Supreme Court upholds health care reform

[ThinkToday]

I've not had any issues with getting my wife and child with pre-existing conditions covered. Like yours, the pre-existing conditions were serious. It's been awhile, but as best I can remember, they weren't covered for 12months unless they were transitioning from one insurance to another without a significant break (e.g. typical job change situation). Even then, if they hadn't been treated for the condition within the past 12 months, that was ok too for getting coverage. My understanding was regardless of the outcome of the ACA, pre-existing conditions were being made a thing of the past. A very good thing for those whose illness is through no fault of their own.

 

[mheslep]

The high cost. And my older daughter has a pre-existing condition, and was turned down by everyone.

The cost of insurance has not come down but gone up significantly in the last two years. So you would agree what your daughter really needs from this law is the no pre-existing condition exclusion rule, and not necessarily 2700 pages of other things?

 

[mheslep]

Can't say I understand much of the whole story (and your discussion) as legalese and details of US system are a Greek to me. What struck me was the fact that the decision - nominally taken by the court, so it should be taken solely on the legal ground - seems to be strictly political. At least according to CNN article linked to in the very first post those seen as liberal voted for, those seen as conservative against.

One of the news worthy points of the story is that is not entirely the case here. The Chief Justice, Roberts, appointed by former President Bush, voted to uphold the health care law and for largely unanticipated legal reasoning. Also Justice Kennedy who votes both ways, voted with the minority to strike down the law.

 

[mheslep]

... and their cost of living is higher, because of the VATs they have (Value Added Tax). America has no VAT.

Eh, at the *federal* level America has no across the board VAT, though there are some on certain .. http://www.irs.gov/newsroom/article/0,,id=242812,00.html/ and they hit the poor/middle incomes just as you point out. America has ample State and local VATs, implemented as simple sales taxes.

 

[ThinkToday]

One of the news worthy points of the story is that is not entirely the case here. The Chief Justice, Roberts, appointed by former President Bush, voted to uphold the health care law and for largely unanticipated legal reasoning. Also Justice Kennedy who votes both ways, voted with the minority to strike down the law.

Yes, it doesn't always follow what's expected.

Roberts appointed by GWB
Scalia appointed by Reagan
Kennedy appointed by Reagan
Thomas appointed by GWB
Ginsberg appointed by Clinton
Breyer appointed by Clinton
Alito appointed by GWB
Sotomayor appointed by BO
Kagan appointed by BO

In general, they do tend to vote the way you'd expect, but I think Kennedy becoming a swinger and Roberts swing on this and the AZ immigration case stand out. I think people tend to forget O'Connor (Reagan) was a frequent swinger, and Souter (GWB) and Stevens (Ford) were mid-tending left on many votes, even though conservative republicans appointed them.

 

[CAC1001]

Eh, at the *federal* level America has no across the board VAT, though there are some on certain .. http://www.irs.gov/newsroom/article/0,,id=242812,00.html/ and they hit the poor/middle incomes just as you point out. America has ample State and local VATs, implemented as simple sales taxes.

From my (maybe incorrect) understanding, a sales tax is different from a VAT. A sales tax shows up on the receipt, whereas a VAT taxes each stage of the production and distribution of a good or service. It doesn't show up on the receipt and is thus hidden. You only know it's there by the higher prices for said particular goods and services it is applied to.

 

[mheslep]

From my (maybe incorrect) understanding, a sales tax is different from a VAT. A sales tax shows up on the receipt, whereas a VAT taxes each stage of the production and distribution of a good or service. It doesn't show up on the receipt and is thus hidden. You only know it's there by the higher prices for said particular goods and services it is applied to.

Yes, that's my understanding of how its done in the EU, though I think of notification as an aspect of implementation, and not a fundamental characteristic of the thing itself.

 

[nitsuj]

The cost of insurance has not come down but gone up significantly in the last two years. So you would agree what your daughter really needs from this law is the no pre-existing condition exclusion rule, and not necessarily 2700 pages of other things?

The restrictions on insurance companies looks awesome. I would love to know the income health insurance companies make. Exchanging those profits for more healthcare seems fair (for the greater good), for a business model of "House always wins".

