proposals...but establishment ones linked with the Democratic Party did not.
http://observer.com/2016/02/liberal-economists-defend-bernie-sanders-against-a-chorus-of-critics/

Bill Black and Jaimie Galbraith were among the most prominent...but you never heard about their push-back because the liberal media blocked it out.

pgl , June 23, 2017 at 12:04 PM
Steve Beshear who was the Democratic Kentucky Governor who did a great job of implementing Obamacare for his state was asked about the stances of his state's two Senators. He really laid in McConnell which was no surprise. His comment re Rand Paul? Senator Paul wants to take our nation back to the 18th century.
jonny bakho -> Lee A. Arnold ... , June 23, 2017 at 05:12 PM
Please... Susan Collins is just as bad as the rest of them. Her carefully crafted public image is all show.

GOP moderates always cave because they are not moderates, they just play to the tastes of their purple states

The GOP will throw a few crumbs, make a big show about the "moderates" improving the bill and then they will be free to vote for it.
Trump, ever the con artist will sell it as Trump steak

JohnH -> kurt... , June 23, 2017 at 04:05 PM
Oh, BS. That the party is corrupt was made evident to anyone who watched Bubba sign away Glass-Steagall, just in time for Hillary to announce her run for Senator from New York/Wall Street. Of course, Bubba insists that there was no quid quo pro. Those who believe him would be good customers for buying the Brooklyn Bridge...

Since then, it's only gotten worse.

[Jun 24, 2017] The Secret Republican Plan to Unravel Medicaid by Robert Reich

Jun 24, 2017 | economistsview.typepad.com

Christopher H, June 23, 2017 at 01:23 PM

http://robertreich.org/post/162168911075

The Secret Republican Plan to Unravel Medicaid

by Robert Reich

FRIDAY, JUNE 23, 2017

Bad enough that the Republican Senate bill would repeal much of the Affordable Care Act.

Even worse, it unravels the Medicaid Act of 1965 – which, even before Obamacare, provided health insurance to millions of poor households and elderly.

It's done with a sleight-of-hand intended to elude not only the public but also the Congressional Budget Office.

Here's how the Senate Republican bill does it. The bill sets a per-person cap on Medicaid spending in each state. That cap looks innocent enough because it rises every year with inflation.

But there's a catch. Starting 8 years from now, in 2025, the Senate bill switches its measure of inflation – from how rapidly medical costs are rising, to how rapidly overall costs in the economy are rising.

Yet medical costs are rising faster than overall costs. They'll almost surely continue to do so – as America's elderly population grows, and as new medical devices, technologies, and drugs prolong life.

Which means that after 2025, Medicaid will cover less and less of the costs of health care for the poor and elderly.

Over time, that gap becomes huge. The nonpartisan Urban Institute estimates that just between 2025 and 2035, about $467 billion less will be spent on Medicaid than would be spent than if Medicaid funding were to keep up with the expected rise in medical costs.

So millions of Americans will lose the Medicaid coverage they would have received under the 1965 Medicaid act. Over the long term, Medicaid will unravel.

Will anyone in future years know Medicaid's unraveling began with this Senate Republican bill ostensibly designed to repeal and replace the Affordable Care Act? Probably not. The unraveling will occur gradually.

Will future voters hold Republicans responsible? Again, unlikely. The effects of the unraveling won't become noticeable until most current Republican senators are long past reelection.

Does anyone now know this time bomb is buried in this bill?

It doesn't seem so. McConnell won't even hold hearings on it.

Next week the Congressional Budget Office will publish its analysis of the bill. CBO reports on major bills like this are widely disseminated in the media. The CBO's belated conclusion that the House's bill to repeal and replace the Affordable Care Act would cause 23 million Americans to lose their health care prompted even Donald Trump to call it "mean, mean, mean."

But because the CBO's estimates of the consequences of bills are typically limited to 10 years (in this case, 2018 to 2028), the CBO's analysis of the Senate Republican bill will dramatically underestimate how many people will be knocked off Medicaid over the long term.

Which is exactly what Mitch McConnell has planned. This way, the public won't be tipped off to the Medicaid unraveling hidden inside the bill.

For years, Republicans have been looking for ways to undermine America's three core social insurance programs – Medicaid, Medicare, and Social Security. The three constitute the major legacies of the Democrats, of Franklin D. Roosevelt and Lyndon Johnson. All continue to be immensely popular.

Now, McConnell and his Senate Republican colleagues think they've found a way to unravel Medicaid without anyone noticing.

Don't be fooled. Spread the word.

[Jun 22, 2017] Playing Games with Drugs at the Wall Street Journal

Jun 22, 2017 | economistsview.typepad.com

anne , June 21, 2017 at 05:02 AM

http://cepr.net/blogs/beat-the-press/playing-games-with-drugs-at-the-wall-street-journal

June 20, 2017

Playing Games with Drugs at the Wall Street Journal

A column * in the Wall Street Journal by Dana P. Goldman and Darius N. Lakdawalla presents a case for high drug prices by making an analogy to the salaries of major league baseball players. They ask what would happen if the average pay of major league players was cut from $4 million to $2 million. They hypothesize that the current crew of major leaguers would continue to play, but that young people might instead opt for different careers, leaving us with a less talented group of baseball players. Their analogy to the drug market is that we would see fewer drugs developed, and therefore we would end up worse off as a result of paying less for drugs.

This analogy is useful because it is a great way to demonstrate some serious wrong-headed thinking. It also leads those of us who had the privilege of seeing players like Bob Gibson, Sandy Koufax, Henry Aaron, and Willie Mays in their primes to wonder if there somehow would have been better players 50 years ago if the pay back then was at current levels.

But the issue is not just how much we should for developing drugs, but how we should pay. Suppose that we paid fire fighters at the point where they came to the fire. They would assess the situation and make an offer to put out the fire and save the lives of those who are endangered. We could haggle if we want. Sometimes we might get the price down a bit and in some occasions a competing crew of firefighters may show up and offer some competition. Most of us would probably pay whatever the firefighters asked to rescue our family members.

This could lead to a situation where firefighters are very highly paid, since at least the ones who came to rich neighborhoods could count on payouts in the millions or even tens of millions of dollars. Suppose someone suggested that we were paying too much for firefighters' services and argued that there we could drastically reduce what we pay for a service we all recognize as tremendously important. Well, Goldman and Lakdawalla would undoubtedly respond with a Wall Street Journal column telling us that fewer people will want to be firefighters.

But this is really beside the point. Just about everyone agrees that it does not make sense to be determining firefighters' pay when they show up at the fire. We pay them a fixed salary. While they sit around waiting most of the time, occasionally they provide an incredibly valuable service saving valuable properties from destruction or even more importantly saving lives.

No one thinks that firefighters get ripped off because they don't walk away millions of dollars when they save an endangered family. They get paid their salary (which we can argue whether too high or too low) for work that we recognize as dangerous, but which will occasionally result in enormous benefits to society.

In the case of developing drugs, we are now largely in the situation of paying the firefighters when they show up at the burning house. As a result of historical accident, we rely on a relic of the medieval guild system, government granted patent monopolies, to finance most research into developing new drugs. These monopolies allow drug companies to charge prices that are several thousand percent ** above the free market price.

This leads to all the corruption and distortion that one would expect from a trade tariff of 1000 or even 10,000 percent. These markups lead drug companies to expend vast resources marketing their drugs. They also frequently misrepresent the safety and effectiveness of their drugs to maximize sales. They make payoffs to doctors, politicians, and academics to enlist them in their sales efforts. And, they use the legal system to harass potential competitors, often filing frivolous suits to dissuade generic competitors.

This system also leads to a large amount of wasted research spending. This is in part because competitors will try to innovate around a patent to share in the patent rents. In a world of patent monopolies it is generally desirable to have competing drugs, however if the first drug was selling at its free market price, it is unlikely that it would make sense to spend large amounts researching the development of a second, third, and fourth drug for a condition for which an effective treatment already exists, rather than researching drugs for conditions for which no effective treatment exists.

Patent monopolies also encourage secrecy in research, as drug companies disclose as little information as possible so that they prevent competitors from benefiting from their research. This also slows the research process.

The obvious alternative would upfront funding, just like firefighters are paid a fixed salary for their work. Under this system a condition of the funding would be that all the research findings are posted on the web as quickly as practical to maximize the ability of the scientific community to benefit. We already do this to some extent with the $32 billion a year that goes to the National Institutes of Health, although this amount would likely have to be doubled or even tripled to make up for the research currently supported by government granted patent monopolies. (I outline a system for this in my book "Rigged: How Globalization and the Rules of the Modern Economy Have Been Structured to Make the Rich Richer" *** - it's free.)

Anyhow, it would be good if we could be having a debate about how we finance drug research rather than just telling silly stories about baseball players salaries. Bernie Sanders, Elizabeth Warren, Al Franken, Sherrod Brown and thirteen other senators have already introduced a bill that would have the government pick up the tab on some clinical trials and then putting the rights to successful drugs in the public domain so they can be sold at generic prices. The bill also has a patent buyout fund that would accomplish the same goal.

It is absurd that we charge people hundreds of thousands of dollars for life-saving drugs that cost a few hundred dollars to produce. Too bad the Wall Street Journal has so little creativity that it cannot even imagine an alternative to a grossly antiquated institution when it comes to financing prescription drug development.

* https://www.wsj.com/articles/take-me-out-to-the-pill-game-1497913367

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

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

-- Dean Baker

[Jun 21, 2017] Neoliberalism and opioids abuse

Jun 21, 2017 | economistsview.typepad.com

libezkova, June 21, 2017 at 07:25 PM

Over 33K people in US died of opiates overdoses in 2015 according to the Centers for Disease Control and Prevention.

Not only unemployed abuse opioids, but more and more college students and recent graduates are abusing the opioids as well, according to a survey of 1200 college aged adults commissioned the same year by Christie foundation.

Federal law does not require colleges to report drug death unless they are deemed criminal. But fatal overdoses have been rising at schools nationwide underscoring and horrifying reality of for administrators: in addition to binge drinking and marijuana, they have another crisis firmly entrenched on campus.

Now losing 30K people in one year is like small scale civil war (like the one they have in Ukraine) and in a way it is: war of wealthy and medical industrial complex against those in difficult circumstances, with dreams crashed and, especially, unemployed.

https://www.usnews.com/news/news/articles/2016-06-14/opioids-linked-with-deaths-other-than-overdoses-study-says

== quote ==

CHICAGO (AP) - Accidental overdoses aren't the only deadly risk from using powerful prescription painkillers - the drugs may also contribute to heart-related deaths and other fatalities, new research suggests.

Among more than 45,000 patients in the study, those using opioid painkillers had a 64 percent higher risk of dying within six months of starting treatment compared to patients taking other prescription pain medicine. Unintentional overdoses accounted for about 18 percent of the deaths among opioid users, versus 8 percent of the other patients.

"As bad as people think the problem of opioid use is, it's probably worse," said Wayne Ray, the lead author and a health policy professor at Vanderbilt University's medical school. "They should be a last resort and particular care should be exercised for patients who are at cardiovascular risk."

His caution echoes recent advice from the Centers for Disease Control and Prevention, trying to stem the nation's opioid epidemic. The problem includes abuse of street drugs like heroin and overuse of prescription opioids such as hydrocodone, codeine and morphine.

The drugs can slow breathing and can worsen disrupted breathing that occurs with sleep apnea, potentially leading to irregular heartbeats, heart attacks or sudden death, the study authors said.

In 2014, there were more than 14,000 fatal overdoses linked with the painkillers in the U.S. The study suggests even more have died from causes linked with the drugs, and bolster evidence in previous research linking them with heart problems.

The study involved more than 45,000 adult Medicaid patients in Tennessee from 1999 to 2012. They were prescribed drugs for chronic pain not caused by cancer but from other ailments including persistent backaches and arthritis.

Half received long-acting opioids including controlled-release oxycodone, methadone and fentanyl skin patches. Fentanyl has been implicated in the April death of Prince, although whether the singer was using a fentanyl patch, pills or other form of the drug hasn't been publicly revealed.

Long-acting opioids remain in the body longer. The study authors noted that the body's prolonged exposure to the drugs may increase risks for toxic reactions.

The remaining study patients had prescriptions for non-opioid drugs sometimes used to treat nerve pain, including gabapentin; or certain antidepressants also used for pain.

There were 185 deaths among opioid users, versus 87 among other patients. The researchers calculated that for every 145 patients on an opioid drug, there was one excess death versus deaths among those on other painkillers.

The two groups were similar in age, medical conditions, risks for heart problems and other characteristics that could have contributed to the outcomes.

The results were published Tuesday in the Journal of the American Medical Association .

The study involved only Medicaid patients, who include low-income and disabled adults and who are among groups disproportionately affected by opioid abuse.

Ray noted that the study excluded the sickest patients and those with any evidence of drug abuse. He said similar results would likely be found in other groups.

Dr. Chad Brummett, director of pain research at the University of Michigan Health System, said the study highlights risks from the drugs in a novel way and underscores why their use should be limited.

[Jun 19, 2017] Republicans are embarrassing Democrats by showing them how legislation gets passed with a bare majority, when Democrats failed with a filibuster proof majority

Jun 19, 2017 | economistsview.typepad.com

JohnH, June 19, 2017 at 06:48 AM

Republicans are embarrassing Democrats by showing them how legislation gets passed with a bare majority...when Democrats could barely get anything done with a filibuster proof majority!

Moral of the story? Democrats under Obama didn't really want to get much done. Rather, they preferred to do nothing and blame Republicans instead. Worse, now that Republicans want to destroy what precious little Democrats managed to accomplish, Democrats are just standing around, frozen like deer in the headlights, clueless as to how to use their 48 votes.

How pathetic can Democrats get?

libezkova, June 19, 2017 at 06:40 PM
"Republicans are embarrassing Democrats by showing them how legislation gets passed with a bare majority...when Democrats could barely get anything done with a filibuster proof majority!"

Not only that.

Neoliberal stooges like Krugman now shed crocodile tears after pushing Sanders under the bus.

They essentially gave us Trump and now have an audacity to complain. What a miserable hypocritical twerp this Nobel laureate is!

Where is the DemoRats "Resistance" now? Are they fighting against the war in Syria on behave of Israel and Gulf states? Protesting sanctions against Cuba? Complaining about the record arms sale with Saudi Arabia (with its possible 9/11 links ?)

No, they are all on MSNBC or CNN dragging out a stupid investigation all the while pushing Russia to war. And congratulating themselves with the latest Russian sanctions designed to block supplies of Russian gas to Western Europe...

I want to repeat this again: Neoliberal Democrats created Trump and brought him to the victory in the recent Presidential elections.

[May 31, 2017] End the Greedy Silence Dissident Voice

Notable quotes:
"... Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website . ..."
"... This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals . ..."
May 31, 2017 | dissidentvoice.org
End the Greedy Silence

Enough Already

by Ralph Nader / May 30th, 2017

It is time Americans rise up against the corruption, inefficiency, and cruelty of our healthcare system and tell its corporate captors and Congress – Enough Already!

For decades other countries have guaranteed universal health insurance for all their people, at lower costs and better outcomes (President Truman proposed it 72 years ago in the US). When are we going to break out of this taxpayer-subsidized prison built by the giant insurance companies, drug goliaths and monopolizing hospital chains?

How long is Uncle Sucker going to pay through the nose for gouging drug prices, patient-denying health insurance companies and all the brutal fine print rules in consumer contracts whose trap doors are maddening tens of millions of Americans?

Deductibles, exclusions, waivers, co-pays, corporate immunities from injured patients, disqualifying changes in patients' status and just plain stonewalling are just some examples of this cruel madness.

Not to mention the endless electronic bills with their inscrutable codes and unchallengeable charges – that is if you can get anyone on the phone to answer your questions. Billing fraud and abuses alone cost us up to $330 billion a year!

Why do we put up with "pay or die" drug prices? Why do we tolerate our fellow Americans dying in the tens of thousands each year because they cannot afford health insurance to get diagnosed and treated in time?

Do we know that the profiteering drug companies regularly are given a slew of handouts, including huge tax breaks, free drugs developed by our National Institutes of Health, and few restraints on their high pressure sales of dangerous and addictive drugs (eg opioids) or, together with their corporate middlemen, return the favor by charging Americans the highest prices in the world? Other countries put limits on such blatant greed and exploitation.

Groping for ever more profits, the big drug companies offshore production to less regulated labs in China and India, which amount to 60% of the drugs we buy and 80% of the active ingredients in all medicines sold in the US. Unpatriotic in the extreme!

Compounding these inhumane practices is a supine Congress, with few exceptions like Rep. Lloyd Doggett (D, TX), and state legislatures, misusing the power we entrusted to them. These legislators see large pharmaceutical companies as honey pots for campaign cash that work as hush money paid by hordes of drug industry lobbyists. So craven was the majority in Congress in 2003 that, when the drug benefits bill was passed, it prohibited Medicare from negotiating volume discounts for this lucrative corporate sales bonanza (Past Congresses authorized the Pentagon and Veterans Administration to bargain and they get lower prices as a result).

Despite the fact that these healthcare challenges have been dealt with more humanely and economically by other Western countries in the world, Americans are consistently told to tolerate an aggravating status quo. Scores of books, articles and television exposés highlight all the ways we're pushed around, denied, excluded, harmed, overcharged and deceived, yet so many of these authors still maintain that our system of health insurance/healthcare can't be replaced with a much better one? So these writers continue to advise us how to duck, slide and swivel our escape from a few of these commercials chains and scams.

In all the fine articles written to help consumers navigate Obamacare, Medicare, and private health plans, the authors trap themselves in this vast corporate cul-de-sac by never mentioning the way out.

That way is Single Payer or Full Medicare for all, everybody in, nobody out, with free choice of doctors and hospitals – at far lower costs, mortality and morbidity. These narrow reformers can't escape their "it ain't going to happen here" syndrome.

Really? Don't they know that the public has long viewed Single Payer favorably (including a majority of doctors and nurses), even without political leaders standing up for it or mass media reporting this proven safe path.

The surrender to corporate tyranny infects the 113 members of the House of Representatives who have co-signed HR 676 to create full Medicare for all. They signed, but then gave in to a silent resignation by not fighting for it in Congress and back home.

When the companies and their apologists argue for a "free market" approach to healthcare, you can retort – what free market? Half the money coming to these companies is from the federal, state and local governments. Taxpayers also pay tens of billions of dollars for much of the discovery and testing of drugs. Tax breaks and loopholes in patent laws block generic drugs and distort the free market.

Drug patents are by definition monopolies. Concentration by mergers and acquisitions of hospitals, clinics and physician practices (note dwindling independent cardiology practices) raise serious anti-trust issues. Fine print contract peonage takes away the consumers' freedom of contract, as do the daily buy and sell equations, so often rendered by third parties for patients. Corporate billing and other crimes are endemic. What free market?

Each of you can help the Single Payer movement build momentum. Ask your members of Congress in writing if they support HR 676 and, if not, demand their appearance in person at a town meeting arranged by people like you to answer why. If they refuse, peacefully picket their local offices.

Ask the newspapers, radio and television stations, including the culpable public radio and public television, when are they going to cover the basic full Medicare reform supported by tens of millions of their listeners and viewers?

Finally, go to the website SinglePayerAction.org to find out what other people are doing and what more you can do with your friends and co-workers.

One percent of you, together with popular backing, can make it happen, through a persistent civic hobby. Remember, you only have to turn around less than 450 members of Congress.

Enough Already?

Ralph Nader is a leading consumer advocate, the author of Unstoppable The Emerging Left Right Alliance to Dismantle the Corporate State (2014), among many other books, and a four-time candidate for US President. Read other articles by Ralph , or visit Ralph's website .

This article was posted on Tuesday, May 30th, 2017 at 5:18pm and is filed under Capitalism , Health/Medical , Pharmaceuticals .

[May 29, 2017] As long as there is no countervailing force, financialization of healthcare will continue unabated

May 29, 2017 | economistsview.typepad.com

Health care -- skyrocketing cost of (USA only).

Financialization of health care makes Goldman-Sachs look like amateurs. Just read Suskind's Confidence Men -- now reading Rosenthal's American Sickness.

First hundred pages I thought her medicine was the exact same story as his Wall Street -- but hundreds more pages of her story goes on. The most unimaginable book I've read in a decade (decades?).

Single payer Medicare has none little to slow medical financialization. You can pick any health system you want from any country you like.

As long as there is no countervailing force, financialization will continue unabated. Repeat: 6% labor union density equates to 20/10 blood pressure -- starves every healthy process.

[May 22, 2017] Medical insurance coverage is measure of social security for nearly everyone amd as such is close to Four Freedoms that were articulated by FDR

Notable quotes:
"... Being able to access care is an important freedom as well ..."
"... Trump as candidate promised no cuts to Medicaid. But then he had to get the Paul Ryan seal of approval so it is a massive cut that will leave 10 million people uninsured: ..."
"... Republicans have been using free lunch economic theory to make increasingly bigger promises leading to Trump promising universal health care with no taxes or mandates that will give everyone many more choices on getting far more health care with it costing much less. Trump won by being more extreme and explicit in the free lunch promises the Republican started making with Reagan. ..."
"... It's just standard Reaganomics... the same propaganda (trickle-down & rising tides) & standard tax cuts for the rich based on supply side b.s. ..."
May 22, 2017 | economistsview.typepad.com

Sanjait, May 22, 2017 at 11:36 AM

This is an important concept that has been fought for but hasn't been well articulated by Dems since Four Freedoms.

ACA is an example. It provides insurance coverage for many and a measure of security for nearly everyone. It reduces the risk of living as an American, nominally limiting the "freedom" to benuninsurednor buy crappy insurance in exchange for giving everyone enhanced ability to access preventative and major medical care, even if low income or stricken with a pre-ex medical condition.

Being able to access care is an important freedom as well .

Dems really face planted politically trying to sell this notion, but now that it is under threat of being taken away, Americans suddenly realized they like it and think it is right that people should have this access.

pgl - , May 22, 2017 at 11:50 AM
Exactly. I wonder if the folks have this captured in their little freedom indices.
ilsm - , May 22, 2017 at 03:32 PM
my freedom index has nothing to do with hospital insurance, or NCA. DNC (as good as Cato's) freedom index very far right of Thoreau!
DrDick , May 22, 2017 at 03:32 PM
For conservatives, freedom means the freedom of the rich and corporations from taxes and restrictions on their actions and nothing else.
pgl , May 22, 2017 at 11:53 AM
Trump as candidate promised no cuts to Medicaid. But then he had to get the Paul Ryan seal of approval so it is a massive cut that will leave 10 million people uninsured:

https://www.washingtonpost.com/business/economy/trump-to-propose-big-cuts-to-safety-net-in-new-budget-this-week/2017/05/21/62c01f44-3e34-11e7-adba-394ee67a7582_story.html?utm_term=.01d130c2f913

More tax cuts for the rich! That is their entire agenda.

mulp - , May 22, 2017 at 12:44 PM
Progressives see conservatives as winning by hijacking the Republican Party and being more and more radical, making Congress totally incapable of doing anything and increasingly popular, and getting Trump elected with a minority of the vote to an environment where he can accomplish even less that very moderate Obama and a Democratic majority, and they want Democrats to become more like Republicans:

able to win power, but unable to deliver on anything.

Republicans have been using free lunch economic theory to make increasingly bigger promises leading to Trump promising universal health care with no taxes or mandates that will give everyone many more choices on getting far more health care with it costing much less. Trump won by being more extreme and explicit in the free lunch promises the Republican started making with Reagan.

Progressives want a Bernie elected making big free lunch promises.

It's not about delivering, but about winning.