As far as the subsidy side / "tax increase" ect it maybe just growing pains.

Come budget cuts for 2015+ maybe, just maybe citizen health will be put before military/philanthropy/NASA/...what budget expense could possibly force healthcare funding back onto the chopping block?

Oh right politicking.

 

[Borg]

The high cost. And my older daughter has a pre-existing condition, and was turned down by everyone.

This is one of the reasons that I am for health care reform in some form. The big problem is that this isn't fair to the insurance companies if only the sick had to get insurance.

If you don't buy car insurance and wreck your car, you're out a car. But, with the way health care is, you don't have to buy insurance and you can still be treated by going to a hospital that can't turn you away. Even if you gave people the ability to opt out (no pay, no coverage), the evening news would be full of sob stories of people who suddenly didn't think that it was fair once they became very ill. So, until someone comes up with a plan for something better and not just the desire to kill it, I think that this is a reasonable compromise to achieve the goal of universal health care.

I am curious though what happens to the money paid as 'tax'. Does that money go to the insurance companies or does the federal government keep it?

 

[Astronuc]

Some interesting commentary on the decision and Roberts's vote:

http://news.yahoo.com/blogs/power-p...ice-roberts-save-supreme-court-103301790.html

I think Roberts played his hand well. He established that tax for what it is, and basically left it to Congress to rescind it as they see fit. Now it's up to the people, as it should be, to elect officials that represent their collective will. If the majority want this healthcare program or not - let them elect their representatives accordingly. The next Congress will have a chance in 2013 to rescind the law. Whether or not, there will be another chance in 2015.

Meanwhile - neither presidential candidate, nor Congress, is addressing the chronic budget deficit or failing economic recovery.

 

[CAC1001]

From what I have researched of universal healthcare systems, single-payer is not the ideal form. Single-payer is the form the political left in the United States want, but that usually is more ideology-driven on their part. The best forms of universal healthcare, from what I've seen, are systems that are a combination of public and private elements.

 

[Jimmy Snyder]

Russ_watters does the US not have required mandatory insurance for vehicle drivers?

I'll step in for Russ. This is wrong on two points. First, the federal govt does not require insurance for vehicle drivers, only states do. Second, the states do not require you to own a vehicle and hence, they do not require you to have insurance.

 

[ThinkToday]

If you don't buy car insurance and wreck your car, you're out a car. But, with the way health care is, you don't have to buy insurance and you can still be treated by going to a hospital that can't turn you away.

Part of the problem is the people that wreck the car and want to buy the insurance after the wreck, expecting it to cover the wreck. IMO, there are important issues with ACA.

1) Clearly, the people that have medical issues by no fault of their own shouldn't be penalized with a higher rate. IMO, there should be a high risk subsidized pool for inherently high risk people that are victims of genetics, the environment, accident, war, crime, etc.

2) On the other hand, people that engage in risky activity should have to pay a premium for that behavior. If I have a stack of speeding tickets, should you (with a clean record) and I pay the same for car insurance? The ACA model says yes, no pre-existing conditions (tickets, accidents, drunk driving convictions), which is silly, IMO. If I engage in risky behavior, smoke, eat all high fat food, drink a lot, use drugs, sky dive, motocross, drag race, free climb, etc., should I pay the same for health care as someone that lives a relatively "normal" healthy lifestyle, gets plenty of safe exercise, and doesn't routinely engage in high risk activities? The ACA model says yes, no pre-existing conditions (drug convictions, gang leader in south LA, etc.), which is silly, IMO.

IMO, a serious problem with ACA is the lack of personal responsibility and accountability.

 

[Ryan_m_b]

From what I have researched of universal healthcare systems, single-payer is not the ideal form. Single-payer is the form the political left in the United States want, but that usually is more ideology-driven on their part. The best forms of universal healthcare, from what I've seen, are systems that are a combination of public and private elements.

Having single payer and private systems are not mutually exclusive. In the UK anyone can use a public NHS hospital/doctor/dentist but they also have the choice to go to private clinics paid for with private health insurance. There's little difference in the actual care but waiting times (a notorious problem for the NHS) are reduced.

 

[ThinkToday]

Having single payer and private systems are not mutually exclusive. In the UK anyone can use a public NHS hospital/doctor/dentist but they also have the choice to go to private clinics paid for with private health insurance. There's little difference in the actual care but waiting times (a notorious problem for the NHS) are reduced.

Years ago, I worked with a doctor that was trained in Great Britain. He commented the health care for someone with and emergency condition is very good (heart attack, stroke, MVA), but care for more chronic conditions wasn't very good, unless you had some private paying option to be treated outside the government system. How are things now? You commented about the waiting times. Do the people have a say about their care, as far as quality and timeliness with the government? Does the government adequately respond to the concerns of patients, or has it become something people just have to live with? Do you see change in the future of medicine in England or is the system pretty well locked down?

Is your health care like Canada? I had an acquaintance that worked for CP Railroad, and he had a brain tumor with an estimate of about 6-12 months to live, if untreated. They told him he had to wait 6 months to get an MRI to determine course of care! Apparently, there were very few MRI and they were booked. A friend of his is a US radiologist, and he flew him to the US and did a stat MRI on him to take back to his doctors in Canada. As a practical matter, what he had was going to kill him, treated or not, but not even scheduling critical tests ASAP is unheard of in the US health system. Perhaps he could have lived another 6-12 months, if treated early and aggressively.

 

[Ryan_m_b]

I don't think this thread is a great place to start a conversation about the National Health Service (don't want to detract from the actual conversation of the SCOTUS decision) but I'll quickly answer best I can.

Years ago, I worked with a doctor that was trained in Great Britain. He commented the health care for someone with and emergency condition is very good (heart attack, stroke, MVA), but care for more chronic conditions wasn't very good, unless you had some private paying option to be treated outside the government system. How are things now? You commented about the waiting times. Do the people have a say about their care, as far as quality and timeliness with the government? Does the government adequately respond to the concerns of patients, or has it become something people just have to live with? Do you see change in the future of medicine in England or is the system pretty well locked down?

Of course the people have a say, we are a democracy you know. The NHS has to conform to various targets which are always political issues and is constantly under review (we've just enacted a big reform to shake up the organisation again). I'm not too clued up on the runnings of the NHS myself though I have a friend who is somewhat of an expert, we've had many conversations about the endless peer-reviewed studies that come out about how to better allocate resources, what organisational methods should be employed etc and that's all before you actually get down to the medicine itself. "Locked down" would imply a static organisation which is very much not the case.

Is your health care like Canada? I had an acquaintance that worked for CP Railroad, and he had a brain tumor with an estimate of about 6-12 months to live, if untreated. They told him he had to wait 6 months to get an MRI to determine course of care! Apparently, there were very few MRI and they were booked. A friend of his is a US radiologist, and he flew him to the US and did a stat MRI on him to take back to his doctors in Canada. As a practical matter, what he had was going to kill him, treated or not, but not even scheduling critical tests ASAP is unheard of in the US health system. Perhaps he could have lived another 6-12 months, if treated early and aggressively.

That wouldn't happen here and I'm very surprised that happened in Canada (I'm not doubting you but that sounds like one of those freak cases that gets reported on the media as though it was a widespread thing). Here you might have to wait weeks to months for a consultation/test/operation on a non-emergency illness which isn't ideal at all and is an issue constantly being tackled but for an emergency you would get it right away.

 

[CAC1001]

Having single payer and private systems are not mutually exclusive. In the UK anyone can use a public NHS hospital/doctor/dentist but they also have the choice to go to private clinics paid for with private health insurance. There's little difference in the actual care but waiting times (a notorious problem for the NHS) are reduced.

Can you have both though? From what I have been read, if you start using the private-sector care in Britain, then you lose your ability to use the NHS, that they don't let you both use the NHS and then get additional private care on the side.

 

[Ryan_m_b]

Can you have both though? From what I have been read, if you start using the private-sector care in Britain, then you lose your ability to use the NHS, that they don't let you both use the NHS and then get additional private care on the side.

No that's not the case, you can use both and they often work together.