TANSTAAFL

Longtooth , May 22, 2017 at 03:38 PM
It's just standard Reaganomics... the same propaganda (trickle-down & rising tides) & standard tax cuts for the rich based on supply side b.s.

[May 08, 2017] Can we rescue the individuals with no exchange choices by allowing them to buy into MediCare

Notable quotes:
"... We have more good cop/bad cop. We are supposed to forget that the DNC democrats gave us deregulation, killed Glass-Steagall, refused to prosecute banksters, gave us a hokey republican health insurance plan, tried to give us TPP, continued more ME wars, screw with Russia, etc. ..."
May 08, 2017 | economistsview.typepad.com
paine , May 08, 2017 at 05:47 AM
Pk instead of keening away over
her lead role in the latest

FED borg folly

Trumpcare is a nasty

paine -> EMichael... , May 08, 2017 at 06:47 AM
A simple side swipe at trumpcare
to wield against yellen and the fed borg

Now is the moment to

RC AKA Darryl, Ron -> paine... , May 08, 2017 at 06:47 AM
The Fed Borg has not done anything unexpected whether we are basing that on Krugman's expectations or the expectations that you and I shared of her way back when she lead the Fed to liftoff. Now, we might have had different hopes and maybe even Krugman as well had different hopes, but none of us ever expected anything different than what the Fed actually did from then to now. We all know that we have a bankers' Fed and not a people's Fed.

OTOH, Krugman had very different expectations about the 2016 POTUS election than what actually happened in November. Krugman is just dealing with his disappointment in the best way that he can. It at least creates the illusion that he is making a difference and perception is at least 90% of reality for intellectual elites.

RGC , May 08, 2017 at 06:06 AM
"This is an act of deliberate betrayal":

PK knows whereof he speaks.

We have more good cop/bad cop. We are supposed to forget that the DNC democrats gave us deregulation, killed Glass-Steagall, refused to prosecute banksters, gave us a hokey republican health insurance plan, tried to give us TPP, continued more ME wars, screw with Russia, etc.

The bad cop tells us he is going to have some guys beat us up and then he has some guys beat us up. The good cop tells us he is going to take care of us and then he has some guys beat us up.

How long do people fall for that game?

RGC -> RGC... , May 08, 2017 at 06:24 AM
Pelosi Refuses to Back Single Payer, Despite GOP Deathmongering Suddenly Taking Center Stage

"No, I don't," Rep. Nancy Pelosi (D-Calif.) promptly said, when asked by a reporter if she thinks single payer should be in Democrats' 2018 party platform.

"I was carrying single payer signs probably around before you born, so I understand that aspiration," the House Minority Leader told Vice's Evan McMorris-Santoro. She then claimed that "the comfort level with a broader base of the American people is not there yet," with single payer.

"So I say to people: if you want it, do it in your states. States are laboratories," the Dem leader added. "States are a good place to start," she also said.

Pelosi's assertions about single payer's popularity, however, are called into question by public polling.

http://rinf.com/alt-news/newswire/pelosi-refuses-to-back-single-payer-despite-gop-deathmongering-suddenly-taking-center-stage/

RGC -> RGC... , May 08, 2017 at 06:35 AM
Nancy Pelosi Feels the Bern, Faces Pro-Sanders Primary Challenger

House Minority Leader is 'really out of touch'

http://observer.com/2017/04/nancy-pelosi-pro-sanders-primary-challenger-stephen-jaffe/

DeDude -> pgl... , May 08, 2017 at 09:14 AM
Yes and you can cherry pick pools (that have deliberate or unintended flaws) such that you can get one answer or the other. So you have to get consistency of pooling on an issue before you even consider trusting them. The good news is that Pelosi does not write the Democratic platform, the delegates do. If a majority of democratic party actives believe we are ready to include a national health care plan in the platform, then it will become the dems policy and I will support them. If they refuse to get it in there then we are not ready and I will support that position.
paine -> RGC... , May 08, 2017 at 06:49 AM
Rescue the exchanges
with a pub op

That is all dems should push

DeDude -> paine... , May 08, 2017 at 09:19 AM
Or we could rescue the individuals with no exchange choices at all - by allowing them to buy into MediCare. That way we would not need to "build" a public option (that could be attacked). We could also claim to have given the private sector the opportunity - and only let the government step in when private sector solutions fail. Most importantly the GOP would suddenly start doing everything they could to help the exchanges rather than trying to sabotage them.
paine -> DeDude... , May 08, 2017 at 12:45 PM
Excellent
libezkova -> DeDude... , May 08, 2017 at 07:10 PM
The costs are not going away in your solution.

I understand that we spend much more on bombing brown people, but still uncontrolled expansion of Medicare is somewhat problematic solution.

Simple question to you -- treatment of opiates epidemics victims -- who should pay for their treatment and multiple conditions they already have? Normally private insurers avoid those people as a plague.

Alaska model ( compensating private insurers for most complex and expensive cases -- outliers in costs) also can work. On state level more in known about those people and some measures can be legislated to cut the costs of most egregious cases connected with neoliberalism as a very cruel social system.

For example, homeless people are periodically taken to the hospital and then released to the streets to get in to hospital again and again until they die; some have dangerous for public infections (such a tuberculosis).

RGC -> RGC... , May 08, 2017 at 06:51 AM
Three More Join HR 676 Single Payer Bill in House

Three more members of the House of Representatives have signed on as co-sponsors of HR 676, the single payer bill in the House.

Carolyn Maloney (New York), Adriano Espaillat (New York) and Nanette Barragan (California) - signed onto HR 676 yesterday, bringing the total number of co-sponsors to 72.

https://www.singlepayeraction.org/2017/03/23/three-more-join-hr-676-single-payer-bill-in-house/

JohnH -> pgl... , May 08, 2017 at 08:57 AM
Who's talking about giving up? The Washington Generals always made it a good show against the Harlem Globetrotters...and lost by design...kind of like corrupt, sclerotic Democrats...

[May 08, 2017] How Alaska fixed Obamacare

Notable quotes:
"... That's when Wing-Heier and other Alaska officials had an idea. The state already had a tax on insurance plans (not just health but also life and property insurance). Usually the money goes to a general Alaska budget fund, but the state decided to divert $55 million of the tax revenue into a reinsurance program. ..."
"... The new reinsurance program convinced Premera to only raise rates 7 percent in 2017. Alaska suddenly went from having one of the highest rate increases in the nation to one of the lowest. ..."
"... This didn't just save customers money. The federal government subsidizes premium costs for 86 percent of Alaska's Obamacare enrollees. With cheaper premiums, the federal government didn't have to spend as much money. The cost of these subsidies fell by $56 million when Alaska created the reinsurance fund. ..."
"... If the waiver does go through - and Wing-Heier says she is "confident" the Trump administration will approve it - Alaska expects that Obamacare rates might actually do something unheard of in 2018: They might decrease. The state estimates that an additional 1,650 people will join the marketplace due to the lower premiums. ..."
Apr 17, 2017 | economistsview.typepad.com
im1dc , April 16, 2017 at 09:39 AM
"How Alaska fixed Obamacare"

A potential model that could save and expand Obamacare that the Trump Administration apparently agrees with

http://www.msn.com/en-us/news/us/how-alaska-fixed-obamacare/ar-BBzNr7p

"How Alaska fixed Obamacare"

by Sarah Kliff...Vox.com...4-16-2017...4 hrs ago

"Last year, Alaska's Obamacare marketplaces seemed on the verge of implosion. Premiums for individual health insurance plans were set to rise 42 percent. State officials worried that they were on the verge of a "death spiral," where only the sickest people buy coverage and cause rates to skyrocket year after year.

So the state tried something new and different - and it worked. Lori Wing-Heier, Alaska's insurance commissioner, put together a plan that had the state pay back insurers for especially high medical claims submitted to Obamacare plans. This lowered premiums for everyone. In the end, the premium increase was a mere 7 percent.

"We knew we were facing a death spiral," says Wing-Heier. "We knew even though it was a federal law, we had to do something."

Now other states are interested in trying Alaska's idea, especially because Wing-Heier is working with the Trump administration to have the federal government, not the state, cover those costs.

There are rampant concerns about the future of Obamacare right now. We don't know whether its marketplaces will remain stable in 2018 or, as the president has predicted, explode as premiums rise and insurers drop out. But Alaska's experiment is a reminder that the future of Obamacare isn't entirely up to Republicans in Washington. The work happening 3,000 miles away in Alaska shows that states have the ability to fix Obamacare too - and that the Trump administration might even support those policies.

How Alaska prevented an Obamacare horror story - and is trying to make the federal government pay for it

Premiums in the individual market went up a lot last year. The national average was a 25 percent hike. Alaska was bracing for an even higher 42 percent increase from its one remaining Obamacare insurer, Premera Blue Cross.

That's when Wing-Heier and other Alaska officials had an idea. The state already had a tax on insurance plans (not just health but also life and property insurance). Usually the money goes to a general Alaska budget fund, but the state decided to divert $55 million of the tax revenue into a reinsurance program.

This would give Obamacare insurers - at this point, just Premera - extra money if they had some especially large medical claims. Reinsurance essentially backstops insurers' losses; it guarantees they won't be on the hook for the bills of a handful of exceptionally sick patients.

The new reinsurance program convinced Premera to only raise rates 7 percent in 2017. Alaska suddenly went from having one of the highest rate increases in the nation to one of the lowest.

This didn't just save customers money. The federal government subsidizes premium costs for 86 percent of Alaska's Obamacare enrollees. With cheaper premiums, the federal government didn't have to spend as much money. The cost of these subsidies fell by $56 million when Alaska created the reinsurance fund.

This got Wing-Heier thinking: Why shouldn't we get that money back?

"Why shouldn't the money come back to us to fund the reinsurance program?" she recalls thinking. "It was that simple."

Alaska applied for a waiver in late December, asking the federal government to refund its spending. The state got conditional approval in mid-January from former Health and Human Services Secretary Sylvia Mathews Burwell. Current HHS Secretary Tom Price has spoken favorably of the Alaska approach too.

In a letter last month to governors, he described their idea as an example for other states to follow. It was, he said, an "opportunity for states to lower premiums for consumers, improve market stability, and increase consumer choice."

Alaska officials say the Trump administration has so far been easy to work with, helping them make sure the application looks right and moves quickly toward review.

If the waiver does go through - and Wing-Heier says she is "confident" the Trump administration will approve it - Alaska expects that Obamacare rates might actually do something unheard of in 2018: They might decrease. The state estimates that an additional 1,650 people will join the marketplace due to the lower premiums.

Other states want to get that same kind of funding too

Alaska's marketplace is far from perfect. The state only has one insurance plan selling coverage on its Obamacare marketplace, and doesn't project any more to join in 2018. Premiums are high in Alaska; the state is large and rural, which means it can be expensive to get patients to a hospital or a specialty doctor. A midlevel plan on the Obamacare marketplace there cost, on average, $904 in 2017.

But even with those problems, Wing-Heier says, it's still a whole lot better than where the state would have been without this policy change.

"Do I think it's a perfect solution? No, but it works for us," she says. "It's working in the right direction. It did what it was intended. It brought stability to our market, and the waiver is going to bring funding to us."

Alaska's approach has inspired other states. Minnesota is looking into building a reinsurance fund. At the insurance conference I went to last weekend, regulators from New York were asking lots of questions about Alaska's approach.

It's easy to see why this is appealing to other states, given the combination of additional federal money and lower Obamacare premiums. Most interesting, though, is that Alaska's approach is something the Trump and Obama administrations apparently agree on. There aren't many examples of that right now - so the ones that exist are certainly worth watching."

EMichael -> im1dc... , April 16, 2017 at 10:09 AM
Strange for Kliff not to mention in her piece the effects of the GOP destruction of the risk corridor program on premiums, amount of insurance companies participating, and co-ops.

Alaska's actions are why the risk corridor program was in the ACA.

"The risk corridors were intended to help some insurance companies if they ended up with too many new sick people on their rolls and too little cash from premiums to cover their medical bills in the first three years under the health law. But because of Mr. Rubio's efforts, the administration says it will pay only 13 percent of what insurance companies were expecting to receive this year. The payments were supposed to help insurers cope with the risks they assumed when they decided to participate in the law's new insurance marketplaces.

Mr. Rubio's talking point is bumper-sticker ready. The payments, he says, are "a taxpayer-funded bailout for insurance companies." But without them, insurers say, many consumers will face higher premiums and may have to scramble for other coverage. Already, some insurers have shut down over the unexpected shortfall.

"Risk corridors have become a political football," said Dawn H. Bonder, the president and chief executive of Health Republic of Oregon, an insurance co-op that announced in October it would close its doors after learning that it would receive only $995,000 of the $7.9 million it had expected from the government. "We were stable, had a growing membership and could have been successful if we had received those payments. We relied on the payments in pricing our plans, but the government reneged on its promise. I am disgusted."

Blue Cross and Blue Shield executives have warned the administration and Congress that eliminating the federal payments could have a devastating impact on insurance markets.

Twelve of the 23 nonprofit insurance cooperatives created under the law have failed, disrupting coverage for more than 700,000 people, and co-op executives like Ms. Bonder have angrily cited the sharp reduction in federal payments as a factor in their demise."

https://www.nytimes.com/2015/12/10/us/politics/marco-rubio-obamacare-affordable-care-act.html?_r=0

trump is continuing the attack.

im1dc -> EMichael... , April 16, 2017 at 11:18 AM
Not so strange imo b/c Rubio's undermining of the Obamacare subsidies happened years ago and the Alaska Obamacare subsidies are today and forward looking not back looking.
EMichael -> im1dc... , April 16, 2017 at 11:42 AM
To a point, but what happened this year in Alaska would not have happened if the risk corridors were not unfunded.

Moving forward, once the insurance companies had a realistic basis for the respective markets, they would stabilize. That was the plan at the very beginning.

Everyone knew that new markets would be incredibly risky for insurance companies. But that given a couple of years, they would figure out the price levels. They also knew that the first year or two would be really rough, as people who had gone without insurance put off healthcare for decades.

According to the CBO (who has been pretty accurate throughout) premiums are stabilizing. If Rubio and the GOP's attack had not happened, Alaska would not have to have done this.

Course, no one can figure out what other attacks will happen, but if they stopped with the risk corridors Alaska will have no need to do such in the future.

I will not bet that the GOP will not make it even worse, so they can just say the ACA collapsed upon itself.

im1dc -> EMichael... , April 16, 2017 at 06:06 PM
Agreed but the point is that the Obamacare Risk Corridors did not work as hoped but this Alaska workaround appears to be working in its place.

I am sure you and I don't care how we get there as long as we get there, saving Obamacare for 30,000,000 Americans.

I don't trust Trump or the Conservative Tea Baggers in Congress either. If they can they will pull defeat from the jaws of victory and call themselves saviors.

They are not nice or caring or smart, just ideologues without a clue to what they are doing.

cm -> im1dc... , April 16, 2017 at 07:05 PM
TLDR: The fedgov pays a significant part of this reinsurance scheme. (According to the article funds that come out of "saved" premium subsidies? - not clear.)

But one can argue this is how it is supposed to work. It doesn't really matter at what "level" the subsidizing happens.

im1dc -> cm... , April 17, 2017 at 04:42 AM
Agreed.

[May 08, 2017] Under the most recent version of the GOP repeal bill, states would be allowed to opt out of requiring insurers to cover everyone at the same price and to offer all 10 essential health benefits in all policies

May 04, 2017 | www.nakedcapitalism.com
MyLessThanPrimeBeef , May 4, 2017 at 4:27 pm

From the CNN article in the Links:

Prior to the health reform law, consumers who have or who previously had medical issues - even if it were years earlier and completely resolved - could be denied coverage or charged much more in premiums. Obamacare remedies that by requiring insurers to cover everyone and charge them the same amount, regardless of their health history. Also, it mandates all policies cover 10 essential health benefits, including prescription drugs, hospitalization and doctors' visits , so the sick could be assured their treatments are covered.

"The rules under Obamacare were comprehensive," said Karen Pollitz, senior fellow at the non-partisan Kaiser Family Foundation.

This expansive coverage, however, comes with a high price tag. It bumps up the cost of premiums for everyone. That's why the conservative Freedom Caucus set its sights on getting rid of these popular provisions.

Related: Key GOP lawmakers flip on health care after Trump meeting
Under the most recent version of the GOP repeal bill, states would be allowed to opt out of requiring insurers to cover everyone at the same price and to offer all 10 essential health benefits in all policies. This would likely lead insurers to jack up rates for those with pre-existing conditions who didn't maintain continuous coverage and to offer skimpy plans that don't pay for the treatments the sick need.

---

1. Is it still a plan if it doesn't offer 'doctors visits?'

That is scary. And I have to ask, is it me not reading it correctly, or is it on the writer?

2. It bumps up the cost of premiums for everyone those popular provisions.

Probably the situation is more complex. Intuitively, more costly for everyone is not often associated with being popular.

3. jack up rates for those with pre-existing conditions who didn't maintain continuous coverage.

Those with pre-existing conditions are today covered for those who are not paying a penalty. They are in 'continuous' coverage, are they not? And the risk is jacked up rates – that is, a money issue.

The difference between Medicare for All, and Free Medicare for All is also a money issue.

Ian , May 4, 2017 at 4:30 pm

This is a gift to the corporate democrats as it provides cover for and shifts blame to the GOP in regards to a system that was well on its way to painfully dying. The people that keep focus on single payer will be blamed even more as well for worsening the situation. A lot more revisionism is coming our way as the terrible reality that was Obama will be made out to look like Trump is the root cause of what is going on. As stated earlier, if Trump wanted to destroy the Dems all he'd have to do is let ACA be run by the Dems and let that run it's natural course, now the GOP own it. As shown by the first commenter. Political Kabuki.

[May 08, 2017] There are three general types of universal health care systems: socialized medicine, single-payer, all payer

Apr 21, 2017 | economistsview.typepad.com
RGC , April 20, 2017 at 05:00 AM
Different Universal Health Care Systems
17 Apr 2017

Jon Walker

There are three general types of universal health care systems. Each system, which other industrialized democracies rely upon, has its quirks.

Socialized medicine
Examples: United Kingdom, Norway, and Denmark
Closest American analogy: Veterans Health Administration


Single-payer
Example: Canada
Closest American analogy: Medicare


All-payer
Examples: Belgium, Japan, Germany, Switzerland
Closest American analogy: Federal Employer Health Benefits, ACA exchanges
.....................
https://shadowproof.com/2017/04/17/road-single-payer-understanding-different-universal-health-care-systems/

Fred C. Dobbs -> RGC... , April 20, 2017 at 05:25 AM
FWIW,

Should there be 'bare counties' (no insurance
plans offered) under ObamaCare in the coming
year it *might* be possible that a Medicaid
Buy-in plan would be offered.

NYT: Katherine Hempstead, who studies health insurance markets at the Robert Wood Johnson Foundation, was more confident than former Obama administration officials that a motivated executive branch could devise new policies to help people in bare counties, such as letting them buy a Medicaid plan, or including them in the state employee benefit pool. "I do think there will be solutions," she said. ...

Bare Market: What Happens if Places Have No
Obamacare Insurers? https://nyti.ms/2pxTTEY
via @UpshotNYT - Margot Sanger-Katz - APRIL 18

RGC -> Fred C. Dobbs... , April 20, 2017 at 05:40 AM
How about a Medicare plan, instead of Medicaid?
Fred C. Dobbs -> RGC... , April 20, 2017 at 06:05 AM
Personally, I'm guessing that
the latter is more likely, but
not much more so, than the former.
paine -> RGC... , April 20, 2017 at 06:17 AM
Yes the public option
at least in counties under provided
By corporate insurers

[May 07, 2017] The Unspeakable

Notable quotes:
"... The Donald did not care what bill was passed, as long as he ended up with something that would allow him to say he kept his promise and could claim as an accomplishment. He is all appearance over substance. ..."
May 07, 2017 | jessescrossroadscafe.blogspot.com
"A culture that does not grasp the vital interplay between morality and power, which mistakes management techniques for wisdom, and fails to understand that the measure of a civilization is its compassion, not its speed or ability to consume, condemns itself to death."

Chris Hedges


"In this way people are thrown aside as if they were trash."

Francis I


"Those who are at present so eager to be reconciled with the world at any price must take care not to be reconciled with it under this particular aspect: as the nest of The Unspeakable. This is what too few are willing to see."

Thomas Merton, The Unspeakable

The French elections will be this weekend, with market pricing in a win by the Europhile businessman Macron over the nationalist right with Le Pen.

The SP and Nasdaq closed at all time highs today. Gold and silver continued to move sideways. The dollar also moved lower. Must have been a 'risk on' day for the one percent and their financiers.

The Health-scare Bill (sic) passed by the House is widely being disregarded by the more astute observers as a cynical exercise in political flimflammery. It is so outrageously bad that the Senate is unlikely to pass it at anything like its current form. It is yet another of their symbolic repeals of a healthcare system formulated by the conservative Heritage Foundation and embraced by the Wall Street wing of the Democrats under Obama and Clinton. The Donald did not care what bill was passed, as long as he ended up with something that would allow him to say he kept his promise and could claim as an accomplishment. He is all appearance over substance.

No matter if this legislation would devastate members of the woeful working class who carried him into office. He and the Congressmen cared so little for the consequences of this law to the public that they did not even wait for the impact analysis that is customary for major legislation.

The House GOP took advantage of Donald's egomania by passing a bill which would deny affordable healthcare insurance to millions of Americans, the weak, the poor, and the elderly, in order to finance a $600 billion tax cut over the next ten years for the richest of the one percent. And afterwards they all celebrated with a beer party in the Rose Garden.

It would have been better for them if they had never been born.

[May 05, 2017] William Binney - The Government is Profiling You (The NSA is Spying on You)

Very interesting discussion of how the project of mass surveillance of internet traffic started and what were the major challenges. that's probably where the idea of collecting "envelopes" and correlating them to create social network. Similar to what was done in civil War.
The idea to prevent corruption of medical establishment to prevent Medicare fraud is very interesting.
Notable quotes:
"... I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity. ..."
"... 500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it. ..."
"... People are so worried about NSA don't be fooled that private companies are doing the same thing. ..."
"... In communism the people learned quick they were being watched. The reaction was not to go to protest. ..."
"... Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause ..."
Apr 20, 2017 | www.youtube.com
Chad 2 years ago

"People who believe in these rights very much are forced into compromising their integrity"

I suspect that it's hopelessly unlikely for honest people to complete the Police Academy; somewhere early on the good cops are weeded out and cannot complete training unless they compromise their integrity.

Agent76 1 year ago (edited)
January 9, 2014

500 Years of History Shows that Mass Spying Is Always Aimed at Crushing Dissent It's Never to Protect Us From Bad Guys No matter which government conducts mass surveillance, they also do it to crush dissent, and then give a false rationale for why they're doing it.

http://www.washingtonsblog.com/2014/01/government-spying-citizens-always-focuses-crushing-dissent-keeping-us-safe.html

Homa Monfared 7 months ago

I am wondering how much damage your spying did to the Foreign Countries, I am wondering how you changed regimes around the world, how many refugees you helped to create around the world.

Don Kantner, 2 weeks ago

People are so worried about NSA don't be fooled that private companies are doing the same thing. Plus, the truth is if the NSA wasn't watching any fool with a computer could potentially cause an worldwide economic crisis.

Bettor in Vegas 1 year ago

In communism the people learned quick they were being watched. The reaction was not to go to protest.

Just not be productive and work the system and not listen to their crap. this is all that was required to bring them down. watching people, arresting does not do shit for their cause......

[Apr 06, 2017] The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market.