 

[jim hardy]

I'm no expert, but how does the 16th Amendment prevent the government from being able to tax for whatever they want? I've always thought they could do that...

i think the pemise is that legislative branch members would have to face tar & feathers at home.
Here in Arkansas we wrote Blanch Lincoln(our senator) telling her if she voted for Obamacare she'd get fired, and when she did anyway we fired her.


Roberts took it away from the bureaucrats and laid it right at congress's feet.
Now it's not some lame nameless bureaucrat assessing a fine for which yo have no recourse, it's your elected representative levying a tax . Give 'em hell.

 

[Evo]

Seems people are coming to their senses.

Support for Obama healthcare law rises after ruling


Among all registered voters, support for the law rose to 48 percent in the online survey conducted after Thursday's ruling, up from 43 percent before the court decision. Opposition slipped to 52 percent from 57 percent.

The survey showed increased backing from Republicans and, crucially, the political independents whose support will be essential to winning the November 6 presidential election.

And this is only after a few days. Looks like approval will keep growing, IMO.

http://news.yahoo.com/ruling-ups-support-obama-healthcare-still-unpopular-040755810.html

 

[Angry Citizen]

Don't jump the gun. This is just one poll. Wait to see an average of all poll data from several sources and over a few weeks before making claims. It's only prudent.

 

[Evo]

Don't jump the gun. This is just one poll. Wait to see an average of all poll data from several sources and over a few weeks before making claims. It's only prudent.

Very true, but I think people will see how it benefits society, IMO. I haven't completely lost faith in the human race yet. Close, but not completely.

 

[Angry Citizen]

Personally I think the poll data is misleading anyway. I'm technically against the PPACA, but only because it's not a single-payer system. I think it's a vast improvement over the status quo, but some people don't look at it that way. They want all-out, Waterloo-style victory, or nothing at all. And I think the poll data includes some of those people.

 

[Ryan_m_b]

I'm not sure who said it (will report back with name later) but I heard an opponent of the bill state that repealing it before it comes into full effect is a priority because once it's fully in place it will be nigh on impossible to get of. With so many people better off they aren't going to vote for someone to get rid of their healthcare.

Whilst this isn't universal healthcare as some people have lamented it is IMO a fantastic step in the right direction.

 

[BobG]

The high cost. And my older daughter has a pre-existing condition, and was turned down by everyone.

The ACA will mean a person can get insurance in spite of pre-existing conditions, but how will it lower the cost of insurance?

With having to choose between buying health insurance or paying a tax/penalty (whichever you want to call it), I could see insurance premiums dropping, since young, healthy people are chipping in money, as well. But insuring people with pre-existing conditions should push insurance costs higher, since people likely to use more health services are covered.

The only thing I see in the ACA related to the cost of health insurance is that some certain percentage of premiums (80% to 85%) has to be spent on medical care (and then requires companies to spend time and money reporting their performance) and the requirement for insurance companies to justify any increase in premiums of 10% or more.

I think it's just unclear what happens to insurance rates in the end and will it ever be clear when the cost of medical services is always increasing?

 

[Angry Citizen]

The ACA will mean a person can get insurance in spite of pre-existing conditions, but how will it lower the cost of insurance?

You forgot the subsidies. If you make less than 400% of the poverty line (which is to say, most people) you'll qualify for a subsidy if you're purchasing on the exchange. Plus employers have to offer you insurance if they have more than 50 employees, and they too will qualify for subsidies if they aren't some gigantic corporation. All of which will be paid for through taxes on the rich. In short, the rich will cough up some dough, and your insurance cost will be lowered.

 

[Ryan_m_b]

Personally I think the poll data is misleading anyway. I'm technically against the PPACA, but only because it's not a single-payer system. I think it's a vast improvement over the status quo, but some people don't look at it that way. They want all-out, Waterloo-style victory, or nothing at all. And I think the poll data includes some of those people.

For single payer proponents this could be seen as the only possible step towards that at this time. Given the constant defeat of bills like the national health care act it may take some time with a more universal system to sway opinion.

 

[Borg]

From a Journal of the American Medical association article on the http://jama.jamanetwork.com/article.aspx?articleid=1104195.

The individual mandate is integral to the health reform legislation for at least 3 reasons. First, and critically for physicians, it strengthens the patient-physician relationship. Second, it generally stabilizes insurance premiums, increases access to health insurance coverage, and provides security against significant medical expenses. Third, it addresses the pernicious “free rider” problem that is unique to US health care because of the long dysfunctional health insurance market.

The ability to access preventative care will reduce usage of expensive "emergency" services which is a significant cost. Also, many studies have shown that preventative care improves patient health and reduces overall medical costs. If you're going to end up treating someone anyway, why not treat them in a more cost effective manner that has the additional benefit of improving their health?

Patients with insurance are more likely to have physicians routinely involved in coordinating their care, are more apt to receive screening and other preventive services, and are less likely to engage in substance abuse.
Although some persons without insurance attend self-pay clinics, many seek care only in the emergency department and on a semi-urgent basis. This pattern of care-seeking behavior is costly and inefficient, and limits the ability of a physician to know a patient as an individual, rather than simply as a patient with an illness.

Plus, it gets rid of the freeloaders who can afford health care but choose not to pay for it.

With rare exception, at some point every individual will require health care services. Therefore, the decision of many individuals not to purchase coverage—whether consciously or not—presents a free rider problem. These individuals will generally receive care, whether or not they are able to pay toward that care. For those individuals for whom health coverage is unaffordable, there is a societal obligation to create remedies. On the other hand, for those individuals who could afford to purchase coverage, yet choose not to, it should be clear that “free riding” cannot be sanctioned.

 

[mheslep]

No that's not the case, you can use both and they often work together.

Is it?

A WOMAN will be denied free National Health Service treatment for breast cancer if she seeks to improve her chances by paying privately for an additional drug.

Colette Mills, a former nurse, has been told that if she attempts to top up her treatment privately, she will have to foot the entire £10,000 bill for her drugs and care. The bizarre threat stems from the refusal by the government to let patients pay for additional drugs that are not prescribed on the NHS.

(snip)

Ministers say it is unfair on patients who cannot afford such top-up drugs and that it will create a two-tier NHS. It is thought thousands of patients suffer as a result of the policy.

(snip)

The Department of Health said: “Co-payments would risk creating a two-tier health service and be in direct contravention with the principles and values of the NHS.

Pay walled:
http://www.timesonline.co.uk/tol/life_and_style/health/article3056691.ece

 

[Ryan_m_b]

Is it?


Pay walled:
http://www.timesonline.co.uk/tol/life_and_style/health/article3056691.ece

Your example is niche and pretty much explains itself: you can't top up one treatment you are getting on the NHS with a private one i.e. if NHS treatment is drugs A-E and private is A-F you can't use the NHS for the first five and private for the last. However having private health insurance does not preclude you from using the NHS (the question I was addressing) and by working together that often happens with the treatments are the same i.e. you could go some of the way with the NHS then jump to private to pick up where you left off (usually done if at some point in your treatment you'll have to be put on an NHS waiting list). In addition private doctors and clinics can and do work out of NHS hospitals and can even be brought in if it is in the patient's interests and private treatments can use NHS facilities in some circumstances.

Whilst there are examples where the two don't mesh (like in the story linked) most of the time when they are both employed so long as they don't violate NHS ethical guidelines a patient can receive both.

However it's worth mentioning that over the next year or so the full effects of the Health and Social Care Act will come into effect and that's a major restructuring of the NHS so all this may change.

 

[D H]

The restrictions on insurance companies looks awesome. I would love to know the income health insurance companies make. Exchanging those profits for more healthcare seems fair (for the greater good), for a business model of "House always wins".

Google is your friend. Most of the health care insurance industry business are publicly owned, so their profits are there for the public to see. And they aren't very big. A profit margin of 2.2% in 2009, a bit better since then, but not much and never outrageous. The left and the right each have their favorite villains (the insurance industry and trial lawyers respectively), neither of which contributes much to the high cost of health care in the US. This is part of the problem. Each side wants to fix a problem that doesn't exist while letting the root cause continue unchecked.