Apr 06, 2017 | economistsview.typepad.com
anne , April 06, 2017 at 05:31 AM
http://cepr.net/blogs/beat-the-press/robert-atkinson-pushes-pro-rich-protectionist-agenda-in-the-washington-post

April 6, 2017

Robert Atkinson Pushes Pro-Rich Protectionist Agenda in the Washington Post

The Washington Post is always open to plans for taking money from ordinary workers and giving it to the rich. For this reason it was not surprising to see a piece * by Robert Atkinson, the head of the industry funded Information Technology and Innovation Foundation, advocating for more protectionism in the form of stronger and longer patent and copyright monopolies.

These monopolies, legacies from the medieval guild system, can raise the price of the protected items by one or two orders of magnitudes making them equivalent to tariffs of several hundred or several thousand percent. They are especially important in the case of prescription drugs.

Life-saving drugs that would sell for $200 or $300 in a free market can sell for tens or even hundreds of thousands of dollars due to patent protection. The country will spend over $440 billion this year for drugs that would likely sell for less than $80 billion in a free market. The strengthening of these protections is an important cause of the upward redistribution of the last four decades. The difference comes to more than $2,700 a year for an average family. (This is discussed in "Rigged: How Globalization and the Rules of the Modern Economy Were Structured to Make the Rich Richer," ** where I also lay out alternative mechanisms for financing innovation and creative work.)

Atkinson makes this argument in the context of the U.S. relationship with China. He also is explicitly prepared to have ordinary workers pay the price for this protectionism. He warns that not following his recommendation for a new approach to dealing with China, including forcing them to impose more protection for U.S. patents and copyrights, would lead to a lower valued dollar.

Of course a lower valued dollar will make U.S. goods and services more competitive internationally. That would mean a smaller trade deficit as we sell more manufactured goods elsewhere in the world and buy fewer imported goods in the United States. This could increase manufacturing employment by 1-2 million, putting upward pressure on the wages of non-college educated workers.

In short, not following Atkinson's path is likely to mean more money for less-educated workers, less money for the rich, and more overall growth, as the economy benefits from the lessening of protectionist barriers.

* https://www.washingtonpost.com/opinions/global-opinions/how-trump-can-stop-china-from-eating-our-lunch/2017/04/05/b83e4460-1953-11e7-bcc2-7d1a0973e7b2_story.html

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

-- Dean Baker

[Apr 06, 2017] Health Care Renewal Not Going to Take it Anymore - Doctors in the Pacific Northwest Unionize, Begin Collective Bargaining with Hospital Systems

Apr 06, 2017 | hcrenewal.blogspot.com
Managerialist Tactics: Outsourcing

The NYT article opened with

in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists , the hospital doctors who supervise patients' care, to a management company that would become their employer.

The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.

Outsourcing is a now familiar entry in the managerialists' playbook. It is seen more in manufacturing than in health care. Although touted as improving economic "efficiency," it also may reduce the accountability of the managers of the organization that does the outsourcing.

Pursuit of Economic Efficiency

In this case,

Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day - which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum.

It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. 'We're doctors, we're professionals,' Dr. [Rajeev] Alexander said. 'Giving me a bonus for seeing two more patients - I'm not sure I should be doing that. It's not safe .' (A hospital representative said patient safety was 'inviolate.')


A constant theme of managerialism, and the neoliberalism that underlies it, is economic efficiency. The usual narrative is that efficiency means providing better goods and services at lower costs. Instead, managerialism and neliberalism may mean decontenting goods and services so as to lower costs to the organizations providing them, but not necessarily providing more value to consumers. In health care terms, managerialism and neliberalism may lead to less accessible, more mediocre health care that increase revenue to the organizations providing it, as implied by the physicians' comments above. Making the US the most commercialized, managerialist run, and arguably neoliberal health care system among the developed countries has not led to lower costs, better access, or better health care quality.


The backstory for the outsourcing emphasizes that managerialism, and the resulting economic efficiency was indeed the goal of PeaceHealth...

In 2012, Sacred Heart's parent, PeaceHealth, a nonprofit health care system, installed an executive named John Hill to adapt its Oregon hospitals to the latest trends in health care . Mr. Hill, in an effort to rein in the budget and improve the efficiency of a hospital that administrators said was lagging in key respects, including how long the typical patient stayed, eventually concluded that the hospitalists at Sacred Heart should be outsourced.

Centralization of Control

Furthermore,

The hospitalists also chafe at the way the administration has tried to centralize decisions they used to make for themselves. This might include hiring fellow doctors or the order in which they see patients on any day. They also complain of being loaded down with administrative tasks.

'We're trained to be leaders, but they treat us like assembly line workers ,' said Dr. Brittany Ellison, a hospitalist in the group. 'You need that time with the patient,...'


A major feature of managerialism is the concentration of power within (generic) management. To quote Komesaroff(1),

In the workplace, the authority of management is intensified, and behaviour that previously might have been regarded as bullying becomes accepted good practice. The autonomous discretion of the professional is undermined, and cuts in staff and increases in caseload occur without democratic consultation of staff. Loyal long-term staff are dismissed and often humiliated, and rigorous monitoring of the performance of the remaining employees focuses on narrowly defined criteria relating to attainment of financial targets, efficiency and effectiveness.

We're Only In It for the Money

Also, the negotiations that started once the PeaceHealth physicians formed their union demonstrated a central tenet of managerialism

Even starker than the divide over these questions are the differences in worldview represented on opposite sides of the table. During a bargaining session last fall, the administration proposed increasing the number of shifts a year. Hospitalists now earn about $223,000 a year for 173 shifts and are paid extra for working more. The hospital offered $260,000 for a mandatory 182 shifts, and up to $20,000 in bonus pay for hitting certain medical performance targets. The hospitalists work seven days on and seven days off, so this would have effectively eliminated any time off for sick days or vacation.

When the doctors pointed this out, the administration responded that if they missed a few days, it would make sure they got extra days to hit the required number of shifts for full pay.

The hospitalists assured the administration negotiators that their concern had nothing to do with money - that none of this had ever been about money. They preferred to work less and make less to avoid burnout, which was bad for them and worse for patients. At which point the administration responded that money was always the issue , according to several people in the room. (The hospital declined to comment.)

Suddenly it dawned on the doctors why they had failed to break through, Dr. Alexander said. 'Imagine Mr. Burns,' the cartoonishly evil capitalist from 'The Simpsons,' 'sitting across the table,' he said. 'There's no way we can say, 'This isn't what we're talking about. We're not trying to get the bonus.''


Again, managerialism is based on neoliberalism, and neoliberal view is that the market rules. The market is the arbiter of success, and money is the only outcome that matters. As Komesaroff put it(1),

The particular system of beliefs and practices defining the roles and powers of managers in our present context is what is referred to as managerialism. This is defined by two basic tenets: (i) that all social organisations must conform to a single structure; and (ii) that the sole regulatory principle is the market .

Mission-Hostile Management

Never mind that the centrality of money seems entirely inconsistent with the stated mission of PeaceHealth ,

We carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way.

Ostensibly, this is accompanied by core values, such as,

Stewardship We choose to serve the community and hold ourselves accountable to exercise ethical and responsible stewardship in the allocation and utilization of human, financial, and environmental resources. and,

Social Justice
We build and evaluate the structures of our organization and those of society to promote the just distribution of health care resources.


We have frequently discussed how leadership of contemporary health care organizations often seem to act contrary to the organizations' stated mission, that is, mission-hostile management .

Value Extraction

Finally, while managerialism is ostensibly concerned with economic efficiency, whose efficiency matters. When managers address physicians' efficiency, they seem to look at amount of work done divided by the cost to the hospital of paying physicians. However, they never seem to look at their own costs, the costs of management, as being a negative.

The PeaceHealth 2014 form 990 , the latest available, states that the then CEO, Mr Alan Yordy (whose highest academic degree was an MBA, according to his LinkedIn page ) had total compensation in 2013 of $1,366,742, and 11 other managers had total compensation greater than $250,000, with 9 having total compensation greater than $500,000. Those figures should be compared to the highest compensation offered the hospitalists, a maximum of $280,000 for 182 shifts a year, eliminating all vacation and sick leave. So if it is all about the money, the managers are making the most of it.

We have discussed ad nauseum the ridiculous compensation of the leaders of health care organization, even non-profit organizations. Value extraction by top management has become a central feature of the US and global economy (look here ).

The NYT article did not discuss whether the upset hospitalists knew about their bosses' compensation. I suspect they did.

Forming a Functioning Union at the University of Washington

The media coverage of the UW housestaff unionization was less detailed. It does appear, though, that a stimulus was the pursuit of economic efficiency by UW management through squeezing the pay of housestaff, as described in the December article in the Seattle Times . In it the house staff said,

they account for about one-fifth of King County's doctors and they want higher pay, new child-care benefits and free parking. Some UW residents and fellows earn so little that they qualify for welfare programs like Temporary Assistance for Needy Families and the Seattle City Light Utility Discount Program, according to the UWHA [University of Washington Housestaff Association.]

Another article in early January, 2016 in the Seattle Times added,

The association has proposed that residents and fellows earn at least the same salary as the UW's lowest-paid physician assistants . Because the doctors in training work very long hours, they sometimes earn less than Seattle's minimum hourly wage , the UWHA has said.

The council members, in their letter to Cauce, called the situation shocking. And based on information from the UWHA, they wrote that some residents and fellows qualify for welfare programs like Temporary Assistance for Needy Families (TANF).


The Seattle articles noted that the UW housestaff may earn from just over $53,000 to just under $70,000 a year. Keep in mind, however, that under current rules, house staff may work up to 80 hours a week. So $53,000 for someone working those hours translates into $13.25/ hour, under what many people now claim is the living wage. That could be considered exploitation of workers with doctoral degrees working in often highly stressful situations where lives may be on the line. Whether there were issues other than money (and the respect it implies) involved at UW was not apparent based on the minimal press coverage.

[Apr 05, 2017] Health Care Renewal managerialism

Apr 05, 2017 | hcrenewal.blogspot.com
John Stossel Discovers Health Care Dysfunction, Blames it on "Socialists" - Like Maurice Greenberg (AIG), John Thain (Merrill Lynch), Sanford Weill (Citigroup), and David H Koch? We have been ranting for a while about the dysfunctionality of the US health care system. Unfortunately, many people only realize how bad things are when they become patients, when they have bigger things to worry about than complaining. Furthermore, even if they complain, many patients may not feel they understand enough about what has gone wrong to suggest solutions.

Bad Customer Service at New York Presbyterian

This may not apply when media pundits, especially those with strong ideological views, become patients. So this week Fox News commentator and well known libertarian John Stossel disclosed his new illness, and vented his opinions about his hospital stay . Mr Stossel unfortunately developed lung cancer, although he was optimistic about his prognosis: "My doctors tell me my growth was caught early and I'll be fine. Soon I will barely notice that a fifth of my lung is gone."

However, he was not happy about his hospital's customer service:

But as a consumer reporter, I have to say, the hospital's customer service stinks . Doctors keep me waiting for hours, and no one bothers to call or email to say, 'I'm running late.' Few doctors give out their email address. Patients can't communicate using modern technology.

I get X-rays, EKG tests, echocardiograms, blood tests. Are all needed? I doubt it. But no one discusses that with me or mentions the cost .

Also,
I fill out long medical history forms by hand and, in the next office, do it again . Same wording: name, address, insurance, etc.
And,
In the intensive care unit, night after night, machines beep, but often no one responds . Nurses say things like 'old machines,' 'bad batteries,' 'we know it's not an emergency.'
Finally,
Some of my nurses were great -- concerned about my comfort and stress -- but other hospital workers were indifferent .
Unfortunately, long wait times, poor communications, excess paperwork, and misapplied technology are all too familiar problems to those in the health care system.

Moreover, this all was happening at one of the most highly rated US hospitals,

After all, I'm at New York-Presbyterian Hospital. U.S. News & World Report ranked it No. 1 in New York .
Were "Socialist Bureaucracies" Responsible?

Mr Stossel had his own ideas about the causes of these problems.

Customer service is sclerotic because hospitals are largely socialist bureaucracies. Instead of answering to consumers, which forces businesses to be nimble, hospitals report to government, lawyers and insurance companies.

Whenever there's a mistake, politicians impose new rules: the Health Insurance Portability and Accountability Act paperwork, patient rights regulations, new layers of bureaucracy...

Also,

Leftists say the solution to such problems is government health care. But did they not notice what happened at Veterans Affairs? Bureaucrats let veterans die, waiting for care. When the scandal was exposed, they didn't stop. USA Today reports that the abuse continues. Sometimes the VA's suicide hotline goes to voicemail.

Patients will have a better experience only when more of us spend our own money for care. That's what makes markets work.

A "Socialist Bureaucracy" with a VIP Penthouse?

I am sorry to hear Mr Stossel has lung cancer, and hope that his prognosis is indeed good. I am a bit surprised that a media celebrity who became a patient found big issues with "customer service" at such a prestigious hospital. After all, many big hospitals have programs to give special treatment to VIPs (for example, see these posts from 2007 and 2011 ).

In particular, back in 2012 we posted about the contrast between the VIP services specifically at New York - Presbyterian Hospital and how poor patients are treated there. Then we quoted from a 21 January, 2012 article from the New York Times focused on the ritzy comforts now provided for wealthy (but perhaps not very sick) patients at the renowned New York Presbyterian/ Weill Cornell Hospital. It opened,

The feverish patient had spent hours in a crowded emergency room. When she opened her eyes in her Manhattan hospital room last winter, she recalled later, she wondered if she could be hallucinating: 'This is like the Four Seasons - where am I?'

The bed linens were by Frette, Italian purveyors of high-thread-count sheets to popes and princes. The bathroom gleamed with polished marble . Huge windows displayed panoramic East River views. And in the hush of her $2,400 suite, a man in a black vest and tie proffered an elaborate menu and told her, 'I'll be your butler.'

It was Greenberg 14 South, the elite wing on the new penthouse floor of NewYork-Presbyterian/Weill Cornell hospital . Pampering and décor to rival a grand hotel, if not a Downton Abbey, have long been the hallmark of such 'amenities units,' often hidden behind closed doors at New York's premier hospitals. But the phenomenon is escalating here and around the country, health care design specialists say, part of an international competition for wealthy patients willing to pay extra, even as the federal government cuts back hospital reimbursement in pursuit of a more universal and affordable American medical system.

Additional amenities include:

A waterfall, a grand piano and the image of a giant orchid grace the soaring ninth floor atrium....
Also,
the visitors' lounge seems to hang over the East River in a glass prow and Ciao Bella gelato is available on demand....
An architect who specializes in designing such luxury facilities for hospitals noted:
'These kinds of patients, they're paying cash - they're the best kind of patient to have,' she added. 'Theoretically, it trickles down.'
It appears that someone failed to book Mr Stossel into the penthouse. Instead, he found out what service was like for the masses.

Perhaps this was why Mr Stossel railed at the "socialist bureaucracies" he perceived as running New York - Presbyterian Hospital. However, calling the hospital management "socialist" seems - not to put too fine a point on it - wrong.

A "Socialist Bureaucracy" Paying Millions to its CEOs?

First of all, New York Presbyterian is hardly a government agency. It is a private, non-profit corporation. Every year as such it files a form 990 with the dread US Internal Revenue Service. (The latest publicly available version is from 2013, here.) Obviously, US government agencies do not file with the IRS.

In fact, the New York Presbyterian system seems about as far from a federal government agency as one can imagine.

First, its top managers are paid like for-profit corporate executives. In 2014, we posted about the humongous compensation given to its previous, long-serving CEO, Dr Herbert Pardes, who received multi-million dollar compensation every year through his 2011 retirement, and then continued to receive several million a year from the system in his retirement. His successor, current CEO Dr Steven Corwin, received $3.6 million in 2012. (More recent compensation figures are not yet available.)

A "Socialist Bureaucracy" Dominated by Managers, with Stewardship by Top Financial Executives, and one of the Koch Brothers?

The current leadership of New York Presbyterian is dominated by businesspeople, not physicians, nurses, or other health care professionals. Only 10 of 33 listed senior leaders are health care professionals. The rest have administrative/ management or legal backgrounds and training. Many appear to be generic managers , that is, people with background and experience primarily in administration or management, but not in medicine, health care, public health, etc.

The hospital system's board of trustees was and is filled with some of the top business executives in the US, including some finance executives who have been cited as responsible for the global financial collapse/ great recession.

For example, we wrote about Mr Dick Fuld, a trustee until recently. Mr Fuld was the CEO who presided over the bankruptcy of Lehman Brothers, which heralded the beginning of the great financial crisis/ great recession of 2008 onward. Mr Fuld seemed to lack the sort of compassionate approach one might expect from someone charged with the stewardship of a big hospital system. He had once publicly said about those who sold Lehman Brother stock short: "what I really want to do is I want to reach in, rip out their heart, and eat it before they die ."

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

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

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

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

The acerbic Pinboard comments:
D Pinboard * Follow

@Pinboard

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

11:41 PM-21 Mar 2017

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

cocomaan , March 22, 2017 at 4:03 pm

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

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

Totaly fair.

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

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

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

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

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

Dean Baker

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

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

John Kenneth Galbraith

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

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

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

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

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

... ... ...

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

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

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

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

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

...

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

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

March 20, 2017

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

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

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

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

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

-- Dean Baker

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

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

(1) This is really the Paul Ryan agenda.

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

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

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

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

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

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

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

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Thousands without insurance for entire year)

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

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

2015 ( 28,966)

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

September 13, 2016

People Without Health Insurance Coverage, 2007-2015

(Percent without insurance for entire year)

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

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

2015 ( 9.1)

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

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

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

March 16, 2017

Government Granted Patent Monopolies Cause People to Skip Cancer Treatments

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

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

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

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

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

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

-- Dean Baker

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

October, 2016

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lesseevilism in action ;-)

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

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

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

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

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

At least we know what Trump stands for!

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

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

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

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

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

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

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

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

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

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

[Mar 10, 2017] The neoliberal media blizzard over the American Health Care Act is not about people dying in the streets nor [OMG] tax cuts for people with too much power. It is red herring to preserve neocons attack on Trump

Mar 10, 2017 | economistsview.typepad.com
ilsm : March 10, 2017 at 01:33 PM

, 2017 at 01:33 PM
Stalinist pk etc...... Obama conned the US to 'give up liberty for safety' but his deep state and the baying media could not prevent Trump.

The neoliberal media blizzard over the American Health Care Act is not about people "dying in the streets" nor [OMG] tax cuts for people with too much power. It is red herring to preserve Obama's attack on the US constitution.

The media is still talking phony show trials over Trump and Putin while diminishing Sessions' draining the deep state swamp.

Health care does not matter; Obama's schemes to keep terror away destroyed the constitution do.

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

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

March 2, 2017

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

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

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

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

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

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

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

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

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

They're in the pocket of the lobbyists.

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

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

December, 1963

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

I. Introduction: Scope and Method

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

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

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

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

a

[Mar 07, 2017] Notes on US healthdoesntcare

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

The problems with US Healthdoesn'tcare started around 1980.

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

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

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

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

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

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

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

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

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

Is not neoliberalism wonderful social system ?

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

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

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

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

Or it's terrible?

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

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

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

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

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

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

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

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

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

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

== quote ==

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

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

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

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

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

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

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

== end of quote ==

See also

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

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

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

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

== quote ==

Revenue Guard Executive Team

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

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

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

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

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

Jennifer Aldana, Vice President of Revenue Cycle
Jennifer joined Revenue-Guard in 2007 to manage and run the billing services division. She manages a staff of 60 billing specialist processing over $120M in ambulance claims annually. Jennifer is a former revenue cycle manager at Rural-Metro The country's largest EMS service based in Scottsdale, Arizona. She handles all system customizations, ePCR integration and client support services. Jen studied at Pace University in New York City.

[Mar 03, 2017] U.S. Medical Coding System

Notable quotes:
"... Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid. ..."
"... Each diagnosis code has to be coded to the highest level of specificity , so the insurance company knows exactly what the patient's diagnosis was. ..."
"... I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. ..."
"... A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep. ..."
"... Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy. ..."
"... thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising. ..."
"... More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that. ..."
"... The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software. ..."
"... eight of 10 bills its members have audited from hospitals and health care providers contain errors. ..."
"... It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. ..."
"... Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent. ..."
"... Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image). ..."
"... ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims. ..."
Mar 03, 2017 | www.nakedcapitalism.com
From my review of Akerlof and Shiller's Phishing for Phools , November 25, 2015 :

As businesspeople choose what line of business to undertake - as well as where they expand, or contract, their existing business - they (like customers approaching checkout) pick off the best opportunities. This too creates an equilibrium. Any opportunities for unusual profits are quickly taken off the table, leading to a situation where such opportunities are hard to find. This principle, with the concept of equilibrium it entails, lies at the heart of economics.

The principle also applies to phishing for phools. That means that if we have some weakness or other - some way in which we can be phished for fools for more than the usual profit - in the phishing equilibrium someone will take advantage of it . Among all those business persons figuratively arriving at the checkout counter, looking around, and deciding where to spend their investment dollars, some will look to see if there are unusual profits from phishing us for phools. And if they see such an opportunity for profit, that will (again figuratively) be the "checkout lane" they choose.

And economies will have a "phishing equilibrium," in which every chance for profit more than the ordinary will be taken up.

We might summarize Akerlof and Shiller as "If a system enables fraud, fraud will happen," or, in stronger form, "If a system enables fraud, fraud will already have happened."[1] And as we shall see, plenty of "opportunities for unusual profits" exist in medical coding.

... ... ...

Here is the medical coding process, from the coders perspective, as described by MB-Guide, a site for aspiring medical coders :

Successful medical coders learn and follow coding guidelines and use them to their benefit. Often if a claim is denied incorrectly, medical coders and billers use coding guidelines as a way to appeal the denial and get the claim paid.

Hmm. "Their" benefit. Here are the guidelines:

I've helpfully underlined places where an "unusual opportunity for profit" might be spotted and amplified; after all, it's not the coder's job to set policy in borderline cases; that's for management. The Denver Post gives a horrific example:

Miscoding Fictions, frauds found to abound in medical bills

A pair of transposed digits in a medical identification number was the difference between insurance coverage for Mike Dziedzic and the seemingly never-ending hounding for payment by the hospitals that cared for his dying wife. The astute eye of a medical billing advocate who Dziedzic hired for help caught the innocuous mistake - the sole reason his insurance company had refused to pay more than $100,000 in claims that had piled up and why collectors were now at his doorstep.

Had it remained unnoticed - as often happens to patients faced with daunting medical debt - Dziedzic said, he most surely would have lost his Rifle home, his way of life and had little choice but to live in bankruptcy.

Finally, there's "upcoding," and if you are reminded of "upselling" you are exactly right. The Center for Public Integrity :

But the Center's analysis of Medicare claims from 2001 through 2010 shows that over time, thousands of providers turned to more expensive Medicare billing codes, while spurning use of cheaper ones. They did so despite little evidence that Medicare patients as a whole are older or sicker than in past years, or that the amount of time doctors spent treating them on average was rising.

More than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade. Officials said such changes in billing can signal overcharges occurring on a broad scale. Medical groups deny that.

The most lucrative codes are billed two to three times more often in some cities than in others, costly variations government officials said they could not explain or justify. In some instances, higher billing rates appear to be associated with the burgeoning use of electronic medical records and billing software.

Now, I'll be the first to admit that I can't quantify the impedance mismatches, the miscoding, and the upcoding. Regardless, medical coding is the key dataflow in the healthcare system :

"Roughly $250 billion is moving through those codes," [says Steve Parente, professor of finance at the Carlson School of Management at the University of Minnesota]. On top of that, about 80% of medical bills contain errors, according to Christie Hudson, vice president of Medical Billing Advocates of America, making already-expensive bills higher. Today's complex medical-billing system, guided by hundreds of pages of procedure codes, allows fraud, abuse and human error to go undetected, Hudson says. "Until the fraud is detected in these bills the cost of health care is just going to increase. It's not accidental. We've been fighting these overcharges they continue to happen and we continue to get them removed from bills." These errors, which are hard to detect because medical bills are written in a mysterious code, can result in overcharges that run from a few dollars to tens of thousands.

That "mysterious code" is (now) ICD-10, and it's the mystery plus the profit motive that creates the phishing equilibrium. Kaiser Health News quotes the Denver Post :

Experts say there are tens of thousands more like Dziedzic across the country with strangling medical debts.

Medical Billing Advocates of America, a trade group in Salem, Va., says that eight of 10 bills its members have audited from hospitals and health care providers contain errors.

It's estimated that at least 3 percent of all health care spending – roughly $68 billion – is lost to fraud and billing errors annually. Some say new reform laws will only make things worse." Others say that errors occur largely because of "the complexity of deciphering bills and claims weighted down by complex codes."

Even if the "trade group" is talking it's book, it's still quite a book . NBC :

Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients' behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.

Gee, I wonder if the errors are randomly distributed?

Neoliberal "Consumer"-Driven Solutions

My guts have started to gripe, so I won't go into detail about how you too, the citizen , can learn medical billing codes if you want to dispute your bill. See this cheery post from NerdWallet on "How to Read Your Medical Bill :

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Your medical bill is going to be chock-full of codes and words you may not understand, so the first step is gathering resources that will translate them into plain English.

Ivy , March 2, 2017 at 2:29 pm

One useful adjunct to the coding discussion concerns other billing details such as meds. There is wide variability in prices charged, and when you see $160 for a single pill (e.g., Hexabrix) or $26 for a single Tylenol, then something is not right. Of course, that does not include any allocation for nurses, pharmacy or other potential costs, since those are rolled into other line items to decipher. When hospital billing reps are asked about the reasonability and basis of their charges, they spout the canned line about being in line with their local competitors.

Why not have some program with mutual insurance companies, removing in theory some of the profit that is driving the typical health care insurers?

TheBellTolling , March 2, 2017 at 2:31 pm

Most services don't get paid based on ICD, they get paid based on HCPCs/CPTs (healthcare procedure codes) which is what is shown in the nerdwallet image. Also revenue codes will be used for facility services (such as the room charge in image).

ICD-Diaganosis codes just tell you what conditions the provider diagnosed you with. ICD-Procedure codes are sometimes used for payments but usually only on inpatient claims.

_________________________________

Additionaly, coding also affects "risk adjustment" in Medicare Advantage and ACA payments and this form of payment does use ICD codes. They use the codes on the claims to determine how "sick"(has conditions that will cost more) each member is and give insurers more or less money based on the average risk scores of their members. Since it relies on coding this system is also subject to gaming.

In Medicare Advantage this is done relative to non-Medicare Advantage population, so if the MA plans are upcoding they get more money from Federal government. In 2010 CMS was given the ability to use some adjustment factors to MA payments to address the issue but I don't really know how effective it is.

In ACA this is done relative to all the other insurers in the individual/small group market(so all the money is changing hands between the insurers). More established plans generally do better since they have more data on members from before ACA to make sure they get coded in addition to resources they probably built from Medicare Advantage. This ends up disadvantaging smaller and newer plans like co-ops.
_____________

[Mar 03, 2017] How to Read Your Medical Bill

Notable quotes:
"... That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this: ..."
NerdWallet
Clerical errors are more likely than you might think, says Gross, who has seen small mistakes in names and addresses result in huge billing complications. Before you move on, make sure your name, address, insurance information and dates of care are correct on the top of the bill.

header

When you receive inpatient or outpatient care, the first statement you'll receive is most likely a summary bill. Often, but not always, health care providers will send only a summary of charges with a final charge at the end. The body of the bill has a few generic categories and no codes, looking something like this:

summarybill

That is not the bill you want. To know what you're actually being charged for, you'll want to call the clinic or hospital and ask for the complete, itemized bill for all services you received, with codes. It is your right to know what you're being charged for, but you will probably have to call and request the detailed charges. The body of that bill should look more like this:

detailed

Once you have the itemized medical bill for your care, you're ready to analyze it for mistakes and overcharges.

Next, know what the codes are for

Before we get into the nuts and bolts of reading your medical bill, it's worth noting that there's more than one type of code that may be listed on your bill.

svccode

HCPCS Level I, or CPT Codes, are universal, used by all providers in the U.S. and consist of five digits that identify procedures or tests. Often, they are listed as service codes.

svccode2

HCPCS Level II Codes identify supplies or products used during your visit. These codes often start with a letter, rather than a number, but are also referred to as service codes.

[Feb 27, 2017] Why Markets Can't Cure Healthcare

Feb 27, 2017 | economistsview.typepad.com
anne -> anne... February 26, 2017 at 02:07 PM , 2017 at 02:07 PM
http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/

July 25, 2009

Why Markets Can't Cure Healthcare
By Paul Krugman

Judging both from comments on this blog and from some of my mail, a significant number of Americans believe that the answer to our health care problems - indeed, the only answer - is to rely on the free market. Quite a few seem to believe that this view reflects the lessons of economic theory.

Not so. One of the most influential economic papers of the postwar era was Kenneth Arrow's "Uncertainty and the Welfare Economics of Health Care," * which demonstrated - decisively, I and many others believe - that health care can't be marketed like bread or TVs. Let me offer my own version of Arrow's argument.

There are two strongly distinctive aspects of health care. One is that you don't know when or whether you'll need care - but if you do, the care can be extremely expensive. The big bucks are in triple coronary bypass surgery, not routine visits to the doctor's office; and very, very few people can afford to pay major medical costs out of pocket.

This tells you right away that health care can't be sold like bread. It must be largely paid for by some kind of insurance. And this in turn means that someone other than the patient ends up making decisions about what to buy. Consumer choice is nonsense when it comes to health care. And you can't just trust insurance companies either - they're not in business for their health, or yours.

This problem is made worse by the fact that actually paying for your health care is a loss from an insurers' point of view - they actually refer to it as "medical costs." This means both that insurers try to deny as many claims as possible, and that they try to avoid covering people who are actually likely to need care. Both of these strategies use a lot of resources, which is why private insurance has much higher administrative costs than single-payer systems. And since there's a widespread sense that our fellow citizens should get the care we need - not everyone agrees, but most do - this means that private insurance basically spends a lot of money on socially destructive activities.

The second thing about health care is that it's complicated, and you can't rely on experience or comparison shopping. ("I hear they've got a real deal on stents over at St. Mary's!") That's why doctors are supposed to follow an ethical code, why we expect more from them than from bakers or grocery store owners.

You could rely on a health maintenance organization to make the hard choices and do the cost management, and to some extent we do. But HMOs have been highly limited in their ability to achieve cost-effectiveness because people don't trust them - they're profit-making institutions, and your treatment is their cost.

Between those two factors, health care just doesn't work as a standard market story.

All of this doesn't necessarily mean that socialized medicine, or even single-payer, is the only way to go. There are a number of successful healthcare systems, at least as measured by pretty good care much cheaper than here, and they are quite different from each other. There are, however, no examples of successful health care based on the principles of the free market, for one simple reason: in health care, the free market just doesn't work. And people who say that the market is the answer are flying in the face of both theory and overwhelming evidence.

* https://web.stanford.edu/~jay/health_class/Readings/Lecture01/arrow.pdf

anne -> anne... , February 26, 2017 at 02:44 PM
Correcting again and continuing:

Though Krugman always praises the work of Arrow on healthcare markets, Krugman never seems much been influenced by the work.

Though praising Arrow on healthcare markets, Krugman seemingly has spent no time on or possibly has dismissed research affirming Arrow and has not supported the sorts of healthcare insurance systems that would follow from accepting the work of Arrow:

https://promarket.org/there-is-regulatory-capture-but-it-is-by-no-means-complete/
/
March 15, 2016

"There Is Regulatory Capture, But It Is By No Means Complete"
By Asher Schechter

Kenneth J. Arrow, one of the most influential economists of the 20th century, reflects on the benefits of a single payer health care system, the role of government and regulatory capture.

Mr. Bill : , February 26, 2017 at 03:32 PM
So Anne, what your saying is that "health care" is a monopolistic industry that makes more money by restricting care and charging more ? Allowing people that can't afford to live, too die?

Well. yes, I agree with your presumed hypothesis, and I admire your boldness for stepping out in front of this moving freight train, risking your beloved tenure.

To me ? Thanks for asking.

I think that the 3 % administrative costs of the existing single payer system are more pareto optimal than the 25 % that the monopolists' extract. What do I know. This is America. Dumb is not an option.

anne : , February 26, 2017 at 06:33 PM
Turning again to Kenneth Arrow and healthcare markets, assuming that Arrow was correct for all these years, and subsequent research repeatedly has confirmed Arrow, then a typical American market-based healthcare insurance system is going to prove unworkable. Why then has the work of Arrow which is at least superficially so broadly praised by economists not been more influential in forming policy?
libezkova -> anne... , February 26, 2017 at 07:12 PM
"It is difficult to get a man to understand something, when his salary depends on his not understanding it."

― Upton Sinclair, I, Candidate for Governor: And How I Got Licked

[Feb 26, 2017] Clowbacks to benefits manager is like crack cocaine

This is racket. Plain and simple.
Notable quotes:
"... Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask. ..."
"... "Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate." ..."
"... Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks. ..."
"... The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively." ..."
"... Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws. ..."
"... Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals. ..."
"... The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price. ..."
Feb 26, 2017 | economistsview.typepad.com
im1dc: February 24, 2017 at 05:26 PM
Real World Economics

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

https://www.bloomberg.com/news/articles/2017-02-24/sworn-to-secrecy-drugstores-stay-silent-as-customers-overpay

"You're Overpaying for Drugs and Your Pharmacist Can't Tell You"

by Jared S Hopkins...February 24, 2017...9:52 AM EST

> Gag clauses stop pharmacists from pointing out a cheaper way

> Cigna, UnitedHealth and Humana face at least 16 lawsuits

"Eric Pusey has to bite his tongue when customers at his pharmacy cough up co-payments far higher than the cost of their low-cost generic drugs, thinking their insurance is getting them a good deal.

Pusey's contracts with drug-benefit managers at his Medicap Pharmacy in Olyphant, Pennsylvania, bar him from volunteering the fact that for many cheap, generic medicines, co-pays sometimes are more expensive than if patients simply pay out of pocket and bypass insurance. The extra money -- what the industry calls a clawback -- ends up with the benefit companies. Pusey tells customers only if they ask.

"Some of them get fired up," he said. "Some of them get angry at the whole system. Some of them don't even believe that what we're telling them is accurate."

Graphic

Clawbacks, which can be as little as $2 a prescription or as much as $30, may boost profits by hundreds of millions for benefit managers and have prompted at least 16 lawsuits since October. The legal cases as well dozens of receipts obtained by Bloomberg and interviews with more than a dozen pharmacists and industry consultants show the growing importance of the clawbacks.

"It's like crack cocaine," said Susan Hayes, a consultant with Pharmacy Outcomes Specialists in Lake Zurich, Illinois. "They just can't get enough."

The cases arrive at a critical juncture in the quarter-century debate over how to make health care more affordable in America. President Donald Trump is promising to lower drug costs, saying the government should get better prices and the pharmaceutical industry is "getting away with murder." The Pharmaceutical Care Management Association, a benefits-manager trade group, says it expects greater scrutiny over its role in the price of medicine and wants to make its case "vocally and effectively."

Racketeering Accusations

Suits have been filed against insurers UnitedHealth Group Inc., which owns manager OptumRx; Cigna Corp., which contracts with that manager; and Humana Inc., which runs its own. Among the accusations are defrauding patients through racketeering, breach of contract and violating insurance laws.

"Pharmacies should always charge our members the lowest amount outlined under their plan when filling prescriptions," UnitedHealthcare spokesman Matthew Wiggin said in a statement. "We believe these lawsuits are without merit and will vigorously defend ourselves."

Mark Mathis, a Humana spokesman, declined to comment. Matt Asensio, a Cigna spokesman, said the company doesn't comment on litigation.

"Patients should not have to pay more than a network drugstore's submitted charges to the health plan," Charles Cote, a spokesman for the Pharmaceutical Care Management Association, said in a statement.

Read more: Escalating U.S. drug prices -- a QuickTake explainer

Benefit managers are obscure but influential middlemen. They process prescriptions for insurers and large employers that back their own plans, determine which drugs are covered and negotiate with manufacturers on one end and pharmacies on the other. They have said their work keeps prices low, in part by pitting rival drugmakers against one other to get better deals.

The clawbacks work like this: A patient goes to a pharmacy and pays a co-pay amount -- perhaps $10 -- agreed to by the pharmacy benefits manager, or PBM, and the insurers who hire it. The pharmacist gets reimbursed for the price of the drug, say $2, and possibly a small profit. Then the benefits manager "claws back" the remainder. Most patients never realize there's a cheaper cash price.

"There's this whole industry that most people don't know about," said Connecticut lawyer Craig Raabe, who represents people accusing the companies of defrauding them. "The customers see that they go in, they are paying a $10 co-pay for amoxicillin, having no idea that the PBM and the pharmacy have agreed that the actual cost is less than a dollar, and they're still paying the $10 co-pay."

On Feb. 10, a customer at an Ohio pharmacy paid a $15 co-pay for 15 milligrams of generic stomach medicine pantoprazole that the pharmacist bought for $2.05, according to receipts obtained by Bloomberg. The pharmacist was repaid $7.22, giving him a profit of $5.17. The remaining $7.78 went back to the benefits manager.
Opaque Market

Clawbacks are possible because benefit managers take advantage of an opaque market, said Hayes, the Illinois consultant. Only they know who pays what.

In interviews, some pharmacists estimate clawbacks happen in 10 percent of their transactions. A survey by the more than 22,000-member National Community Pharmacists Association found 83 percent of 640 independent pharmacists had at least 10 a month.

"I've got three drugstores, so I see a lot of it," David Spence, a Houston pharmacist, said in an interview. "We look at it as theft -- another way for the PBMs to steal."

Lawsuits began in October in multiple states, and some have since been consolidated. Most cite an investigation by New Orleans television station Fox 8, which featured interviews with Louisiana pharmacists whose faces and voices were obscured.
Tight Restrictions

Many plans require pharmacies to collect payment when prescriptions are filled and prohibit them from waiving or reducing the amount. They can't even tell their customers about the clawbacks, according to the suits. Contracts obtained by Bloomberg prohibit pharmacists from publicly criticizing benefit managers or suggesting customers obtain the medication cheaper by paying out of pocket.

Pharmacists who contract with OptumRx in 2017 could be terminated for "actions detrimental to the provider network," doing anything that "disparages" it or trying to "steer" customers to other coverage or discounted plans, according to an agreement obtained by Bloomberg.

"They're usually take-it-or-leave-it contracts," said Mel Brodsky, who just retired as chief executive officer of Pennsylvania's Keystone Pharmacy Purchasing Alliance, which buys drugs on behalf of independent pharmacies.

OptumRx is among the three largest benefit managers that combine to process 80 percent of the prescriptions in the U.S. The other two, Express Scripts Holding Co. and CVS Caremark, haven't been accused of clawbacks. CVS doesn't use them, it said in a statement. Express Scripts is so opposed that it explains the practice on its website and promises customers will pay the lowest price available.
Potential Death Blow

Pharmacies fear getting removed from reimbursement networks, a potential death blow in smaller communities. But some pharmacists jump at opportunities to inform customers who question their co-pay amounts.

"Most don't understand," said Spence, who owns two pharmacies in Houston. "If their co-pay is high, then they care."

States are responding. Last year, Louisiana began allowing pharmacists to tell customers how to get the cheapest price for drugs, trumping contract gag clauses. In 2015, Arkansas prohibited benefit managers and pharmacies from charging customers more than the pharmacy will be paid.

"The consumers don't know what's going on," said Steve Nelson, a pharmacist in Okeechobee, Florida. "We try to educate them with regards to what goes into a prescription, OK? You've got to kind of tip-toe around things."

ilsm -> im1dc... , February 24, 2017 at 07:08 PM
pharma to USG

like drug cartel in Mexico

except no briefcases

im1dc -> ilsm... , February 24, 2017 at 07:47 PM
That's a valid observation.

[Feb 19, 2017] As Democrats stare down eight years of policies being wiped out within months, but those policies did virtually nothing for their electoral success at any level.

Notable quotes:
"... This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples. ..."
"... missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium.. ..."
Feb 19, 2017 | economistsview.typepad.com
Peter K. -> Chris G ... , February 18, 2017 at 07:35 AM
via J.W. Mason (lots of F-bombs!):

http://democracyjournal.org/arguments/keep-it-simple-and-take-credit/

Keep It Simple and Take Credit

BY JACK MESERVE
FROM FEBRUARY 3, 2017, 5:42 PM

As Democrats stare down eight years of policies being wiped out within months, it's worth looking at why those policies did virtually nothing for their electoral success at any level. And, in the interest of supporting a united front between liberals and socialists, let me start this off with a rather long quote from Matt Christman of Chapo Trap House, on why Obamacare failed to gain more popularity:

There are parts to it that are unambiguously good - like, Medicaid expansion is good, and why? Because there's no f!@#ing strings attached. You don't have to go to a goddamned website and become a f@!#ing hacker to try to figure out how to pick the right plan, they just tell you "you're covered now." And that's it! That's all it ever should have been and that is why - [Jonathan Chait] is bemoaning why it's a political failure? Because modern neoliberal, left-neoliberal policy is all about making this shit invisible to people so that they don't know what they're getting out of it.

And as Rick Perlstein has talked about a lot, that's one of the reasons that Democrats end up f!@#$ing themselves over. The reason they held Congress for 40 years after enacting Social Security is because Social Security was right in your f!@ing face. They could say to you, "you didn't used to have money when you were old, now you do. Thank Democrats." And they f!@#ing did. Now it's, "you didn't used to be able to log on to a website and negotiate between 15 different providers to pick a platinum or gold or zinc plan and apply a f!@#$ing formula for a subsidy that's gonna change depending on your income so you might end up having to retroactively owe money or have a higher premium." Holy shit, thank you so much.

This point has been made before on Obamacare, but the tendency behind it, the tendency to muddle and mask benefits, has become endemic to center-left politics. Either Democrats complicate their initiatives enough to be inscrutable to anyone who doesn't love reading hours of explainers on public policy, or else they don't take credit for the few simple policies they do enact. Let's run through a few examples.

...

ilsm -> Peter K.... , February 18, 2017 at 12:47 PM
missed the point the big winner is FIRE. ACA should have been everyone in medicare, and have medicare run Part B not FIRE. Obamcare is welfare for FIRE, who sabotage it with huge deductibles and raging rises in premium..

[Jan 23, 2017] Consumer Guide to Health Care - Coping with Medical Bills and Debt Wisconsin Department of Health Services

Notable quotes:
"... Record the names and phone numbers of the people you are dealing with. ..."
"... Document the date, time, and results of your phone calls. ..."
"... Pay something - even a small amount - on each bill each month as a gesture of good faith. ..."
"... Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. ..."
"... Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately. ..."
"... Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt ..."
Jan 23, 2017 | dhs.wisconsin.gov
Unless you have successfully challenged your bill, you are responsible for paying all of your medical bills. If you cannot pay, here are some things to consider.
  1. Try to negotiate a payment plan. Your hospital or provider may be willing to accept smaller monthly payments. Keep in mind that your payments generally need to be reasonable and you must keep up with your payments. In its advice to parents of chronically ill children (link is external) , the American Academy of Family Physicians recommends the following:
    • Notify the appropriate offices quickly.
    • Keep in touch with your creditors.
    • Record the names and phone numbers of the people you are dealing with.
    • Document the date, time, and results of your phone calls.
    • Pay something - even a small amount - on each bill each month as a gesture of good faith.
  2. Get information on charity care in Wisconsin hospitals.
  3. Apply for Wisconsin Medicaid or BadgerCare Plus . If you are eligible, Medicaid may pay for some of your existing medical bills. Wisconsin Medicaid coverage can begin as early as the first day of the month, three months before the month you apply, if you would have been eligible in those months, so apply as soon as possible.
  4. Go for credit counseling. Be aware, though, that some services charge high fees and do nothing to really help reduce your debt. Make sure you are working with a credit counseling service (also known as an adjustment service agency) that is licensed by the Wisconsin Department of Financial Institutions.
  5. Be creative about finding help from outside sources. Charitable foundations, civic organizations and churches and community groups might be able to help. The Patient Pal (link is external) (PDF, 197 KB) from the Patient Advocate Foundation (link is external) includes some fundraising ideas for those with high medical bills.
  6. Don't ignore bills. Though tempting, this is not a good strategy. Hospitals and providers are more likely to negotiate with you if you contact them immediately.
  7. Don't transfer debt to a credit card. Most experts warn that this is a poor choice for paying off medical debt for two reasons:
    • The interest rates on your credit card will add significantly to your total payment.
    • Transferring medical debt to a credit card may affect your eligibility for Medicaid. Some medical costs can be deducted from gross income to determine your Medicaid eligibility. Medical debt on a credit card may no longer qualify as medical debt.
Dealing with collection agencies

If your hospital or other health care provider has turned your bill over to a collection agency, you are protected against harassment by the Fair Debt Collection Practices Act (FDCPA).

If you have questions about your rights or the conduct of a collection agency, contact the Department of Financial Institutions at (608) 264-7969, or 1-800-452-3328 (in Wisconsin only).

Bankruptcy The decision to file for bankruptcy should be last resort. More (PDF, 129 KB) information on how bankruptcy works and the different types (link is external) is available from the Wisconsin Department of Agriculture, Trade and Consumer Protection.

Legal help

If you find that you need legal help to deal with your medical debt, the Wisconsin State Bar Association's website provides general information on finding a lawyer (link is external) and information on finding a lawyer if you have a low income (link is external) .

The Legal Services Corporation (link is external) , a private, non-profit corporation established by Congress, provides a list of Wisconsin local legal aid programs (link is external) from its website.

[Jan 23, 2017] Medical Debt Collections –Unexpected Health Problems Costs

Jan 23, 2017 | www.debt.org

Medical debt collectors must abide by specific regulations, as set forth by the Fair Debt Collection Practices Act . Collectors cannot harass or lie to debtors, or perform any other practices deemed unfair.

[Jan 23, 2017] Medical Debt Collection

You can get a free Kindle version of "Debt Collection Answers" ebook on Amazon here .
Notable quotes:
"... We have heard from consumers who first hear about a medical bill from a collection agency. There is no federal law that protects you from this type of situation. ..."
Jan 23, 2017 | www.debtcollectionanswers.com
Having even a small medical debt reported as past due or in collections can seriously damage your credit history, you may be tempted to pay just to protect your credit.

Some medical providers may even try to pressure you into paying your debt owe by refusing to provide you (or one of your family members) with additional medical care until you do. Some of them may even refuse you future care while you are paying off your debt through an installment plan! Others may have a policy that as long as you owe them money, you must pay up-front for all future medical services they provide to you.

Warning: Aggressive medical providers can be a special problem for seniors living on fixed incomes when their spouses have been hospitalized or have accumulated a large outstanding bill with one or more of their doctors.


When Can I Be Sent to Collections On a Medical Bill?

If at all possible, you want to keep a medical bill out of collections. Once it is turned over to a collection agency, it will likely appear on your credit reports as a collection account and damage your credit rating.

Your medical debt may be turned over to collections:

How can you protect yourself from medical debt collection? Don't ignore medical bills. Talk to the medical provider. Get everything in writing, or follow up in writing yourself

... ... ...