Health care is so expensive in the US because the providers charge a lot. Pharmaceuticals cost a lot more than elsewhere, and this is an incredibly profitable industry. The same goes for medical equipment. Doctor's salaries are much higher in the US than elsewhere. The hospital and insurance industry might not be all that profitable, but it is quite profitable for the people who work for them. Salaries here are a bit higher than elsewhere.

There's a lot of waste and overhead too. This doesn't show up in profits; it hinders profits. We have a hodgepodge of 51+ governments (federal, state, sometimes local) that get their fingers in the mix. The medical industry has to kowtow to this, and this too costs money.

The PPACA is not addressing these root causes.

 

[jim hardy]

IMHO this act just hands to insurance industry the power to levy taxes.

I would have supported a public option

but to have 23% of healthcare cost going to paperwork is insanity .

The insurance industy takes something out of every dollar that passes through their hands
so it's in their interest to blow up the bureaucracy
and the result is, predictably, what we have - two symbiotic bureaucracies one on the provider side and one on the payor side
with unfortunate consumer as the beast of burden supporting both
while the bean counters endlessly expand their ranks and acquire ever more powerful bean microscopes..
now they no longer have to worry about rates - they have power to tax thanks to the best Congress they could buy. Roberts has exposed the collusion, and i hope JQPublic takes the hint..


When i went on medicare i saw
my paperwork processed 10X more quickly and accurately than with private insurance
my doctors paid qiuckly, but only about a third what my private insurance used to pay them

but now i pay more for the medicare supplement (pays 20%) than i paid for full coverage before -
and still have to spend hours dealing with the insurance bureaucrats.

i'm tired of being gouged by insurance industry. It has coiled itself around us as stealthily as a python.

We should replace the stars on our flag with the Rock of Gibraltar because we have become "The Underwriter's State of America".

 

[nitsuj]

Google is your friend. Most of the health care insurance industry business are publicly owned, so their profits are there for the public to see. And they aren't very big. A profit margin of 2.2% in 2009, a bit better since then, but not much and never outrageous. The left and the right each have their favorite villains (the insurance industry and trial lawyers respectively), neither of which contributes much to the high cost of health care in the US. This is part of the problem. Each side wants to fix a problem that doesn't exist while letting the root cause continue unchecked.

Health care is so expensive in the US because the providers charge a lot. Pharmaceuticals cost a lot more than elsewhere, and this is an incredibly profitable industry. The same goes for medical equipment. Doctor's salaries are much higher in the US than elsewhere. The hospital and insurance industry might not be all that profitable, but it is quite profitable for the people who work for them. Salaries here are a bit higher than elsewhere.

There's a lot of waste and overhead too. This doesn't show up in profits; it hinders profits. We have a hodgepodge of 51+ governments (federal, state, sometimes local) that get their fingers in the mix. The medical industry has to kowtow to this, and this too costs money.

The PPACA is not addressing these root causes.

Thanks for the figure. being in finance it does raise more questions for me (dividends are a business expense, and other common expensed "perks").

But one thing seems certain is 2.2% is close to zero. However many billions of revenue that's on.

I wonder, since the "tax" (premium) is collected by insurance companies (i.e. doesn't flow through Gov' admin & then insurance admin) if that will help improve efficiency.

But I have heard the number of current health insurance subscribers and it seems this legislation gets the "high income" & "low income" into the insurance "pool". (and most significantly limits premiums)

That said having only 2.2% of room to work with, it could quickly become devastating for health insurance companies. They're largely publicly held you say eh? Yikes!

Haven't had my head in the news for sometime, let alone business news. Maybe the US is conditioned to helping out the health insurance companies if things get too bad for them. But if I were investing, I would be fearful of the position health insurance is in right now. Are they "out on a limb", or "under the government's wing".

 

[nitsuj]

IMHO this act just hands to insurance industry the power to levy taxes.

I would have supported a public option

but to have 23% of healthcare cost going to paperwork is insanity .

The insurance industy takes something out of every dollar that passes through their hands
so it's in their interest to blow up the bureaucracy
and the result is, predictably, what we have - two symbiotic bureaucracies one on the provider side and one on the payor side
with unfortunate consumer as the beast of burden supporting both
while the bean counters endlessly expand their ranks and acquire ever more powerful bean microscopes..
now they no longer have to worry about rates - they have power to tax thanks to the best Congress they could buy. Roberts has exposed the collusion, and i hope JQPublic takes the hint..