If You Have Insurance and Your Insurer Refuses to Pay All or a Portion of Your Medical Bills

It's not unusual for health insurers to deny coverage for medical care. If that happens to you and you believe that the care should be covered, or if your insurer pays some but not all of your medical bill and you believe it should cover the entire bill, here's what we recommend:

[Jan 23, 2017] In debt and afraid: dealing with debt collectors

Notable quotes:
"... The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service. ..."
"... Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you. ..."
"... Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney. ..."
"... Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die! ..."
"... Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. ..."
"... Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death ..."
Jan 23, 2017 | finance.yahoo.com
Sarah Skidmore Sell, AP Personal Finance Writer

It's a scary place to be - in debt and afraid.

A new Consumer Financial Protection Bureau report found that more than one in four consumers felt threatened when contacted by debt collectors. The first-ever national survey of consumer experiences with debt collectors found consumers often faced calls that came too often, at odd hours and contained warnings of jail time and other threats. Some were contacted for debts they didn't owe. And many said when they asked the collector to stop contacting them, the request was ignored.

CFPB Director Rich Cordray said the report casts a "troubling light" on the industry, and that the bureau is working to stop abuses. But what are your rights when facing off with a debt collector?

A few things to know:

YOU ARE NOT ALONE

The CFPB says debt collection is a multi-billion dollar industry affecting 70 million consumers. People are most often contacted about medical and credit card debt. And more consumers complain to the CFPB about debt collection than any other financial product or service.

The Federal Trade Commission, which enforces the Fair Debt Collection Practices Act, also said debt collectors generate more complaints to its offices than any other industry. While many debt collectors are careful to comply with consumer protection laws, some engage in illegal practices.

YOU ARE PROTECTED

The Fair Debt Collection Practices Act provides protection for those being pursued for personal debts, such as money owed on a credit card account, an auto loan or a mortgage. It doesn't cover debts incurred to run a business.

YOU HAVE RIGHTS

Debt collectors can contact you by phone, letter, email or text message, as long as they follow the rules and disclose that they are debt collectors. It's against the law for a debt collector to pretend to be someone else to harass, threaten or deceive you.

They may not contact you at inconvenient times or places, such as early in the morning or late at night. And they may not contact you at work if they're told not to.

Debt collectors may not harass, oppress, or abuse you, according to the FTC. That includes threats of violence or using obscene language. Federal law also limits the number of calls a debt collector can place.

Collectors cannot lie to collect a debt, by falsely representing themselves or the amount you owe. And other than trying to obtain information about you, such as a telephone number or whereabouts, a debt collector generally is not permitted to discuss your debt with anyone other than you, your spouse, or your attorney.

YOU CAN TAKE ACTION

Report any problems you have with a debt collector to your state Attorney General's office, the Federal Trade Commission and the Consumer Financial Protection Bureau. Many states have their own debt collection laws that vary from federal law, so contact your attorney general's office for help.

Gary G

They are debt collectors the lowest form of bottom feeding #$%$ on the planet.step one, NEVER tell them any personal information whatsoever.step two, get a phone number and case number so you can call them back.step three call them from a phone that can record the conversation (theres an app for that)step three, call them when you are really ready to talk to them Inform them the call is being recorded. let them know clearly what forms of contact are and are not acceptable.step four, get the pertinent information about the debt including the debtor any account numbers and any settlement offers they have. Still NEVER give away any personal information. once you have all the information you need end the call, if at any time during the call you feel you are being harassed or intimidated inform them it is not acceptable (remember you are recording the conversation) and terminate the call. call back later.Now you are in control and can make informed decisions.If at some point you want/need to work out a settlement NEVER finalize anything on the phone, GET IT IN WRITING. NEVER, agree to give them your credit card or banking information under any circumstances!!!once you make an arrangement keep the printed document with the arrangement on file for the rest of your life.

Also when you pay them off keep the document marked paid in full or zero balance or whatever else the send you on file including your financial proof (canceled check, money order, credit card receipt) keep it until you die!

steven

Based on personal experience, the worst debt collectors are of the medical variety. Two years of a fatal ovarian cancer case overwhelmed not only my finances, but jeopardized my mental health as well. The only thing that kept me going was the necessity of showing up for work, and the support of coworkers and (may I say this?) my managers as well.

Mark

Consumer Financial Protection Bureau will be gutted under the GOP agenda. So the next time some cable company, Wall Street bank, or some other huge corporation screws you over, you'll have no recourse and you'll be on your own.

pfk

I find tgheses stories and the ads on TV (If you owe $1000 to IRS..., If you have more than $5,00 credit card debt, Reduce $50,00 debt to $5000..., etc) to e morally contemptible. If you cannot afford something do not buy it; if you have a job, pay your IRS taxes, etc. I'm tired paying extra for everything I buy or do for these people who spend and expect someone else (me) to pay.

a

hogwash! To scare off a junk debt buyer attorney all you need to do is make one call to your attorney. Many of you collectors "start fake lawsuits" to coerce debtors to pay. With no filing numbers, court stamps, etc... Once the debtor's attorney files a 'notice of appearance' and asks for a real lawsuit/trial, what happens? The creditor never files the lawsuit. Why? Because the junk debt buyer has to PROVE IT. The JDB creditor has no original contract signed to prove the debt exists, no chain of assignment/invoice to show they have standing to sue (own the debt) nor the account statements to verify what is owed. They are hoping at best for default judgements.

Debt industry buys billions of dollars of dead debt. 90% does end up as default judgement because scared debtors do not have the money to hire a attorney or do not know what to do. The other 10% of debtors who hire attorneys are off the hook. You see Junk Debt Buyers buy debt with no contract signed by debtors, have no invoice they even own this particular debt in detail and no account statements to verify correct amount owed.

So debtors, beware, pay the few hundred dollars to your attorney to ask for a lawsuit and notice of appearance and see how fast that debt collector disappears. 99% of junk debt buyers/creditors buy unwarranted debt and CAN NOT PROVE IT IN COURT. There is a disclaimer on the debt stating there is no contract, invoice that it is sold nor account statements offered.

Just sue these junk debt buyers and they go away. If they sell the debt to another JDB again sue again and they drop the debt again. Resold debt has even less chance of winning in court because even less proof is available every time it is sold.

But DO NOT AVOID the fake lawsuit. If you do the creditor gets the default judgement and will garnish wages, lien your house, and will win. Now if the original creditor files the lawsuit you will most likely lose and owe (they have all the proof in their records). So in this case make a settlement offer of lump sum repay or payments you can afford.

Call me scum or whatever but I have used this strategy and it works. After a few decades of paying usurious interest rates I have some cash finally coming back; and no need to file bankruptcy. After 7 years it drops off your credit report and credit score goes way up. Make it anywhere to 4-7 years (depending on your state law timeframe) and the statute of limitations kicks in and money not legally owed any longer. Just do not make any payments on it to renew statute of limitations. No problems! Hell I gambled the money away anyway, how was I suppose to get it back -Ha, Ha. Joke was on the JDB in my case!

Gregory

Very poor article. Take it from some one who was being threatened for some one else's debt. A certified letter to the debt collector explaining you do not owe the debt means that once they receive the letter they can no longer contact you.

Violation of that law carries a 10,000 dollar fine. If the amount is in dispute the same tactic works, except they can contact you with the proof of what you owe. A lot times this involves too much work and they do not pursue it. So if they do not pursue it once the Statute of Limitations is over the debt can no longer be collected.

The limit varies by State Law and amount. Finally be aware that uncollected debts are often sold and the new "owner" of the debt may try to collect on it. Again a certified letter stops them as you have proof of notification that the debt is not owed. I hope this helps the victims out there.

Chub

Buying debt has become a large industry that attracts a lot of crooks. Companies buy debt for as little as a dime on the dollar! The original lender benefits because they are getting a little something out of a debt that they have no hope of collecting. The buyer of the debt benefits because the potential profit is very

Many of the people buying debt aren't your traditional debt collection agency. They are many times just an individual with a cell phone who could bend the rules because they can change their name and location as easy as you can report their activity. Many times you are just dealing with thugs with cellphones. If you owe them, don't be afraid to offer a lesser amount because they had bought the debt so cheap that they may still make a pretty good profit.

Chief_blamestormer

Realize that some debtors never borrowed a dime. It could be the result of a civil judgement. If you think all civil judgements are fair, then have a look at the cases in your local courthouse, or serve a couple rounds of jury duty.

W, 19 hours ago

Industry? There's nothing industrious about. Bill collectors are mostly thugs who can't get real jobs so they have to leverage their values off other people's misery. Consumer debts are self inflicted foolishness, medical debts aren't, but just goes to show the Empire is ran by business interests who refuse to allow any type of universal medical and have installed a system that allows them profits for illness and death , which is similar to a developing country, not a developed superpower.

[Jan 16, 2017] Trump said he will target pharmaceutical companies over drug prices and demand that they negotiate directly with Medicaid and Medicare.

Jan 16, 2017 | economistsview.typepad.com

pgl -> Fred C. Dobbs... , January 16, 2017 at 05:57 AM

If Trump is serious about what he said - expect a real battle with Speaker Ryan.
DeDude -> pgl... , January 16, 2017 at 06:57 AM
That may be exactly what Trump is counting on. Trump is a classic bully, he gets back at people (to make an example and reduce future "resistance"). It would be very difficult for the GOP to fight with Trump publicly in the first year. Question is what his specifics are. He may even be able to get bipartisan support and split the GOP, the way Bush did with his prescription drug plan for seniors.
reason -> DeDude... , January 16, 2017 at 07:35 AM
Trump doesn't do details. Details are for little people.
libezkova -> DeDude... , January 16, 2017 at 07:44 AM
Crushing Speaker Ryan is not bulling per se. This is a great service for the country.

He is definitely out of touch with reality.

Peter K. -> Fred C. Dobbs... , January 16, 2017 at 05:55 AM
"We're going to have insurance for everybody," Mr. Trump said. "There was a philosophy in some circles that if you can't pay for it, you don't get it. That's not going to happen with us."

In the interview, Mr. Trump provided no details about how his plan would work or what it would cost. He spoke in the same generalities that he used to describe his health care goals during the campaign - that it would be "great health care" that left people "beautifully covered."

Single payer!

ilsm -> Peter K.... , January 16, 2017 at 06:10 AM
Trump would have to sell it, but in the past he has praised European style single payer, but said it would be a hard sell in the US.

If Nixon could go to China.

MLK would observe "if US can pay to gut the world, it can afford a little for the home front".

Peter K. -> ilsm... , January 16, 2017 at 06:52 AM
"Beautifully covered."

Can't wait!

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
The GOP's strategy for Obamacare? Repeal and run.
http://www.bostonglobe.com/opinion/2017/01/15/gop-strategy-for-aca-repeal-and-run/aCcjrJWQDjx4r4aRxkMCaL/story.html?event=event25 via @BostonGlobe
Elizabeth Warren - January 15, 2017

For eight years, Republicans in Congress have complained about health care in America, heaping most of the blame on President Obama. Meanwhile, they've hung out on the sidelines making doomsday predictions and cheering every stumble, but refusing to lift a finger to actually improve our health care system.

The GOP is about to control the White House, Senate, and House. So what's the first thing on their agenda? Are they working to bring down premiums and deductibles? Are they making fixes to expand the network of doctors and the number of plans people can choose from? Nope. The number one priority for congressional Republicans is repealing the Affordable Care Act and breaking up our health care system while offering zero solutions.

Their strategy? Repeal and run.

Many Massachusetts families are watching this play out, worried about what will happen - including thousands from across the Commonwealth that I joined at Faneuil Hall on Sunday to rally in support of the ACA. Hospitals and insurers are watching too, concerned that repealing the ACA will create chaos in the health insurance market and send costs spiraling out of control.

They are right to worry. Massachusetts has worked for years to provide high-quality, affordable health care for everyone. But there's no magic wand we can wave to simply snap back to our old system if congressional Republicans decide to rip up the Affordable Care Act and run away.

Health care reform in Massachusetts wasn't partisan. Democrats, Republicans, business leaders, hospitals, insurers, doctors, and consumers all came together behind a commitment that every single person in our Commonwealth deserves access to affordable, high-quality care. When Republican Governor Mitt Romney signed Massachusetts health reform into law in 2006, our state took huge strides toward offering universal health care coverage and financial security to millions of Bay State residents.

That law was a major step forward. Today, more than 97 percent of Bay Staters are covered - the highest rate of any state in the country.

But Massachusetts still has a lot to lose if the ACA is repealed. One big reason for our state's health care success is that we took advantage of the new opportunities offered under the ACA. In addition to making care more accessible and efficient, our state expanded Medicaid, using federal funds to help even more people. And we combined federal and state dollars to help reduce the cost of insurance on the Health Connector.

When the ACA passed, Massachusetts already had in place some of the best consumer protections in the nation. But the ACA still made a big difference. It strengthened protections for people in Massachusetts with pre-existing conditions, allowed for free preventive care visits, and - for the first time in our state - banned setting lifetime caps on benefits.

If the ACA is repealed, our health care system would hang in the balance. Half a million people in the Commonwealth would risk losing their coverage. People who now have an iron-clad guarantee that they can't be turned away due to their pre-existing conditions or discriminated against because of their gender could lose that security. Preventive health care, community health centers, and rural hospitals could lose crucial support. In short, the Massachusetts health care law is a big achievement and a national model, but it also depends on the ACA and a strong partnership with the federal government.

If the cost-sharing subsidies provided by the ACA are slashed to zero, Massachusetts will have a tough time keeping down the cost of plans on the Health Connector. The state can't make funds appear out of thin air to help families on the Medicaid expansion if Republicans yank away support. And our ability to address the opioid crisis will be severely hampered if people lose access to health insurance or if the federal funding provided through the Medicaid waiver disappears. Even in states with strong health care systems - states like Massachusetts - the ACA is critical.

The current system isn't perfect - not by a long shot. There are important steps Congress could take to lower deductibles and premiums, to expand the network of doctors people can see on their plans, and to increase the stability and predictability of the market. We should be working together to make health care better all across the country, just like we've tried to do here in Massachusetts.

This doesn't need to be a partisan fight. But if congressional Republicans continue to pursue repeal of the ACA with nothing more than vague assurances that they might - someday - think up a replacement plan, the millions of Americans who believe in guaranteeing people's access to affordable health care will fight back every step of the way.

Repeal and run is for cowards.

pgl -> Fred C. Dobbs... , January 16, 2017 at 06:00 AM
"Providing health insurance to everyone in the country is likely to be very costly, a fact that could diminish support from fiscal conservatives."

Herein lies the real issue. Of course we could reduce these costs by ending the doctor cartel, ending the oligopoly power of the health insurance giants, and pushing back on Big Pharma. Alas, Speaker Ryan is not interested in any of these things.

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 06:01 AM
Rand Paul says he's drafting
a measure to replace Obamacare http://www.bostonglobe.com/news/politics/2017/01/15/rand-paul-says-drafting-measure-replace-obamacare/y6wMEPKjbi1oEkj9TkekSO/story.html?event=event25 via @BostonGlobe
Miles Weiss - Bloomberg - January 15, 2017

Republican Senator Rand Paul said he's drafting legislation for a health-care insurance plan that could replace Obamacare, including a provision to ''legalize'' the sale of inexpensive insurance policies that provide abbreviated coverage.

''That means getting rid of the Obamacare mandates on what you can buy,'' Paul said in an interview on CNN's ''State of the Union'' on Sunday. Obamacare, which Republicans are moving to repeal, requires insurers to cover a number of procedures -- such as preventive care and pregnancy -- that Paul said drives up the cost.

The Kentucky Republican said he'll propose helping people pay for medical bills through tax credits and health savings accounts, which allow users to set aside money tax-free to pay for medical expenses. His bill would allow individuals and small businesses to form associations when buying insurance, giving them more leverage, he said.

''There's no reason why someone with four employees shouldn't be able to join with hundreds and hundreds of other businesses'' to negotiate better prices, Paul said. Becoming part of larger pools would help small companies secure coverage ''that guarantees the issue of the insurance even if you get sick.'' ...

Paul said his legislation is meant to address concern among Democrats and some Republicans that ending Obamacare would also end health-care coverage for many of the 20 million people who acquired insurance under the law. While Republicans move ahead with their plans to eradicate Obamacare, they have yet to outline an alternative.

''It's incredibly important that we do replacement on the same day as we do repeal,'' Paul said on CNN. ''Our goal,'' he added, is to ''give access to the most amount of people at the least amount of cost.''

Fred C. Dobbs -> Fred C. Dobbs... , January 16, 2017 at 07:28 AM
(I urge that Dr Paul's plan include
guv'mint-supplied snake bite kits
for all. That could save a bundle.)

[Jan 15, 2017] Doctors in the United States get paid on average more than $250,000 a year

Jan 15, 2017 | economistsview.typepad.com
libezkova -> anne... , January 14, 2017 at 10:45 PM
"Doctors in the United States get paid on average more than $250,000 a year,"

I am sure that this is a right estimate. Certain specialties probably yes (dentists, cardiologist, gastroenterologists, neurosurgeons, etc), but family doctors, probably no.

[Jan 15, 2017] The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States

Jan 15, 2017 | economistsview.typepad.com
JohnH -> anne... , January 14, 2017 at 08:00 AM
The Congressional defeat, insured by Democrats, of the proposal by Bernie Sanders to allow the import of drugs from Canada to lower drug prices in the United States.
'
This is only the beginning of Democrats' appeasement of Trump and Republicans...it will be stunning to watch how much damage Republicans can do during Trump's first 90 days with only a slim majority in the Senate. During the first 90 days under Obama, who had a true electoral mandate and big majorities in both houses, Democrats basically sat on their hands, blaming Republicans for their unwillingness to do much for the American people.
Observer -> anne... , January 14, 2017 at 08:50 AM
So if we matched Canada, we'd see a 30% decrease, of a segment which comprises 10% of health care spending, or 3% overall decrease.

"PwC's Health Research Institute projects the 2017 medical cost trend to be the same as the current year – a 6.5% growth rate."

So reaching Canadian spending levels would counter ~ 6 months of health care cost increases. Reaching OECD levels buys you another couple of months.

Put another way, reaching OECD levels for drug spending closes 10% of the US-OECD spending gap.

Not nothing, but "fixing" drug prices seems more like an emotional (i.e. political) talking point than a real silver bullet for health care costs.

http://www.pwc.com/us/en/health-industries/health-research-institute/behind-the-numbers.html

pgl -> Observer... , January 14, 2017 at 11:17 AM
Ever noticed that marketing costs are 30% of revenue? This is a by product of the monopoly power in this sector. Dean Baker has often noted we could have the government do the R&D and then have real competition in manufacturing.
libezkova -> Observer... , January 14, 2017 at 10:40 PM
Don't be a lobbyist for Big Farma.

You forgot that those researchers often produce useless or even dangerous drags, which are inferior to existing. Looks as scams practiced with hypertension drugs.

This rat race for blockbuster drugs is the same as corruption in financial industry.

http://www.alternet.org/story/148907/15_dangerous_drugs_big_pharma_shoves_down_our_throats

pgl -> anne... , January 14, 2017 at 11:16 AM
Actually the industry profile is very relevant but goes in a different direction - if US firms were compelled to charge market (not monopoly) prices, we would better compete with foreign firms.
pgl -> Observer... , January 14, 2017 at 11:14 AM
Any excuse to charge sky high prices for drugs that don't cost that much to manufacture? If these monopoly profits were not so high, we would buy more drugs and employ more people.
Observer -> pgl... , January 14, 2017 at 12:57 PM
Do you think we would really buy materially more drugs if prices were lower? Particularly enough more, at those (30-50%?) lower prices, to generate the funds to employ more people?

(If that actually generated at much or more funds, it would seem like the pharma companies, seeking to make as much money as possible, would have already set prices at that lower per unit level.)

In any case, that seems like a LOT more drugs.

Perhaps Anne has data on the number of scripts per person in the US vs OECD.

pgl -> Observer... , January 14, 2017 at 01:06 PM
There are lots of poor people who don't take drugs because they can't afford them. This will become especially true if the Republican repeal Obamacare.
anne -> Observer... , January 14, 2017 at 09:05 AM
The point of course is wildly exploiting ordinary people in need of healthcare in every possible way, or a reflection of what we have come to. Returning now to the market...

[Jan 14, 2017] Insurance overhead runs are probably the best argument for single payer

Jan 14, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , -1
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

[Jan 13, 2017] Reducing the cost of healthcare

Jan 13, 2017 | economistsview.typepad.com
pgl -> Fred C. Dobbs... , January 13, 2017 at 06:14 AM
There are 3 ways we could reduce what we pay for health care:

(1) Ending the oligopoly power of the health insurance companies;

(2) Ending the doctor cartel;

(3) Reducing the monopoly power of Big Pharma.

Alas, the Republicans have no intention in doing any of this. So when they tell people they want to lower their costs, they are talking to rich people. The cost to the rest of us will go up if they have their way.

Observer -> pgl... , January 13, 2017 at 07:12 AM
From what I read, and recall from data Anne has posted a number of times, pharma costs are about 10% of total health care costs, and run about 2X EU average, or Canada, if we adopt that as a reference baseline. If we cut it in half, that would reduce our costs about 5%.

Doctors fees (physicians and clinical services in this reference) are about 20%. I think you have mentioned before we pay about 2X typical EU wages. So if we cut that in half, it reduces our costs about 10%.

Taken together, that's ~ 15% reduction. Not nothing, but in a few years of cost growth we are back to current cost levels.

Do you see that differently?

I don't have offhand figures for what insurance overhead runs. I think reducing that is probably the best argument for single payer, although comparisons to medicare overhead seem suspect (I'd expect much lower overhead percentages when much of your costs you are processing are $40K end of life hospital events vs. routine GP visits.) So one might zero out the profit, and reduce costs by having one IT/billing system. What's the scale of the opportunity here - another 15%?

https://www.cdc.gov/nchs/fastats/health-expenditures.htm

anne -> Observer... , January 13, 2017 at 07:37 AM
https://www.nytimes.com/2017/01/12/us/politics/health-care-congress-vote-a-rama.html

January 12, 2017

Senate Takes Major Step Toward Repealing Health Care Law
By THOMAS KAPLAN and ROBERT PEAR

In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes....

[Jan 13, 2017] What was at stake why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine

Jan 13, 2017 | economistsview.typepad.com
anne -> Observer... , January 13, 2017 at 07:39 AM
https://twitter.com/lhfang/status/819677587408568320

Lee Fang ‏@lhfang

What was at stake & why Cory Booker joined Senate Republicans to kill a measure to import cheaper medicine:

https://theintercept.com/2017/01/12/cory-booker-joins-senate-republicans-to-kill-measure-to-import-cheaper-medicine-from-canada/

BERNIE SANDERS INTRODUCED a very simple symbolic amendment Wednesday night, urging the federal government to allow Americans to purchase pharmaceutical drugs from Canada, where they are considerably cheaper.

2:49 PM - 12 Jan 2017

Peter K. -> anne... , January 13, 2017 at 09:33 AM
Cory Booker, another progressive neoliberal....
pgl -> Observer... , January 13, 2017 at 09:37 AM
Very good. On health insurance, they get 20% gross margins. I have argued many times we can cut this to 10%.

[Jan 12, 2017] Almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 12, 2017] Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

Jan 12, 2017 | www.nakedcapitalism.com
Benedict@Large , January 12, 2017 at 2:53 pm

Cory Booker understands that a candidate cannot expect the Democratic nomination if he/she goes against the interests of BigPharma.

RUKidding , January 12, 2017 at 3:26 pm

After spending day time hours publically going after Jeff Sessions (good), Booker uses the cover of darkness to reveal who he really works for.

Here's a clue: it isn't any of the 99%, whether in NJ or elsewhere.

Talk's cheap, but money walks – eh, Booker?

EndOfTheWorld , January 12, 2017 at 3:40 pm

Somewhere I saw that Bernie praised Trump taking on Big Pharma.

curlydan , January 12, 2017 at 3:33 pm

'specially if you're from Jersey. Kind of like Biden, Delaware, and credit cards. The strings on the puppets are awfully tight.

[Jan 12, 2017] 200PM Water Cooler 1-12-2017 naked capitalism

Jan 12, 2017 | www.nakedcapitalism.com
Class Warfare

"Hierarchies aren't natural phenomena within the human race. Outside of parenting, human beings aren't born with the inclination to be ruled, controlled, 'managed,' and 'supervised' by other human beings" [ The Hampton Institute ]. Hierarchies are artificial constructs designed to serve a purpose. They are a necessity within any society that boasts high degrees of wealth and power inequities. They are a necessity for maintaining these inequities and ensuring they are not challenged from below."

"In a report from Bankrate.com, the firm found that almost six in 10 Americans don't have enough savings to pay for a $500 car repair or a $1,000 emergency room bill" [ 247 Wall Street ]. "While Millennials may be looked down on by older demographics, they are the most equipped generation to pay for an unexpected expense using their savings. It was found that 47% of those within the ages of 18 to 29 responded that they would use their savings to cover such a burden, up from 33% in 2014." I'd argue that's not virtue, but a rational response to the neoliberal destruction of universal benefits and government services generally.

"[A] good deal of [Wallace] Stevens's poetic output conveyed a feeling of sehnsucht ("inconsolable longing"). For example, in 'Sad Strains of a Gay Waltz,' Stevens writes of American southerners (although the words just as easily apply to their author) as 'voices crying without knowing for what, / Except to be happy, without knowing how.' The object of Stevens's inconsolable longing changed over time. In his early professional days, when he first moved to New York City, it was his hometown of Reading, Pa. Writing to his future wife, Elsie, Stevens lamented that he 'lost a world' when he left there" [ The American Conservative ].

Knifecatcher , January 12, 2017 at 2:12 pm

Re: Bankrate story – is there such thing as a $1k ER bill anymore? We paid nearly $3k for our unexpected trip, which involved 15 minutes with the doc, no tests or scans, and only a single dose of Childrens' Tylenol for consumables. (5 year old tried to poke his eye out with a stick and failed – but only just).

And of course our crapified insurance hadn't hit the deductible so we had to pay the whole bill out of pocket.

Vatch , January 12, 2017 at 2:31 pm

I'm lucky - I only have a $150 deductible, which is what I paid when I needed five stitches in my hand last year. The total bill was "only" about $1250, probably because I never saw an actual doctor. A nurse practitioner sewed me up. The explanation of benefits from the insurance company later showed that they only paid the hospital about one third of the billed price. I'm sorry that you had to pay the whole thing; I guess the insurance companies only enforce their standard payable fees when it's their money on the line.

optimader , January 12, 2017 at 2:58 pm

The kids I grew up with, that would have been crazy-glue/packaging-tape unless a finger articulation was compromised

http://morethanjustsurviving.com/stitches-bandages-or-super-glue/

btw..Animal bites should be left open and bandaged and treated w/ antibiotic so they heal from the inside out..

I remember in my misspent college youth an idiot scuba diver in Honduras (feeding a moray eel cheese wiz out of a can, guess what happened when she ran out?) who came to my friend's dad (a surgeon) insisting he sew her up.
He only bandaged her with butterfly bandages and gave her some kick-ass antibiotics. She was sure she was being undeserved (w/ gratis treatment) because he refused to sew her up, potentially trapping an infection.

ian , January 12, 2017 at 2:43 pm

I had a similar experience: 3 stitches on my sons finger. Treated by nurse (no doc), sutures and lidocaine was $1800. It got me wondering about how anyone could hope to reform health care when the accounting is so completely out of whack with reality.

[Jan 11, 2017] the DEPRAVED nature of the American "Health Kare" system

Jan 11, 2017 | www.nakedcapitalism.com
clarky90 , January 10, 2017 at 6:12 pm

For me, often it is the "small crimes" that exemplify the DEPRAVED nature of the American "Health Kare" system. (See the right hand panel of The Last Judgment Bosch triptych) https://en.wikipedia.org/wiki/The_Last_Judgment_(Bosch_triptych)

US drugmaker charges 200 times UK price for common worm pill

A US drugmaker has put a price tag of more than $800 on a pinworm treatment - 200 times more expensive than the equivalent medicine on British pharmacy shelves, in the latest example of "price gouging" in the world's largest healthcare market.
Impax Laboratories (Bastards!) started selling mebendazole this year at an average wholesale price of $442 per pill, according to figures seen by the Financial Times, which were checked with several US pharmacy chains including Walgreens and CVS.

Most cases of pinworm, a parasitic infection also known as threadworm, require two pills, meaning a course of treatment costs about $884. The drug is available prescription-only in the US but can be bought over the counter in the UK, where Boots, a British chemist chain, charges £6.99 for a pack of four pills, or £1.75 each.

The pinworm parasite, which is common in children, affects 200m people a year worldwide and up to 40m in the US. It is recommended that family members are treated for the highly contagious infection at the same time, meaning a household of five's treatment costs more than $4,400.

https://www.ft.com/content/f0080fe4-c3ad-11e6-9bca-2b93a6856354

"Mebendazole came into use in 1971, after it was developed in Belgium.[4] It is included in the WHO Model List of Essential Medicines, the most important medications needed in a basic health system .[5] Mebendazole is available as a generic medication.[6] The wholesale cost in the developing world is between 0.004 and 0.04 USD per dose .[7] In the United States a single dose is about 884.00 USD as of 2016.[8]

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

[Jan 02, 2017] U.S. Healthcare Is A Global Outlier (And Not In A Good Way)

Jan 02, 2017 | www.zerohedge.com

Historically, the United States has spent more money than any other country on healthcare.

In the late 1990s, for example, the U.S. spent roughly 13% of GDP on healthcare, compared to about a 9.5% average for all high income countries.

However, as Visual Capitalist's Jeff Desjardins notes, in recent years, the difference has become more stark . Last year, as Obamacare continued to roll out, costs in the U.S. reached an all-time high of 17.5% of GDP . That's over $3 trillion spent on healthcare annually, and the rate of spending is expected accelerate over the next decade .

HIGH COSTS, HIGH BENEFIT?

With all that money being poured into healthcare, surely the U.S. must be getting better care in contrast to other high income countries.

At least, that's what one would think.

Today's chart comes to us from economist Max Roser (h/t @NinjaEconomics ) and it shows the extreme divergence of the U.S. healthcare system using two simple stats: life expectancy vs. health expenditures per capita.

Courtesy of: Visual Capitalist

THE DIVERGENCE OF U.S. HEALTHCARE

As you can see, Americans are spending more money – but they are not receiving results using the most basic metric of life expectancy. The divergence starts just before 1980, and it widens all the way to 2014.

It's worth noting that the 2015 statistics are not plotted on this chart. However, given that healthcare spend was 17.5% of GDP in 2015, the divergence is likely to continue to widen. U.S. spending is now closing in on $10,000 per person.

Perhaps the most concerning revelation from this data?

Not only is U.S. healthcare spending wildly inefficient, but it's also relatively ineffective. It would be one thing to spend more money and get the same results, but according to the above data that is not true. In fact, Americans on average will have shorter lives people in other high income countries.

Life expectancy in the U.S. has nearly flatlined, and it hasn't yet crossed the 80 year threshold. Meanwhile, Chileans, Greeks, and Israelis are all outliving their American counterparts for a fraction of the associated costs. buckstopshere , Jan 1, 2017 10:02 PM

A shorter life expectancy makes Social Security look more solvent.

Cooking the books.

junction buckstopshere , Jan 1, 2017 10:08 PM
The chart shows that Monsanto and the New World Order are succeeding, that more glyphosate herbicide in the food, more toxic chemtrails and more unneccessary operations are having the desired effect, to cull the American population. Helped immeasurably by the cocaine and heroin flown into the USA by the Bush Crime Cartel on Air Force cargo planes.
cheka junction , Jan 1, 2017 10:10 PM
nyc runs US health care. that tells one all he needs to know.
Pinch Dog Will Hunt , Jan 2, 2017 12:58 AM
Republitards and Freedumb-lovers need to watch Michael Moore's movie about this called "Sicko"

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

You need MORE socialism, not less.

Tards.

Chief Wonder Bread balolalo , Jan 1, 2017 10:42 PM
Australia, Norway, Switzerland, Germany, South Korea, Japan, Italy, U.S.

Which of these countries is not like any of the others? Haha. Multiculturalism is such a fantastic deal. Some "cultures" just don't make good lifestyle decisions such as thinking that grape drank and swisher sweets are healthful choices.

philipat cheka , Jan 1, 2017 10:35 PM
It is, of course, in part a "Lifestyle" issue but the US system is grossly inefficient because there are adverse incentives built in (Adverse selection etc.). The US still uses a "Fee for service" model which has never been able to control costs anywhere in the world. On top of that, high pharmaceutical prices in the US account for up to 90% of total Big Pharma profits ane Medical Malpractise insurance not only directly adds large costs but indirectly forces the use of an unnecessary number of tests and the use of the newest drugs etc. Without any sensible controls at any point in the system it will only continue to get further out of control, as ACA has illustrated.
Ballin D philipat , Jan 1, 2017 10:41 PM
What's the alternative to "fee for service?" Seems pretty standard to charge for services rendered.
philipat Ballin D , Jan 1, 2017 11:47 PM
Except that more services = more fees = higher costs. Hence multiple tests, multiple procedures and multiple drugs = higher costs and higher fees = inefficiency bias and higher still costs. Physicians are human and the Healthcare providers have become experts at maximising costs to breaking point. There are many alternative models within which to control costs through negotiated standard procedures and fixed costs for each procedure and drug formularies (including the use of generic drugs) etc. Single payer is used by much of the developed world where the supplier agrees to supply at a negotiated price or doesn't get to participate, which focuses their attention nicely. The benefits of scale, in whatever system is used, should result in lower prices but don't in the US where USG is already the largest single provider of healthcare (Medicare/Medicaid etc).
Canoe Driver philipat , Jan 2, 2017 12:36 AM
A lot of people, certainly not just doctors, are making a lot of money from this dysfunctional medical system. That is the difference no one is talking about. The money is not disappearing down a rabbit hole. It is being pocketed by thousands of multi-millionaires. It is a profit-based system. Medicine is the one field where Capitalism has no hope of efficiency. Why? Because the demand is infinite and inelastic. A recipe for the financial rape of millions.
dogsandhoney2 junction , Jan 2, 2017 12:43 AM
yeah,
and it also shows the effect of a
30% increase in psychological stress since 1980.
stress = ^stress hormones = stressed immune system =
anxiety/depression/cardiovascular disease/hyper inflammatory response/etc..

all to be treated by those in the stressed-out health care system,
usually with hyper-cost pharmaceuticals.

it's well past due date for the u.s. to become civilized by starting
single payer medical plans.

health insurance corporations = the terror.

sinbad2 heresy101 , Jan 1, 2017 10:48 PM
I wouldn't count on it.

Private healthcare and insurance is very profitable 2 of the 3 trillion the US spends on healthcare would go to shareholders and management of healthcare companies.

Mr Trump is a businessman and a realist. The media would be calling him a commie if he tried to fix it.

sinbad2 , Jan 1, 2017 10:38 PM
Americans would not have it any other way.

The countries that have the most cost effective healthcare, are countries that provide government run health insurance.

Americans would never tolerate claiming helthcare costs back from a Government run health providor, like in Australia, or waisting taxpayers money building hospitals.

Americans have to pay for their belief that private for profit health insurance is cheaper and better than government provided insurance.

Xena fobe sinbad2 , Jan 1, 2017 11:41 PM
Americans would accept single payer. But insurance companies would not.
TheEndIsNear I Write Code , Jan 2, 2017 12:05 AM
250,000 deaths in 2015 were due to medical error, the third leading cause of death in the U.S.
http://www.hopkinsmedicine.org/news/media/releases/study_suggests_medica...

38,300 people were killed on U.S. roads in 2015.
http://www.newsweek.com/2015-brought-biggest-us-traffic-death-increase-5...

33,636 deaths due to "Injury by firearms" of which only 11,208 were homicides, 21,175 were self inflicted suicides, and the remainder were due to accidental/negligent discharge of a firearm or "undetermined intent".
https://en.wikipedia.org/wiki/Gun_violence_in_the_United_States

brooklinite8 , Jan 1, 2017 11:07 PM
When I was visiting India I saw few women administer a baby birth basically in few minutes with bare hands, water, oil and some sarees. Here in the US I believe the bill comes around 5-10k at the least. Did we ever ask the question as to why do we need insurance to afford health care? Did we ever ask how has it become so out of control? Why has healthcare become such a big business? Where are the morals of humanity?

In USA the welfare of the state takes precedence to the welfare of the people. Human beings are valued at no different rate in USA than India. Welcome to the Land of the Free, Home of the Brave. Good Old USA. We are outliers and Everything we do should be an outlier. If not we will revisit and make sure it becomes an outlier. Lol

Canoe Driver brooklinite8 , Jan 2, 2017 12:57 AM
The total cost per childbirth in the US is said to be $50-65k. This figure is so outrageous that it is impossible to correlate it with the cost of providing the services. It is simply a bunch of profiteers taking their cut. And the profit can be several hundred percent of the underlying cost, precisely because the "customer" has no choice at all. Capitalism, which works well in many contexts, fails miserably in medicine. Demand is infinite and inelastic in the medical field.
hairball48 , Jan 1, 2017 11:15 PM
A shitty diet of sugar laden, high carbohydrate fast food products is what contributes to most Americans' shorter life spans, not "poor health care".

Health care is expensive because it's run by a de facto "health care mafia". I worked in the technical field of health care for 28 years. Excessive regulation is but just one reason health care is so expensive in the USA. Barriers to entry are another. Try to establish a medical school. See how long it takes. Fewer docs, the higher the price of docs. ECO 101. Don't look for a change anytime soon.

hairball

Miffed Microbio... hairball48 , Jan 2, 2017 12:14 AM
When I was an intern for clinical microbiology they gave us $300/month as a stipend. Today an internship costs $24k. This is on top of the 4 years degree. Plus the mechanization of the lab is continuing every year to the point there will be fewer jobs in the future. Hate to say it but my field is fucked. Much of my time is spent meeting regulatory compliance and it gets worse every year.

Miffed

tyberious , Jan 1, 2017 11:52 PM
Me, 20 years in Healthcare BS, MSPH, , started in reference labs, then trauma center, biotech and now in healthcare insurance quality improvement (Medicare). 1st of all the money is in the government, we all know that!

But my main response to the article is that the America sheep are being sheared! The assault starts at birth with 21 vaccines by adulthood( infant mortality), hormones in the food (preteen secondary sex characteristics)(breast cancer)(prostate cancer) , HFC (diabetes, heart diseases, and other complications) GMO's, glycophosphates, glutens, and the multitude of useless pharmaceuticals.

My point is Americans are being poisoned, not so much intentionally, but through fascist business models.

So recap: Chronic preventable illnesses, extensive bureaucracy, poor food choices (# 1 in my book), and a government that cares zero fucks about you!

chosen , Jan 2, 2017 12:18 AM
Doctors are way overpaid. Hospitals charge ridiculous prices that have no relation to reality. Insurance companies screw us even more.

The US medical system is worse than the university system. Both are scams whose main goal is to make the providers more and more money, and the users poorer and poorer. It is sick.

Canoe Driver chosen , Jan 2, 2017 1:12 AM
Basically, you are right. The idea is that the price is all the funds the "customer" has in the world, every time there is significant illness. This is because the demand for healthcare is essentially infinite and inelastic. If you want to live, pay us everything you have, then declare bankruptcy. That is what happens naturally in a for-profit medical system.

[Dec 30, 2016] Payment for Emergency Ambulance Services.

Dec 30, 2016 | dfs.ny.gov
The Office of General Counsel issued the following opinion on June 7, 2006, representing the position of the New York State Insurance Department.

Payment for Emergency Ambulance Services.

Re: Payment for Emergency Ambulance Services.

Questions Presented:

1. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization ("HMO") has made partial payment of a bill?

2. Pursuant to the New York Insurance Law, may a medical provider, such as an ambulance company issued a certificate to operate under N.Y. Pub. Health Law § 3005, bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or health maintenance organization has denied payment entirely?

Conclusions:

1. Pursuant to N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006), the ambulance company may not bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has made partial payment of a bill under an insurance contract that provides major medical or similar comprehensive-type coverage. However, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the patient directly for the balance of the bill.

2. Yes. The ambulance company may bill a patient directly for prehospital emergency ambulance services where a New York authorized insurer or HMO has denied payment entirely, subject to the remedies available to the patient.

Facts:

This inquiry is general in nature.

Analysis:

N. Y. Ins. Law § 4303 (McKinney Supp. 2006) applies to non-profit health plans and HMO's. Although HMO's are primarily regulated by the New York Health Department, their subscriber contracts are regulated by the Insurance Department as if they were subscriber contracts of non-profit health insurers. See N.Y. Public Health Law § 4406(1) (McKinney 2002).

N.Y. Ins. Law § 4303(aa) (McKinney Supp. 2006) provides, in relevant part, as follows:

(aa)(1) Every contract issued by a hospital service company or health service corporation which provides major medical or similar comprehensive-type coverage shall include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law.

(2) Payment by an insurer pursuant to this section shall be payment in full for the services provided. An ambulance service reimbursed pursuant to this section shall not charge or seek any reimbursement from, or have any recourse against an insured for the services provided pursuant to this subsection, except for the collection of copayments, coinsurance or deductibles for which the insured is responsible for under the terms of the policy.

(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.

(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection. . . .

N.Y. Ins. Law § 3221(l)(15) (McKinney Supp. 2006), which applies to group or blanket accident and health insurance policies issued by commercial insurers and N.Y. Ins. Law § 3216(h)(24) (McKinney Supp. 2006), which applies to individual accident and health insurance policies issued by commercial insurers contain identical provisions.

In accordance with the above, if the insurance contract provides major medical or similar comprehensive-type coverage, it must include coverage for prehospital emergency medical services for the treatment of an emergency condition when such services are provided by an ambulance service issued a certificate to operate pursuant to section three thousand five of the public health law. The insurer must provide coverage for emergency ambulance services based upon the rates negotiated between the insurer and the provider of such services. If no participating provider contract exists, the insurer must pay for the services at the usual and customary charge, which shall not be excessive or unreasonable.

Once the insurer makes payment at the usual and customary charge, the provider must accept such payment as payment in full. The provider may not bill the patient directly for emergency ambulance services for the balance of a bill, except for the collection of copayments, coinsurance or deductibles that the insured is responsible for under the terms of the insurance contract.

Please note that N.Y. Ins. Law §§ 3216(h)(24), 3221(l)(15) and 4303(aa) (McKinney Supp. 2006) are applicable only to insurance contracts that provide major medical or similar comprehensive-type coverage. Thus, if such a contract is not involved, these provisions do not apply and there is no prohibition in the Insurance Law against the ambulance company billing the insured directly. In addition, these provisions do not address a situation in which a New York authorized insurer or HMO has denied payment entirely for emergency ambulance services (i.e. where the insurer or HMO states that coverage was not in effect or that treatment was not medically necessary). In such cases, the ambulance company may bill the patient directly, subject to the remedies available to the patient.

If the ambulance company or patient disputes a payment made by the insurer or HMO as not constituting the usual and customary charge or disputes the fact that no payment was made, the ambulance company or patient may raise the issue with the insurer or HMO and/or file a complaint with the Department's Consumer Services Bureau.

Lastly, the New York Attorney General's Office has conducted an investigation on balance billing by ambulance companies. For further information, the inquirer was directed to contact the Attorney General's Office at (518)474-7330 or access their web site which is located at http://www.oag.state.ny.us.

This opinion does not provide an analysis of the No-Fault Insurance Law, which would result in a different analysis and conclusion, since the inquirer already had OGC Opinions on this subject. 1 Please note also that this opinion is limited to an interpretation of the New York Insurance Law. No opinion is rendered on any other laws.

For further information you may contact Associate Attorney Pascale Jean-Baptiste at the New York City Office.


1 See OGC Opinion No. 03-02-18, dated Feb. 18, 2003 and OGC Opinion No. 03-04-36, dated April 30, 2003; see also OGC Opinion No. 05-05-29, dated May 28, 2005.

[Dec 30, 2016] 20 things to know about balance billing

Notable quotes:
"... Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . ..."
"... Balance billing complaints are up 1,000 percent in Texas . ..."
"... The rise in balance billing is partially attributable to a lack of network transparency with patients. ..."
"... The New York Times ..."
"... Kaiser Health News ..."
"... In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635. ..."
"... Montana Public Radio ..."
"... Sunshine State News ..."
"... The New York Times ..."
"... The New York Times ..."
Dec 30, 2016 | www.beckershospitalreview.com

Patients, caught in the financial crosshairs, often feel powerless to negotiate costs. Consumer advocacy groups and federal and state legislators are turning their attention to balance billing practices this year with renewed vigor, forcing payers and providers to find other ways to settle financial disagreements.

Here are 20 things to know about balance billing.

1. Balance billing is on the rise nationally. In 2011, around 8 percent of privately insured individuals used out-of-network care, 40 percent of which resulted in unanticipated medical costs due to balance billing, reports Health Services Research . In 2015, a nationwide study from Consumers Union found nearly one third of privately insured Americans received an unanticipated bill when their health plan paid less than expected for medical services within the past two years.

2. Balance billing complaints are up 1,000 percent in Texas . According to the Texas Department of Insurance , balance billing complaints rose from 112 in 2012 to 1,334 in 2015, an increase of 1,000 percent.

3. Lack of provider, network transparency. The rise in balance billing is partially attributable to a lack of network transparency with patients. In many cases patients are unaware they have received out-of-network care until they receive a balance bill in the mail. Nearly 70 percent of individuals with unaffordable out-of-network medical bills did not know the healthcare provider was not in their plan's network at the time of care, according to a survey conducted by Kaiser Family Foundation and The New York Times .

4. Emergency room services to blame, in part. A Health Services Research survey found in 2011, 68 percent of inpatient involuntary contact with out-of-network physicians was related to emergency care. These kinds of unanticipated medical bills may arise when a hospital participates in an insurer's network but its employed emergency physicians do not. For example, more than half of the hospitals in some Texas insurers' networks did not have a single physician on staff covered by the insurer, according to a 2015 study from the Centers for Public Policy Priorities in Austin.

5. Balance billing and contracted physicians. Many hospitals use physician outsourcing firms for anesthesiologists, emergency physicians, pathologists and radiologists, or will bring in an outside assistant surgeon to help with procedures. In many cases, these physicians do not participate in the same network as the hospital, unbeknownst to the patient. When physician groups and insurers are unable to resolve reimbursement disputes, patients can be served with much higher out-of-network charges. In Texas, for example, the specialty services most likely to submit balance bills are anesthesiologists, lab services, surgery and radiology, reports the Texas Department of Insurance .

6. Payers will fight out-of-network physicians with lower reimbursement rates. Last year, health insurance giant UnitedHealthcare said it would scale back how much it pays out-of-network physicians who practice at in-network hospitals, accusing physicians of demanding excessively high reimbursement levels, according to Kaiser Health News . During a billing dispute with out-of-network Bayonne (N.J.) Medical Center, the insurer accused the hospital of charging out-of-network rates 10 to 12 times higher for a medical service than area hospitals participating in United'snetwork. If a payer refuses to match physician reimbursement rates, the financial burden is passed on to the patient. In the aforementioned dispute between Bayonne and UnitedHealthcare, the patient was balance billed $1,170 for a total of five stitches.