Jim, I must be misunderstanding the limits that have been put on the insurance premiums.

I understood that these "powers" to "tax" (premium) have now been limited by the legislation. i.e. they can't charged what ever they want.


I still haven't wrapped my head around this yet...

 

[ThinkToday]

Health care is so expensive in the US because the providers charge a lot. Pharmaceuticals cost a lot more than elsewhere, and this is an incredibly profitable industry. The same goes for medical equipment. Doctor's salaries are much higher in the US than elsewhere. The hospital and insurance industry might not be all that profitable, but it is quite profitable for the people who work for them. Salaries here are a bit higher than elsewhere.

There's a lot of waste and overhead too. This doesn't show up in profits; it hinders profits. We have a hodgepodge of 51+ governments (federal, state, sometimes local) that get their fingers in the mix. The medical industry has to kowtow to this, and this too costs money.

The PPACA is not addressing these root causes.

I'll disagree with a few points. I've been in the health care profession for over 25 years doing radiological physics (diagnostic and oncology). When we set a price, it's usually a multiplier (~2.5 in most places I've worked) of the Medicare fixed price. Medicare payment rates are pretty minimal for many procedures and some of the things we have to do are not paid at all. For example (and these things change), we would get paid for daily localization of the prostate for IMRT if we used the BAT ultrasound system, however, if we use the better gold seed marker system that uses x-rays, we can't charge, even though the latter is more accurate. We own both, but use the better localization system and forgo the payment. Time, labor, QA, service contract, etc., we have to eat the loss. If I treat a lung cancer and use a custom block and wedge, I could bill a complex treatment device for either... but not both. With Texas Medicaid, if I treated a 6 field pelvis and made six custom Cerrobend blocks, I could only bill for 1, even though 6 were made.

Yes, there are a lot of paperwork issues in hospital billing, but there is almost always a reason. e.g. different insurance companies pay more, less, or not at all for many things, and many patients have more than one insurance company. When you get your EOB from BCBS, etc. the amount paid by insurance is almost always less because BCBS, etc. tells providers "$X" is all we'll pay you for this procedure, and it's written into the contract. Same thing is repeated with each insurance company, and each strike the best deal they can based on the leverage they have. Factor in the self-pay and no-pay patients too. If you ever wondered why the hospital or doctor keeps billing you for that “$5.76” left after insurance pays, it’s the law. We must make a good faith effort to collect before writing it off as bad debt. It’s the same reason we can’t take the “80%” your insurance pays and not to worry about the balance; it’s not legal. We have to charge everyone the same price, even if their contract pays us less. Interestingly, we can bargain self pay prices and usually will, down to the level of a contracted insurance company, and, on a case-by-case basis lower, before turning the account over to collection.

Equipment price are not all up. In many cases they are comparable or down. For example, 1991 purchase price for a Varian 2100C, option dual asymmetric jaws – $1.3M; 2004 purchase price Varian 21EX, options 120 leaf MLC, aSi Portal imager, dual asymmetric jaws, respiratory gating - $1.4M. There is a very big difference between the machines given the price difference. On the other hand, the latest Varian TrueBeam hits $2.9M, but adds things like cone beam CT, on-board imaging (OBI). The first 8 slice CT scanner we purchased was $1.4M, and now you can get a 16 slice for <$700k, although the latest greatest still top $1M. 3-D treatment planning systems first ran around $300k, and are now around $100k and do more.

IMO, there really are no simple answers. As Americans, I think we have become use to having the best and being able to demand it, and have it conveniently located. e.g. My shoulder hurts from crashing my bicycle in the HHH (http://www.hh100.org/) , and I want an MRI. I bet if we had to pay for the MRI we want we’d think differently. I’ve seen this and I’m personally guilty of these same things. At my last hospital an employee could get the MRI for $50 and our PPO paid the balance. If I were John Doe paying my way, I’d treat the injury the way we did in the 50s & 60s, give it rest, hot and cold, take aspirin for pain, come back if it doesn’t get better.