7. Insurers are narrowing networks in an effort to reduce costs. As insurance companies have narrowed provider networks to keep premiums down, the number of patients who inadvertently received out-of-network care has jumped at hospitals, particularly with regard to contracted physicians.

8. Payers have sued providers for 'excessive' out-of-network fees. Aetna has sued a half dozen out-of-network physicians in recent years, alleging gross over charging for medical services. In 2014 Aetna sued a physician at Monmouth Medical Center in Long Branch, N.J., a hospital within Aetna's network, who did not notify a patient he would not accept Aetna's discounted reimbursement rate, according to the lawsuit. The physician charged Aetna $31,939 to treat abdominal pain in the patient. After Aetna paid the amount it deemed reasonable - $2,811, based on Medicare rates - the physician balance billed the patient for an additional $10,635.

9. Balance billing can occur even when a payer adjusts out-of-network emergency bills to in-network rates for patients. A patient recently accused Duke University Medical Center in Durham, N.C., of balance billing his account for an out-of-network rate after the patient submitted in-network payment rates to Blue Cross Blue Shield. Owing to the medical emergency of his situation, Matthew Aitken said he received an in-network rate from Blue Cross Blue Shield of North Carolina. However, Mr. Aitken alleged Duke proceeded to charge him for the remainder of the bill at the higher out-of-network rate, resulting in a bill nearly double that of Mr. Aitken's out-of-pocket limit.

10. Air ambulance billing disputes, complaints on the rise. In rural areas of the U.S. the high price for life-saving air ambulance flights has grabbed media attention as rural residents, faced with excessive balance billing, have turned to state and federal auditors for intervention. Those in rural areas often must rely on air ambulance flights in life-or-death situations in lieu of feasible ground transportation. Reimbursement rate disputes between payers and medical air transport companies have strapped patients with devastating medical bills. When Amy Thomson's newborn daughter was in heart failure, Ms. Thomson had to use an air ambulance service in rural Montana for transport to a more capable facility. At the time her insurance company, PacificSource, did not have an in-network air ambulance company near her family, reports Montana Public Radio . Ms. Thomson received a $43,000 balance bill from Airlift Northwest after PacificSource contributed a policy cap of $13,000.

11. Provider-based billing practices. Consumers have been increasingly vocal about surprise medical bills derived from provider-based billing practices. Provider-based billing allows a healthcare organization to bill patients for physician care in addition to a service charge for the patient's use of hospital facilities and equipment. In some cases, a patient may be responsible for the service bill if their insurance declines to pay or if the patient has a high deductible health plan. Large hospitals like Cleveland Clinic have faced increased scrutiny for provider-based billing practices. After paying a $30 copayment for in-network care with a Cleveland Clinic chiropractor, Julie Beinhardt reported receiving a balance bill of $3,000 for provider-based service fees her insurance plan refused to cover.

12. President Barack Obama signed legislation against provider-based billing. Last year, President Obama signed legislation outlawing provider-based billing at off-campus outpatient facilities. The legislation does not apply to existing outpatient centers that already engage in the practice, however.

13. The president's 2017 budget proposal includes a provision to eliminate surprise medical bills. Although details are minimal, the president's 2017 budget proposal includes a provision to eliminate balance billing privately insured patients. The administration would address the issue by requiring physicians who regularly provide services in hospitals to accept in-network rates for service reimbursement, even if they aren't in the insurer's network.

14. About a quarter of U.S. states have laws that protect consumers from out-of-network medical bills incurred by emergency care. According to a study from Kaiser Family Foundation , 24 states have implemented laws that restrict providers from balance billing in emergency care situations, including California, Delaware, New Jersey, New York and Pennsylvania, among others.

15. More states are proposing independent dispute resolution between payers and providers in balance billing cases. Independent dispute resolution establishes a legal space in which providers and health insurers can settle disagreements regarding balance billing without involving the patient. The states of Illinois and New Yorkhave arbitration methods in place, and Florida , Washington and Pennsylvania are currently considering a similar resolution methods.

16. New York has some of the strongest consumer protection laws. Under New York law , consumers are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services. Patients can complete an assignment of benefits form that absolves them of financial responsibility and allows the provider to pursue payment from the health plan in balance billing disputes.

17. Florida state legislature is currently embroiled in a fight to pass balance billing laws. Legislation to outlaw balance billing in Florida has continued to creep through the state legislature since last fall. Introduced in both the house and senate, the bills have sparked conflicting and outspoken opinions from patients, payers, hospitals and physicians. Hospitals have largely denounced the bill, blaming balance billing disputes on payers that demand allegedly unsustainable reimbursement rates, reports Sunshine State News .

18. The "End Surprise Billing Act". Federal lawmakers are making moves to outlaw balance billing nationally. Co-sponsored by 25 lawmakers, the End Surprise Billing Act would protect patients from balance billing who went to in-network facilities for emergency services, reports Consumerist . In non-emergency cases, it would require providers to notify patients within 24 hours if an out-of-network specialist will be involved in an episode of care.

19. Consumers don't know how to navigate the legal waters. According to a Consumer Union report, 57 percent of patients who encountered balance billing from contracted physicians within the last two years paid in full because they didn't know their rights to fight the bills. An overwhelming majority (87 percent) did not know which agency or department in their state government is tasked with handling complaints about health insurance. "So many times, people just give up [in surprise billing disputes]," Elisabeth Benjamin, vice president of health initiatives with Community Service Society of New York, told NPR .

20. The New York Times dedicated a series to consumer encounters with surprise healthcare bills. Elisabeth Rosenthal's series in The New York Times entitled Paying Til it Hurts examined the personal and financial implications of excessive, unexpected medical costs on Americans, their families and their healthcare consumption. Ms. Rosenthal's installments often feature individuals with unaffordable balance bills like Peter Drier , who was served a $117,000 balance bill for an out-of-network physician's assistant he never knew was present during surgery.

[Dec 26, 2016] Are Psychiatric Medications Hurting More Patients Than They Help?

Notable quotes:
"... Scientific American ..."
Dec 26, 2016 | science.slashdot.org
(scientificamerican.com) 431

Posted by EditorDavid on Sunday December 18, 2016 @01:34PM from the depressing-anti-depressant-news dept.

An anonymous reader quotes Scientific American 's Cross-Check blog :

Two new posts on this website have me contemplating, once again, the terrible possibility that psychiatry is hurting more people than it helps. Reporter Sarah G. Miller notes in "1 in 6 Americans Takes a Psychiatric Drug" that prescriptions for mental illness keep surging. As of 2013, almost 17 percent of Americans were taking at least one psychiatric drug , up from 10 percent in 2011, according to a new study. "Antidepressants were the most common type of psychiatric drug in the survey, with 12 percent of adults reporting that they filled prescriptions for these drugs..."

This increase in medications must be boosting our mental health, right? Wrong. In "Is Mental Health Declining in the U.S.?," Edmund S. Higgins, professor of psychiatry at the Medical University of South Carolina, acknowledges the "inconvenient truth" that Americans' mental health has, according to some measures, deteriorated ...

It's all more evidence of something their blogger wrote in 2012. "American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis -- harmful medical treatment -- in history ."

[Dec 26, 2016] 5 Ways to Lower Your Medical Bills Personal Finance

Notable quotes:
"... "One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills." ..."
Nov 29, 2007 | US News

Insurance companies aren't the only ones who can negotiate a lower price -- you can, too. Here's how.

By U.S. News & World Report

Sanjiv Luthra of Los Altos, Calif., suffered from the pain and fatigue of rapid-onset arthritis so severe that he couldn't walk 10 feet until he underwent double knee-replacement surgery in 2006. Now, two years later, he can walk and run, but he still suffers the fallout from another ailment: medical bills.

Six hours in an operating room, two knee replacements, medications and a five-day hospital stay added up to a bill of $80,000, Luthra estimates. That's not counting bills for an anesthesiologist, physical therapy, additional medicines and special exercise equipment to help him recover.

"One should know what the cost of the procedure is, and that is something that is just impossible to figure out before or after the procedure," Luthra says. "I had no way of knowing beforehand there were going to be these six different types of providers . . . sending me bills."

Luthra's insurance company was able to negotiate with the hospital so that it paid about $20,000, and he parted with about $5,000, including expenses outside the hospital.

But individual patients can haggle for lower medical bills, too. Here are tips on how to go about it.

Work up the courage to ask. It's not just insurance companies that can negotiate.

"The typical insurer gets about a 60% discount," says Gerard Anderson, the director of the Johns Hopkins Center for Hospital Finance and Management. "If you go into the hospital and ask the chief financial officer , you may get a 30% discount, but you have to ask for it. It's totally up to the discretion of the CFO how much they or the person in the billing office are willing to give you."

Although it's common to negotiate with a real-estate agent or car salesperson you probably never will see again, it's much more difficult to negotiate with a doctor you trust to make you well and to provide continuing care for your family. Only 31% of Americans have tried to negotiate the price of medical bills, a survey by Consumer Reports National Research Center indicated. But of those who tried, 93% have been successful at least once, and more than a third saved more than $100.

Explore low-cost treatments. Many doctors incurred large loans to finance medical school and probably understand the need to get a fair price as well as you do.

But even though almost 80% of physicians will prescribe a generic medication over a brand-name drug to save patients money, far fewer consider patient costs when recommending diagnostic tests (51%) or choosing between hospitalization and outpatient treatment (40%), according to a survey of physicians by the Center for Health System Change and the University of Chicago

If money is an issue, you need to ask your doctor if cheaper, medically sound options are available. The trick is to keep it friendly and ask nicely. For minor health ailments such as ear infections and pinkeye, drugstore clinics list reasonable prices upfront, with no negotiating required.

Find the correct person. Although they are heavily involved in treatment decisions, doctors may not be directly involved in other billing issues, so you need to find a person with the ability to adjust your bill.

"I would suggest the consumer go to the office manager," says Timothy Cahill, a health-care consultant in Louisville, Ky., who has negotiated hospital bills on behalf of patients. The office manager should be able to direct you to the person in charge of billing.

Offer cash payments. This could be a mutually beneficial solution for you and the medical establishment.

"Paying cash is worth a lot to a doctor in terms of time and trouble, and it is a lot less complex for the hospital to deal with," says Shankar Srinivasan. He is a co-founder and the chief technology officer of Vimo.com, a company that uses public records to figure out what prices insurers negotiate with hospitals. Cash, he says, saves hospitals the trouble of negotiating financing terms, paying credit card transaction fees and sending collection agencies after patients who fail to pay.

Scrutinize the bill and your insurance. If you don't have the cash to pay a large medical bill, you need to educate yourself about what your insurance should cover and try to negotiate a discount off the sticker price.

"As a consumer, just like a detective, you have to really understand the specifics of your insurance benefit plan, take the initiative of setting up conference calls (including yourself, the hospital and your insurance company) proactively, and you have to document everything," says Luthra, who is chief operating officer of the health-care-consulting company Benu. "You don't just pay the bill as is."

This article was reported and written by Emily Brandon for U.S. News & World Report.

[Dec 26, 2016] How to avoid and handle surprise medical bills

Notable quotes:
"... The average balance billed to patients was $622.55 , though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills. ..."
"... Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill. ..."
"... If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available. ..."
"... Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. ..."
"... At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. ..."
"... If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate. ..."
"... If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org , to estimate what the procedure typically costs in your locality. ..."
"... If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely. ..."
thehill.com
Surprise bills are never a welcome surprise. Typically, they arrive after you arranged care from a doctor and a hospital that were both in your health plan's network, but then you were unexpectedly treated by one or more other providers who, unbeknownst to you, were outside that network.

When these out-of-network providers send you a bill for their services, you may have to pay the full amount out of pocket or, if your health plan covers out-of-network care, to pay the balance of the bill that your insurance fails to cover. And the balance bill generally requires you to pay more than the out-of-pocket amount you would have owed if you had been treated by an in-network provider.

Emergency rooms are one of the most common locations where healthcare results in surprise bills.

As detailed recently in an article by two Yale scholars in the New England Journal of Medicine, in more than one in five cases nationwide, ER visits to an in-network facility involved out-of-network physicians. The average balance billed to patients was $622.55, though the study reported bills as high as $19,603.30. But, ERs are not the only source of surprise bills.

Even when a patient goes to a hospital for routine surgery, and takes care to choose an in-network hospital and in-network surgeon, the anesthesiologist, radiologist or pathologist assigned to the case may be out of network, and follow up with a surprise bill.

Several states have already enacted laws to protect consumers against surprise bills, although some of the statutes protect patients only in the case of balance bills for out-of-network ER services for a serious medical emergency. Currently, the issue is being discussed in a number of statehouses. In the meantime, here are steps you can take to protect yourself from such surprises.

Prevent surprise bills

The best defense against a surprise bill is prevention. If you have a serious medical emergency, your nearest hospital may not be in-network and all your treatment may result in out-of-pocket expense for high surprise bills. But, even if you visit an in-network ER, you have little control over the choice of doctor: By definition, you are facing an emergency, and must take whoever is available.

However, for a planned surgery or other procedure, you probably have time to speak up. Make sure that your doctor and hospital are in your plan's network. Check with them and with your plan. Ask your physician and your hospital in advance if they can arrange to have only in-network providers treat you.

Some hospitals may have no in-network specialist for care you might require. Find out if another hospital in your area can provide all your necessary services on an in-network basis. In some areas, there may be no in-network specialists available of the type you need. In that case, inform your plan that its network lacks necessary services and find out if the terms of the plan or state law provide you protection from large balance bills in such circumstances.

Always refer to your plan by its exact official name. Often insurers have multiple plans with similar names but different networks. If you use the wrong plan name when inquiring about a plan's network, you may get a wrong and costly answer. Make your inquiries and requests in writing so you have documentation. Ask for the names of the providers who will be involved in your care, and check with your insurer and with the providers themselves to see if they are all in your plan's network.

Check if your state protects consumers

If you do get a surprise bill, take action. Check with your state insurance regulator to see if your state has any consumer protections against surprise bills. Many states have laws that require HMOs to protect consumers from surprise bills, especially with respect to necessary ER services. Fewer states have similar protections for other types of health plans, such as PPOs and EPOs.

At present, California, Colorado, Connecticut, Florida and New York do have such protections against unexpected balance bills - either for out-of-network ER situations alone or for additional types of surprise bills. Generally, these laws provide that the consumer is required to pay only the amount he or she would owe for the services if provided in-network. States have different mechanisms for settling the balance, but they generally involve the insurer and the provider, not the patient.

If your state does not provide protection

If your state does not offer protection against surprise bills, check first to make sure the provider is really not in your network. Back offices and billing companies deal with many plans and sometimes make mistakes. Providers who are in your network have to accept the insurer's contracted rate.

If the provider is out of network, do some research on an independent website, such as fairhealthconsumer.org, to estimate what the procedure typically costs in your locality. If your plan's reimbursement is based on an amount that is less than the typical charge, you can use this information to ask the plan to pay the provider on the basis of at least the typical rate. If the out-of-network provider's charge is higher than the typical rate, you might be able to negotiate with the provider to reduce your costs. You can try to persuade the provider to reduce the charge, or to discount an excessive balance bill, by showing the provider that his or her charge is above the typical market rate.

If neither the insurer nor the provider is willing to budge, do not be afraid to seek help. If you get your insurance through your employer, your human resources department may be able to intervene. Call your state representative or your local consumer protection office. With the right assistance, you might be able to reduce the bill, if not make it go away entirely.

Robin Gelburd, JD, is the president of FAIR Health, a national, independent nonprofit with the mission of bringing transparency to healthcare costs and insurance reimbursement. FAIR Health oversees the nation's largest repository of private healthcare claims data, comprising over 21 billion billed medical and dental charges that reflect the claims experience of over 150 million privately insured Americans. Follow on twitter @FAIRHealth

[Dec 25, 2016] How to Fight Back Against Outrageous E.R. Bills

Two excellent resources-Healthcare Blue Book and FAIR Health-can give you estimates of how much health care services should cost in your area. Plus, your insurer's website may also provide a tool that will allow you to compare costs.
Notable quotes:
"... But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says. ..."
"... "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says. ..."
"... "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money." ..."
"... This piece is by Drew Anne Scarantino ..."
www.thefiscaltimes.com

It's no secret that hospital bills in the U.S.-especially ones from the E.R.-can often hit astronomical proportions.

According to a recent cost study conducted by researchers at Stanford University, the University of Minnesota, the University of California, San Francisco and the Ecologic Institute, the median charge for an emergency room trip in the U.S. comes in at $1,233. But where it really gets interesting is when you look at the specific reasons for those E.R. visits: The researchers found that the treatment price for a headache could range from $15 to a whopping $17,797. As for a sprained ankle, it could set someone back a paltry $4 or up to $24,110!

So what gives with these wildly fluctuating price points?

For starters, most emergency room prices are inflated based on the rates at which insurance companies will reimburse the hospital on a patient's behalf. That's why a single aspirin can cost $30 per pill in the E.R., which is more than six times the price for a bottle of them at the drug store.

On the flip side, patients will often contact the hospital or surgeon's billing office to ask for a cost reduction, further adding to the inconsistency in pricing. It's a practice that often works in a patient's favor, says billing advocacy specialist Sharon Salters of Medical Cost Advocatea professional medical bill negotiation service.

And then there's also the fact that most hospitals offer discounts to self-paying individuals-especially if there's a risk that they might not pay at all.

So to help shed some light on the complexities of hospital medical billing for the average consumer, we asked three people to share their craziest emergency room stories, the even crazier bills that followed-and the steps they took to remedy them.

... ... ...

The Emergency: Head Injury
The Bill: $9,000

A few months ago, Amanda Harris, 27, of Morristown, N.J., fainted at work, hitting her head in the process. Due to liability concerns, her production company required Harris to take an ambulance to the emergency room, despite her refusal. "I didn't even have a cut on my head, just a slight bump. No headache, no nausea, no confusion, nothing," she says.

Harris waited for over an hour in the E.R. before her husband told the nurse that they were leaving. Minutes later, a doctor spoke to Harris for under a minute, confirming that she was fine to go. "He didn't do any tests-no light in my eyes, no blood pressure," says Harris. "I left thinking I wouldn't even get a bill."

But the bill did come-all $9,000 of it. The ambulance company charged $6,500, including a $300 fee for the linens and a $30 charge for aspirin. The E.R. billed the remaining $2,500. "My mouth literally dropped open when I saw the cost," she says.

RELATED: Hospital Costs Explode: Between $127 and $151 Billion

What This Patient Did: Harris called her insurer and fought the bill. Luckily, her insurance covered all but a $3,000 deductible-but she was too exhausted to push for more. "I've always heard emergency room visits were costly, but $9,000 for nothing more than a conversation that lasted one minute? That's robbery," she says.

What the Expert Says: Even though Harris didn't want to take an ambulance, Salters says that her company's suggestion was well-advised. "However, she should consider working with her employer to file the claim with her company's worker's compensation carrier," says Salters. "Employers often try to stay away from filing a claim under worker's compensation, so it does not impact their experience rating or trigger an [occupational safety and health administration] review, but it would save her money."

How You Can Avoid Outrageous E.R. Bills (Really!)

When it comes to a trip to the E.R., the reality is that there's usually no time to shop around and compare prices in advance. But if you do some research before an emergency happens, you could potentially keep costs significantly down.

The negotiation can seem like a lot of extra work, but the payoff can be tens of thousands of dollars in savings shaved off a potentially outrageous E.R. bill.

This piece is by Drew Anne Scarantino.

[Nov 23, 2016] 7 Tips For Fighting And Paying A Big Hospital Bill by Caroline Mayer

Notable quotes:
"... Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation. ..."
"... don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections. ..."
Sep 17, 2013 | www.forbes.com

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

2. Vigilantly review the bills. "It's very common for hospital bills to contain errors and overcharges, so make sure you've actually received the services they said you did," Detweiler says.

Candice Butcher, vice president of Medical Billing Advocates of America, says if you're discharged in the morning (as most patients are), protest if you're socked with a full daily-room rate for the date you left the hospital.

And if you brought your medications with you, make sure you weren't charged for them by the hospital. "This frequently happens," Butcher says.

Also, dispute any additional fees on the bill for routine supplies, like gowns, gloves or sheets. These items should be factored into the hospital daily-room charge, because, Butcher says, they are "considered the cost of doing business."

3. Challenge your health insurer's decisions, when warranted. Keep track of any hospital bills the company rejects on grounds that the procedure or drug isn't covered by your policy. If you believe the insurer should be paying more, don't hesitate to appeal its decisions. You'd be surprised how often carriers overturn their earlier rejections.

4. Negotiate bills once you know how much you'll have to pay out of pocket. If you just want extra time to send the money, Dale says, "it is relatively easy to speak with hospital or clinic business office staff to arrange a payment plan."

Conversely, you may be able to wrangle a cash discount for agreeing to pay your entire cost at once.

You may also be able to successfully bargain down the particular dollar amounts you've been charged.

Tell the billing department that if your insurance requires, say, a 20% co-payment to the hospital, you'll pay only 20% of the insurer's negotiated rate with that hospital. That's usually far less than the initial rate quoted - the figure charged to uninsured patients.

Go online to check the rates other local hospitals charge for the procedure you had. Then, if you find your bill was way out of line, use this data as ammunition to try to get your fees lowered. You can get this type of information at such sites as Clear Health Costs, Healthcare Blue Book and FAIR Health.

Also consider using Medicare rates as a guide; the federal health system for people 65 and older typically has the lowest reimbursement rate for hospitals and medical providers. Your hospital may not agree to charge you its Medicare fee, but this figure is a good starting point for any negotiation.

5. Consider hiring a pro. Since hospital bills are hairy, messy beasts, it may be worth your while to bring in a patient- or medical-billing advocate (Detweiler recommends the advocacy firm Copatient.com, which charges 30% of what it saves you) or an attorney. "It's like hiring a CPA to do your taxes," Dale says.

Be sure you won't be required to pay this expert any fees upfront. Patient advocates typically charge 20 to 30% of your savings; some put a cap on their fees. Karis' firm, for example, charges no more than $3,000. Attorneys often charge 30% of the savings they achieve.

... ... ...

Caroline Mayer is a consumer reporter who spent 25 years working for The Washington Post. Follow her on Twitter TWTR -0.69% @consumermayer.

[Nov 22, 2016] Negotiating can cut hundreds off your medical bills

Notable quotes:
"... There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. ..."
13 WTHR Indianapolis
But you can fight back against skyrocketing medical costs.

"I've heard discounts up in the area of 30 percent sometimes, which can be pretty significant," said Cathryn Perron, director of program development with Consumer Credit Counseling.

She says it's possible to negotiate down your medical bills - everything from ambulance rides to surgery. She says you can also bargain with your dentist, the lab that does your blood tests, the eye doctor - even the company that makes you prescription medication.

"Each company has a specific number you can call to fill out an application and many times, you'll get a discount, or you'll get the product free through the drug companies, if you qualify financially," Perron said.

All you have to do, with or without insurance, is make a call. Each case is handled differently. In most cases, everyone wants to pay the bill, but they're afraid to contact their doctor or hospital. They'll work with you to make sure the cost is paid.

So how do you pay less?

There are a number of options:

Charity care - Bills are forgiven, based on your income and expenses, but you'll have to fill out hardship paperwork.

"You'll most likely have to provide proof of income, they'll ask about your monthly living expenses and your other bills that you have to pay every month," said Perron.

Sholar called Indianapolis EMS.

"He says, 'Sir, you got to pay for the ambulance, all the stuff in the ambulance, the two people who drive the ambulance. That's just the way it is'," he said.

But he didn't give up.

"This bill says $1,300. She said, 'Yeah, that sounds about right.' I said, 'Let me talk to a supervisor'," Sholar said. "The supervisor's name is John. John wasn't too happy."

Mike put on the pressure and the bill was reduced by $532. The wounds to his buttocks are healed, but the other injury he got that night, on his thumb, is a constant reminder of the cost of healthcare.

"I don't need no X-rays, I don't need no other stuff. Just give me the stitches and I still haven't received a bill for that," he said.

But he's ready to negotiate and he says, in the future, he'll also weigh the costs before calling 911.

"I would have put a rag over it and got a ride here," he said.

Tips to Negotiate Your Medical Costs

Consumer Credit Counseling and Apprisen offer tips to get your medical bills reduced:

First and foremost be informed. Understand what type of medical insurance coverage you have and what your co-pays or financial responsibilities are. Some insurance companies have contracts with certain medical providers to offer a discount if you receive treatment from a "preferred provider." We encourage individuals to meet with their Human Resource department or contact their insurance company to speak with a representative about their coverage and benefits prior to receiving medical treatment. This could reduce your financial responsibility significantly.

Apprisen recommends for you to review your itemized statement from your medical provider. If you feel there are discrepancies or charges in question, contact your medical provider to meet with their Patient Account Specialist to discuss your questions or discrepancies. Communication is a vital part of resolving your issues. Simply ignoring communication from your medical provider will not resolve the issue and could potentially lead to a negative impact on your credit rating if resolution is not reached.

Whether you have insurance or not, you are encouraged to contact your medical provider prior to treatment (if possible) to discuss costs associated with your treatment and to work out the possibility of negotiating those costs down. Many medical providers will consider giving discounts to individuals who are willing to pay the balance in full upon services rendered or within a short period of time after receiving treatment. If you find yourself in a position where you are not able to pay the balance in full, consider negotiating with your medical provider for a monthly repayment plan interest free. You are encourage to analyze your personal budget to insure you are able to make the financial commitment to your medical provider. Negotiating your medical bill then failing to follow through with the financial payment arrangement could negate your hard effort to reduce your medical bill.

If you are uninsured, you are encouraged to meet with a Patient Account Specialist or a "decision maker" to see if you qualify for any financial hardship programs. Most hardship programs require you to provide evidence of your financial situation and the award is based on financial need. Be prepared to give a full budget disclosure in order to be considered for the hardship program.

Apprisen's mission is "To help people improve their financial well-being through counseling, community outreach and financial education."

You can call Apprisen at 1-800-355-2227 or visit apprisen.com.

There are also companies who claim they have a network of physicians throughout the state who offer medical services for 50 percent off or more. You can find out more about those companies at objectivedx.com.

[Nov 22, 2016] Hiring a Guide to the Medical Bill Maze by Lewis Braham

Notable quotes:
"... As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate . It negotiated with the physician's health-care group to reduce her bill to $7,000. ..."
Apr 29, 2013 | Bloomberg

When Annrose Isaac's twins were born prematurely, she thought her insurer would cover their stay in the neonatal intensive care unit. "The hospital was in our network, but it turned out the physician in the NICU who saw our daughters didn't participate with our insurer," says the Westwood (New Jersey)-based financial planner. "All of a sudden we were getting bills for over $30,000."

As part of her husband's benefits package, Isaac had access to a medical billing assistance company called Health Advocate. It negotiated with the physician's health-care group to reduce her bill to $7,000.

More than 60 percent of all U.S. personal bankruptcies are linked to illness and unpaid medical bills, according to a 2009 Harvard University study, even though 78 percent of those filing for bankruptcy because of illness have some form of health insurance. So hiring a medical billing advocate can be an essential part of the cure to financial ills.

Yet finding the right advocate can be tough, and those in the direst situations can ill afford the typical $75- to $130-an-hour rate. "This business is painfully slow-growing," says Becky Stephenson, co-president of the Alliance of Claims Assistance Professionals (ACAP), an advocate trade group. "There are a lot of people with problems but not a lot of people willing to pay you to help them." Despite long experience, Stephenson herself has trouble making a good living purely from advocacy, so she supplements her income by serving as an expert witness in medical lawsuits.

Employees working at sizable companies may already have access to a health advocate. Just over half of U.S. companies with more than 500 employees offer it as a benefit, according to Steven Noeldner, a senior consultant for Mercer's Total Health Management practice. Many employees don't know the benefit exists, he says, and the services generally aren't as customized as those of an independent billing advocate.

Credential Check

Unlike with more established professions such as accounting or law, there is no standard credential to look for when seeking a qualified advocate. At the most basic level you should ask if an advocate has certifications in medical bill coding from either the American Academy of Professional Coders or the American Health Information Management Association.

Many people with those designations aren't advocates, however, working instead for hospitals or insurers. And understanding the codes is only half the battle. Because of the complexity of our health-care system, you'll need someone who specializes in your specific kind of billing problem.

A good place to start is Claims.org, ACAP's website. It lets you search for experienced advocates by state. In a case like Isaac's, you'd need someone who specializes in hospital bills. Other advocates specialize in Medicare appeals, long-term care insurance, workers' compensation and insurance for special needs children.

Privacy Issues

The best way to find the right specialist is to ask the advocate for a resume and references. This can be tricky, because laws about disclosing private medical information are so strict that some advocates have difficulty providing references. In order to do so, their clients must agree to discuss their medical history.

Stephenson specializes in hospital bill audits. She studies itemized bills line by line, identifies padding and mistakes and negotiates lower rates. Prior to starting her Austin (Texas)-based advocacy firm VersaClaim in 2002, she ran an organization that helped doctors affiliated with hospitals set up their practices. That included all aspects of hospital billing.

A registered nurse for 12 years, Stephenson has an intimate knowledge of medical terminology and hospital procedures. "I ask questions like, Are there dosages of medications that are not compatible with my medical experience in real life?" she says. "Do the charges look realistic, or is there an $85 Tylenol?"

Location Matters

Another important factor to consider is an advocate's location. State laws vary in how they regulate insurers and hospitals. For Katalin Goencz, an advocate in Stamford, Connecticut, location is often irrelevant because she specializes in Medicare appeals: "The rules for Medicare are federal and pretty much universal, so the client's location doesn't really matter."

For a patient negotiating a lower bill directly with a local hospital or private insurer, having an advocate who knows the specific state regulations helps. State rules for advocates can also vary dramatically. Florida has some of the strictest. "Due to the large senior population in our state, we have a strong urge to make sure our people adjusting medical claims are licensed, competent and held to a high standard," says Matthew Guy, a spokesman for Florida's Division of Agent and Agency Services, which licenses and regulates advocates.

The state's Public Adjuster license for advocates requires licensees to be fingerprinted, have a criminal background check and hold a $50,000 surety bond. "If there's any wrongdoing by the adjuster, we can take the bond amount and use that towards restitution for the consumer," Guy says. Adjusters must pass an exam and take 24 hours of continuing education classes every two years.

Contingency Basis

A handful of advocates will work on contingency if they think you have a negotiable claim. Most will impose strict conditions to ensure they get paid if they win. "When I started my practice, I did everything on contingency but learned very quickly that a lot of consumers who want you to take their case on contingency in the end don't want to pay you," says Sheri Samotin, a billing advocate at Life Bridge Solutions in Naples, Florida.

Now Samotin requires a credit-card authorization up front for an amount sufficient to cover what her estimated contingency fee will be if her work succeeds. If the client doesn't pay within 10 days of a settlement being reached, she charges the card. Her fee is 35 percent of the client's medical bill savings.

Samotin is unusual in the advocacy world as she is more of a generalist, taking on all kinds of medical billing problems, including those of the uninsured. She has 25 years of experience in the health-care industry, so she has the knowledge to handle different kinds of problems, Samotin says. For a monthly $285 fee she will manage her clients' entire billing life -- a common need for seniors who have lost their capacity or desire to manage daily finances.

Instead of being a member of ACAP, Samotin is a member of the American Association of Daily Money Managers, a trade group for generalists. Only a handful of the AADMM's 700-plus members have the skills to also handle medical billing advocacy, Samotin says. Nor does she expect rapid growth in the field.

"Because this is a disorganized profession, people entering the field have to be entrepreneurs," she says. "They have to hang out their shingle and go out and get clients. In my experience, the majority of people who are good medical analysts and advocates are not necessarily good business getters."

So until the profession matures, finding a good advocate will remain difficult, no matter how vital the service is.

(Lewis Braham is a freelance writer based in Pittsburgh.)

To contact the editor responsible for this story: Suzanne Woolley at swoolley2@bloomberg.net

[Apr 05, 2013] How to handle medical bill problems by Lisa Zamosky

Notable quotes:
"... Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges. ..."
"... In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service. ..."
"... "Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn. ..."
"... All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections. ..."
"... If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top. ..."
"... filing a complaint with your state's department of insurance. ..."
Apr 05, 2013 | http://articles.latimes.com/2013/apr/05

For those with confusing or huge hospital bills, experts advise knowing rights, getting written explanations, turning to the right places for help and filing complaints if necessary.

When Keith Yaskin and his wife, Loren, rushed their 2-year-old son to the hospital with a dangerous infection in his neck, they weren't thinking about how much his care would cost. After his three-day inpatient stay with nonstop intravenous antibiotics, they were hit with $8,900 in charges.

But the toughest lesson for the Scottsdale, Ariz., couple came a month or so later when they began to sort out the hospital bills. Their insurance policy had a $10,000 deductible. So they scrutinized every item, made some calls and had a few surprises.

When, for instance, they asked a medical group they had never heard of why it was charging them $839.25, they said they got no clear answers, just threats if they failed to pay.

After 21/2 months of calls and a complaint to their state attorney general, the Yaskins finally learned that a pediatrician affiliated with the group had treated their son in the hospital. The medical group eventually cut the bill in half.

None of this surprises Pat Palmer, the founder of Medical Billing Advocates of America. "We get feedback from consumers saying that providers are telling them 'We can't give you an itemized statement' or 'You should have asked for it before you left the hospital.'"

The idea is to discourage patients from asking for the details behind the charges, she said.

Experts offer a range of suggestions for dealing with medical billing problems.

Know your rights. Most states have laws saying that patients are entitled to an itemized medical bill that details what services and supplies are included in their charges.

"You can't be billed if they can't tell you what they are charging for," Palmer says.

Contact the billing department at either the hospital or medical group where you received services, she said. Let them know that you want an itemized bill, and tell them you are aware of your legal right to have it.

Also, a few states have laws limiting how much hospitals can charge patients who pay for care on their own. In 2006, California passed a law to prevent hospitals from collecting more money from uninsured patients than what Medicare or other public programs would pay for the same service.

"Once a patient contacts the hospital and shows evidence of their financial situation, state law requires us to offer a discount based on Medicare rates," says Jan Emerson-Shea, vice president of external affairs for the California Hospital Assn.

Get explanations in writing and take protests to the top. All communications with a provider should be in writing, experts say. Insist that your account be placed on hold until the dispute is resolved to avoid having the bill sent to collections.

If you meet with resistance, don't waste time by calling back the customer service line or billing department. Go straight to the top.

Address a certified letter to the chief executive or chief financial officer of the hospital or medical group explaining that you have tried to resolve billing issues but have hit a brick wall. "The CEO and CFO will take it very seriously," Palmer says.

Get help from your insurer. In the Yaskins' case, both the hospital and the medical group were in their insurer's network and had contracts to provide services at a negotiated discount.

"If you are in network - and this is one of the good reasons to stay in network - you can go to your insurer for help. It has a responsibility to some degree to what happens between you and a contracted physician," says Susan Pisano, spokeswoman for the trade group America's Health Insurance Plans.

Also, ask to make sure you're getting the rate your insurer has negotiated with in-network providers, says Lynn Quincy, senior health policy analyst for Consumers Union, the policy arm of Consumer Reports. Insurers often pass claims through without processing them at the reduced rate. Ask your insurer to re-process the claim if the discount wasn't applied.

Seek help and file complaints. If your bill is large or you're having a hard time making headway, patient advocates can help sort things out. For either a flat fee or a share of the money you save, organizations such as Medical Billing Advocates of America (www.billadvocates.com) and Health Proponent (www.healthproponent.com) can help you fight charges or lower your bill.

If you're being stonewalled by your healthcare provider, and your insurer hasn't helped, Quincy of Consumers Union suggests filing a complaint with your state's department of insurance. In California, patients with HMO coverage can file a complaint with the California Department of Managed Health Care by calling (888) 466-2219 or visiting healthhelp.ca.gov. Californians with PPO coverage should try the Department of Insurance at (800) 927-HELP (4357) or visit http://www.insurance.ca.gov. If your provider isn't contracted with your insurer, your state's attorney general's office is a place to turn for help.

The Yaskins ultimately enlisted the services of an advocate to help them sort through all their billing questions.

[Oct 12, 2009] The Audacity of Greed How Private Health Insurers Just Blew Their Cover

Robert Reich's Blog

The health-insurance industry has finally revealed itself for what it is.

Background: The industry hates the idea that's emerged from the Senate Finance Committee of lowering penalties on younger and healthier people who don't buy insurance. Relying on an analysis by PricewaterhouseCoopers, insurers say this means new enrollees will be older and less healthy -- which will drive up costs. And, says the industry, these costs will be passed on to consumers in the form of higher premiums. Proposed taxes on high-priced "Cadillac" policies will also be passed on to consumers. As a result, premiums will rise faster and higher than the government projects.

It's an eleventh-hour bombshell.

But the bomb went off under the insurers. The only reason these costs can be passed on to consumers in the form of higher premiums is because there's not enough competition among private insurers to force them to absorb the costs by becoming more efficient. Get it? Health insurers have just made the best argument yet about why a public insurance option is necessary.

Right now they run their markets and set their prices, and pass on any increased costs directly to consumers. That's what they're threatening to do if the legislation attempts to squeeze, even slightly, the colossal profits they plan to make off of thirty million new paying customers.

They want every penny of those profits. They demand every cent. And if the government dares raise their costs a tad higher than they expected when they first signed on to support the bill, they'll pass those costs on to consumers in the form of higher premiums. They can carry out their threat only because they have unaccountable, untrammeled market power.

But they've now hoisted themselves on their own insured petard. They've exposed themselves. If they had to compete with a public insurance plan, they couldn't get away with this threat. They couldn't pass on the extra costs. They'd have to compete with a public insurance option that forced them to give consumers the best deals possible.

Now's the time for Congress and the White House to say to the insurance industry: You want to play hardball? Okay. We'll play it, too. You didn't want a public insurance option. That was one of your conditions for supporting the bill. You wanted gigantic profits from having thirty million new paying customers and the market to yourself. The Senate Finance Committee and the White House agreed because they wanted your support and were afraid of the negative ads and hurricane of opposition you could finance. But you're even greedier than we imagined. And now you've demonstrated that greed to the American people. They don't want to turn over even more of their hard-earned money to you. So, insurance companies, we've got news for you. We're going to make sure Americans have the freedom to choose a public insurance option that's cheaper and better, and you're going to have to work hard to keep them your customers.

Unconscionable Math

July 28, 2009 by Taunter

The House hearings on rescission – the retroactive cancellation of individual health insurance policies – were over a month ago, but after its initial run through Daily Kos it seems to have waited a bit before popping up on Baseline and Slate. James Kwak at Baseline described the practice as rare, affecting only 0.5% of the population. The faint light bulb above my head began to flicker: could that be true…that's not rare – that is amazingly common.

It is. In fact, from Don Hamm's (CEO of Assurant) prepared testimony, with the company logo nicely on the front of it in the original:

Rescission is rare. It affects less than one-half of one percent of people we cover. Yet, it is one of many protections supporting the affordability and viability of individual health insurance in the United States under our current system.

What tangled webs we weave…

To understand why 0.5% of the people Assurant covers is a lot of people – a jarring, terrifying, probably criminal lot – you need to understand a little bit of math. You need to understand just enough math to understand what Don and his legal team are not telling you. You need to understand conditional probability. And the folks at Assurant are counting on the fact that you don't.

A typical job interview question for aspiring finance folks is the Monty Hall Question. As typically phrased, you go on a game show and are asked to pick one of three doors. Behind two of the doors are goats. Behind one is a shiny new car. You pick a door. The host ceremoniously opens a door that you did not pick, and behind it is a goat. He turns to you while the audience giggles at the goat. Do you want to change your pick?

As I have pointed out on the Idea Locker comments, this typical phrasing is a bit unfair. If you haven't seen the show, you might think the choice of what door the host opened was random, unrelated to the door you picked. Since there is no correlation, you don't see why you should change your pick. If someone asked you to call the third of three coin tosses in a row, you wouldn't change your pick if the first two were heads, would you?

But the nuance of the game is that the door is not random. The door that is opened will always meet two conditions:

You had a 1/3 chance of being right in your initial pick. That means there was a 2/3 chance the car was behind "not your pick". Well, if you change your pick now, you cover the entire "not your pick" set – you have seen one of the two doors, know that it's empty, and now have the payoff from the other. You should change your pick.

Here's the health care nuance (2005 HHS report based on 2002 data):

Bar graph shows percent of total expenditure by percent of population: Top 1% (greater than or equal to $35,543), 22%; Top 5% (greater than or equal to $11,487), 49%; Top 10% (greater than or equal to $6,444), 64%; Top 20% (greater than or equal to $3,219), 80%; Top 50% (greater than or equal to $664), 97%; Bottom 50% (less than $664), 3%.

Half of the insured population uses virtually no health care at all. The 80th percentile uses only $3,000 (2002 dollars, adjust a bit up for today). You have to hit the 95th percentile to get anywhere interesting, and even there you have only $11,487 in costs. It's the 99th percentile, the people with over $35,000 of medical costs, who represent fully 22% of the entire nation's medical costs. These people have chronic, expensive conditions. They are, to use a technical term, sick.

An individual adult insurance plan is roughly $7,000 (varies dramatically by age and somewhat by sex and location).

It should be fairly clear that the people who do not file insurance claims do not face rescission. The insurance companies will happily deposit their checks. Indeed, even for someone in the 95th percentile, it doesn't make a lot of sense for the insurance company to take the nuclear option of blowing up the policy. $11,487 in claims is less than two years' premium; less than one if the individual has family coverage in the $12,000 price range. But that top one percent, the folks responsible for more than $35,000 of costs – sometimes far, far more – well there, ladies and gentlemen, is where the money comes in. Once an insurance company knows that Sally has breast cancer, it has already seen the goat; it knows it wants nothing to do with Sally.

If the top 5% is the absolute largest population for whom rescission would make sense, the probability of having your policy cancelled given that you have filed a claim is fully 10% (0.5% rescission/5.0% of the population). If you take the LA Times estimate that $300mm was saved by abrogating 20,000 policies in California ($15,000/policy), you are somewhere in the 15% zone, depending on the convexity of the top section of population. If, as I suspect, rescission is targeted toward the truly bankrupting cases – the top 1%, the folks with over $35,000 of annual claims who could never be profitable for the carrier – then the probability of having your policy torn up given a massively expensive condition is pushing 50%. One in two. You have three times better odds playing Russian Roulette.

People lie on their insurance forms, of course, and that is a serious problem. But let's not forget that the very nature of the forms is designed to create inaccuracies, and it doesn't matter in the slightest how minor the error may be once the company comes looking to get out of its policy. Back to Don Hamm:

I mentioned a story in my comment on the Baseline article, and it's a favorite of mine, so I'll repeat it here: Years ago I was walking a casino floor with a casino executive. It was an incredibly detailed tour, and we got to talking about pretty much everything that came to mind about crowds and gaming. Now, a clever observer might notice that even the tolerant people of Nevada will not allow alcohol in vending machines – wouldn't want the little ones to be able to get a Bud Light without a human being verifying their ID. But there we were in the middle of acres of blinking lights, with absolutely no one making sure that underage kids weren't walking up to a slot machine. Indeed, they don't card for the table games.

The executive told me you are free to play if you are underage, you just aren't free to win. You can sit down and pump your money into the slots, and if you look presentable you can drop some chips on blackjack or craps. However, if you should happen to start winning, the pit boss or security team will come over and check your ID. The house edge is 100%.

Conditional probability is tough for the human brain. We tend to think of things as either completely correlated (once the market tanked, McCain had to lose) or completely uncorrelated (coin tosses). To a certain extent, we make the calculations in everyday speech: when someone says that pancreatic cancer is exceptionally lethal, he doesn't mean that it is likely to kill an enormous number of people; he means it will kill an enormous percentage of the people who contract pancreatic cancer. Get a bit more tangential and even very smart people with Nobel Prizes miss things; one of the reasons Long Term Capital Management melted down was that once they started sustaining heavy losses, people bet against LTCM's other holdings – LTCM itself was the correlation. Low frequency, high severity events are also difficult for us to process – look at how much we invest fighting air piracy versus the sacrifices we are unwilling to make on drunk driving or domestic firearm violence.

Put them together and the guys with the actuaries working for them have a nearly insurmountable advantage. I tend to think of traditional banking and traditional insurance as mirror images: when you take out a mortgage, you get a lump sum and make a series of payments; when you get life insurance, you make a series of payments and get a lump sum. Health insurance is somewhat similar to life insurance, except the payout happens sometime during the payment stream instead of at the end.

When a person intentionally defaults on consumer credit, he is called a "ruthless defaulter" and the system, to the extent that it operates with any sort of efficiency, is designed to try to flush him out of the credit market in the future. Society can tolerate taking the risk of inadvertent defaults – the people who through some sort of misfortune are unable to make good their promised payments. The folks who do it on purpose…do it enough and the FBI might step in.

The insurance industry has a bit of a historical difference, in that pretty much everything in health insurance is similar to a liar loan. I tell the company if I have been sick, just like stating an income on a mortgage application. For a host of administrative and medical privacy reasons, the insurance industry has not historically wanted a comprehensive inventory of medical records before taking a client. Few people could probably deliver such a record even with the best of intentions. There is a problem with liar loans, and it was well described by Tanta (Calculated Risk's late writing partner) here:

Well, with Number 1 [a liar loan that has gone bad], it's "clearly" the borrower's fault. He or she lied, and we can pursue a deficiency judgment or other measures with a clear conscience, because we were defrauded here. We can show the examiners and auditors how it's just not our fault. The big bonus, if it's a brokered or correspondent loan, is that we can put it back to someone else, even if we actually made the underwriting determination. No rep and warranty relief from fraud, you know.

It is in the health insurer's interest to have application fraud, not only because it saves time and expense on the front end, but also because it lets them get out of any policy that isn't going well for them. If the health insurer had to verify the information – if, in essence the insurance company had to behave as an accredited investor with adequate expertise to make a decision without reliance – it wouldn't have the opportunity to bail out. It would catch more genuine liars, but many of these liars would have turned out to be healthy, profitable customers, and what the carrier really wants is a population devoid of expensive claims, not devoid of liars.

Years ago, the shameful business was the tobacco industry. There was a certain roguish charm to them; they had great ads and were fun outgoing people, and of course they made a product that if used as directed would kill you.

Say this for the tobacco folks: they printed the dangers right there on the pack. Few people who took up smoking after World War II did so with ignorance of the health consequences. Society wants tobacco, it might as well be produced in clean factories and wrapped in cellophane as opposed to sold on street corners. I hope we legalize marijuana and let Altria and RJR make joints and put the Mexican cartels out of business.

No, the health insurance companies sneak around. They have nice facades, they speak in the bureaucratic language of statistics few understand, and they make the eminently reasonable argument that they just need to protect themselves. They promise great coverage, and when many years later it comes time to pay out and the petitioner is sick and unable to function, sorry, wish we could do better, but there was an error and rules are rules. We're keeping the premiums. It's actually far more like this guy: