News Supreme Court upholds health care reform

[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.

 

[D H]

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.

This is one of the things that both bugs and scares me most. We who do have medical insurance are subsidizing Medicare and it's intentionally lowball prices. What happens when those rates are mandated for everyone? I can't see any outcome other than the health care industry stopping to use what they know are the best practices.

Yes, there are a lot of paperwork issues in hospital billing, but there is almost always a reason. <Lots of reasons elided>

This paperwork mess and tangled bureaucracy is where our system is an unmitigated disaster. And it's no one thing's fault. Disinterested and slow governments can't explain this mess. Capitalistic greed can't explain this mess. Profits certainly can't; streamlining operations is one thing that capitalism is very good at in general. Our health care system is neither capitalist nor socialist. It's a Rube Goldberg nightmare.

Equipment price are not all up. In many cases they are comparable or down.

I said that we pay more than anywhere else, not anywhen else. I'll try to dig up the articles I read later this evening.

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.

That last one is apparently not one of the factors. Once again, I'll try to dig up the articles I read. I did try to read several and did try to look for biases.

I agree that there are no simple answers. But everyone, politicians most of all, want the simple answer. It doesn't matter if it is the wrong answer.

 

[ThinkToday]

This is one of the things that both bugs and scares me most. We who do have medical insurance are subsidizing Medicare and it's intentionally lowball prices. What happens when those rates are mandated for everyone? I can't see any outcome other than the health care industry stopping to use what they know are the best practices.

I see that now in the for-profit sector. The margins aren’t enough to do free work. My cancer center was run out of business when a for-profit company bought up the referral physician practices, and offered a “deal” to get the hospital equipment, since they weren’t going to be sending us any paying patients in the future. Up until that point, they took their paying patients to their center and sent the low/no pay patients to us. Additionally, for example, if insurance companies would pay for IMRT for a base of tongue tumor we did IMRT, otherwise, conventional shrinking field would be used. Not as good, more complications, etc. It’s not malpractice, since it is still within the “standard of care”… it’s just not the best available care, and the fact the choice is based on if the procedure would get paid is very troubling. To be clear. This isn’t a greed issue as much as simple economics. Everyone knows up-coding (charging for a service above that provided) is illegal, but so is down-coding (charging for a service below that provided). I can’t legally do IMRT and charge for a conventional shrinking field technique.

This paperwork mess and tangled bureaucracy is where our system is an unmitigated disaster. And it's no one thing's fault. Disinterested and slow governments can't explain this mess. Capitalistic greed can't explain this mess. Profits certainly can't; streamlining operations is one thing that capitalism is very good at in general. Our health care system is neither capitalist nor socialist. It's a Rube Goldberg nightmare.

Absolutely. But, I would add we (Americans) don’t seem to be wise consumers anymore. The new ACA doesn’t seem to incentivize wise choices in life style or acquiring health care services. I suspect at some point we’ll see the adoption of Appropriateness Criteria for health care such as: http://www.acr.org/Quality-Safety/Appropriateness-Criteria . The American College of Radiology (ACR) formulated these years ago to help a doctor determine when a test was justified. As best I can remember, it was a response to increased patient radiation exposures from more and more tests, as well as “cover” for when more expensive tests were being asked for authorization from an insurance payor.

I suspect we will ultimately see some access issues. I was fortunate enough to spend 10 days golfing in beautiful Alberta and British Columba several years ago with a doctor friend (BTW. I highly recommend Alberta and BC for golfing ). In my little town of 100k in TX we had more MRI than all of BC and we had more CT scanners than all of BC. Access was an issue for them, but not for us. Same day exams weren't generally a big deal.

I said that we pay more than anywhere else, not anywhen else. I'll try to dig up the articles I read later this evening.

My misread

 

[nitsuj]

Regarding the MRI, it's the same in Ontario.

My jaw dropped when I read that an MRI could be done for a mere $50.00. I doubt that would include any analysis, but still 50 bucks seems like a steal given what they do.

I understand them to be great tools for "early intervention" of some tumors.

 

[NeoDevin]

My jaw dropped when I read that an MRI could be done for a mere $50.00. I doubt that would include any analysis, but still 50 bucks seems like a steal given what they do.

I'm a little skeptical of that number. That doesn't even seem enough to pay the nurses and technicians, never mind the cost of purchasing and maintaining the machine, the cost of the facility it's in, cost of insurance, etc.

Edit: It occurs to me that $50 may refer to the incremental cost, after fixed costs like purchasing/maintenance/facilities/insurance are taken out. If that's the case, then it's a little more believable, but a less relevant number.

 

[mheslep]

...
When i went on medicare i saw ... my doctors paid qiuckly, but only about a third what my private insurance used to pay them
...

i'm tired of being gouged by insurance industry.

How much do you suppose you have paid in FICA taxes over a lifetime by comparison?

 

[jim hardy]

How much do you suppose you have paid in FICA taxes over a lifetime by comparison?

hmm as best i remember when health insurance reached $400 a month, SS/FICA was around $320 (260 + 60)


At that time i had so many old folks in my family receiving SS that i decided it was okay and i honestly didn't resent it . Sorta like a tithe , helps out your own .

Medicare operates with 3% overhead, non-profit insurance 16% overhead, and private (for-profit) insurance 26% overhead. Source: Journal of American Medicine 2007

http://www.healthpaconline.net/health-care-statistics-in-the-united-states.htm

what i said above about symbiotic bureaucracies - it's Parkinson's Law.
http://masscare.org/health-care-costs/overhead-costs-of-health-care/

http://www.masscare.org/wp-content/uploads/2007/04/HospitalBilling&AdminUSvsCanada.jpg

The only way to stop a bureaucracy is to cut off its money. Instead we gave 'em taxing authority. Thank goodness Roberts clarified that.

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

nitsuj - could you point me to something on those limits? Might calm me down a bit.

old jim

 

[edward]

Pharmaceutical companies are out of control

$3 Billion fine
http://www.nytimes.com/2012/07/03/b...llion-in-fraud-settlement.html?pagewanted=all

2.5 billion dollar fine
http://www.awareandprepare.com/pfizer-to-pay-a-record-2-5-billion-fine/

another 1.5 Billion
http://www.medicaldaily.com/news/20120413/9521/johnson--johnson-penalty-risperdal-arkansas.htm

And the three above all happened after "Big pharma Pays $8 Billion"
http://abcnews.go.com/Politics/drugmakers-paid-billion-fraud-fines/story?id=15853102

Who really ends up paying for the criminal activity of big Pharma.? We know don't we.

 

[mheslep]

...
At that time i had so many old folks in my family receiving SS that i decided it was okay and i honestly didn't resent it . Sorta like a tithe , helps out your own .

At its creation SS payments were supposed to be for *your* retirement, not another's. Most still consider SS to be a pension system in that form. What you describe is more like a ponzi scheme, given SS now takes in less than it pays out.

http://www.healthpaconline.net/health-care-statistics-in-the-united-states.htm

You take those overhead figures as accurate, as in they are comparing like to like? Why?
http://www.forbes.com/sites/aroy/2011/06/30/the-myth-of-medicares-low-administrative-costs/

our aim is to ... advocate universal health care for all Americans.

http://www.masscare.org/wp-content/uploads/2007/04/HospitalBilling&AdminUSvsCanada.jpg

Mass-Care’s mission is to establish a Single Payer Health Care System...

 

[Evo]

At its creation SS payments were supposed to be for *your* retirement, not another's. Most still consider SS to be a pension system in that form. What you describe is more like a ponzi scheme, given SS now takes in less than it pays out.

You do realize that SS pays survivor benefits. If a person dies, as long as they have had a job that paid SS, their spouse and children get a large monthly payment. Even if they have paid virtually nothing into SS. I disagree with this part.

http://www.ssa.gov/survivorplan/index.htm

Also, SS pays people that are disabled. This I can understand, although fraud is rampant.

SS is not just retirement.

 

[ThinkToday]

I'm a little skeptical of that number. That doesn't even seem enough to pay the nurses and technicians, never mind the cost of purchasing and maintaining the machine, the cost of the facility it's in, cost of insurance, etc.

Edit: It occurs to me that $50 may refer to the incremental cost, after fixed costs like purchasing/maintenance/facilities/insurance are taken out. If that's the case, then it's a little more believable, but a less relevant number.

In our case, the $50 is the co-pay, and yes, it only applies to the technical component of the bill. The professional component is a different bill, unless it's a global bill. If the interpreting physician is a hospitalist employed by the hospital, the exam is billed as a global charge (bundles the technical and professional charges). Specialists have a higher co-pay than a GP. I think the GP co-pay was something like $10, the specialist co-pay was $50. Hospitals with HMOs, PPOs, etc. get the balance from the insurance. So, the exam isn't just $50; rather, that's all it costs us.

The hospital I'm in now has no co-pay for some things, as long as we use their clinic.

 

[mheslep]

You do realize that SS pays survivor benefits. ...

Yes, and disability. I have a family member on SS disability.

 

[nitsuj]

nitsuj - could you point me to something on those limits? Might calm me down a bit.

old jim

I heard it in the Obama address after the ruling. It was the video in the link provided in the OP.

 

[jim hardy]

What you describe is more like a ponzi scheme, given SS now takes in less than it pays out.

Presidents are required by law to review SS and report to congress how things are going. Recall when Bush did that and suggested something needed to be done he was excoriated by the left.
If you go back and read the late 1930's federal register entries , there are two interesting things that show up:
1. Original intent was to invest in interest bearing securities. It took congress less than a year to recognize the bonanza they'd created and change it to "pay as you go" spending the copious leftovers. You won't find that on SS's website in fact they deny it.
2. The administrators figured out by 1940 (dont ask me how) that around 2020 SS would cease to be a profit maker.

So SS is and has been a ponzi scheme for seventy plus years and TPTB cannot say "We never saw it coming".. This lays right at congress' doorstep.

...

You take those overhead figures as accurate, as in they are comparing like to like? Why?
http://www.forbes.com/sites/aroy/201...trative-costs/

Indeed i do.
Look at the last chart in the Forbes article.
It shows that Medicare delivered $8500 of treatment for $509, 5.8%,(2005)
while private delivered perhaps $3500 for $ 453, 13.2%.

It is somewhere between bad arithmetic and sophistry to claim 13% is more efficient than 6%.
By Mr Roy's logic, one should ship by trailer truck instead of rail because the fuel cost is spread out over many trucks instead of one locomotive.
Further Mr Roy's article in Forbes is a near bolt-for-bolt copy of this Hertiage Foundation article two years earlier, whose author Roy mentioned (Robert Book)
http://www.heritage.org/research/re...e-higher-not-lower-than-for-private-insurance
observe the chart is identical and content is on same compass heading.

Note i did take your remark to heart and looked into it a little.
When i saw Heritage Foundation my eyebrows raised, they have been dunning me to join ever since i wrote my senator blasting her for supporting Obamacare as written(namely by the insurance lobby, Cigna to be specific, see PBS Frontline episode "Obama's Deal".)
From Heritage Foundation's homepage:

Our mission is to formulate and promote conservative public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values, and a strong national defense.

I believe Heritage Foundation is probably as unbiased and unlikely to spin facts as Sean Hannity or Thom Hartmann.

But, Heritage's Mr Book in turn used this 2007 article for a reference:

http://www.manhattan-institute.org/html/mpr_05.htm

and among its conclusions:

For the private market, non-benefit costs are about 11-14 percent of total premiums, while the direct administrative costs reported for Medicare are about 3 percent of Medicare outlays. A reasonable allocation of a share of outlays for general government functions and for the administration of justice increase direct and indirect administrative—that is, non-benefit—outlays as reported in the federal budget to about 6 percent of Medicare outlays.

Interestingly that author

Benjamin Zycher
Senior Fellow, Manhattan Institute for Policy Research

estimates Medicare admin at 5-6% as do both subsequent authors.
He suggests that deregulation would be the way to go.

To me, deregulation means un-entwining the industry from government.
And that's the drum i am pounding.


old jim

 

[mheslep]

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

You take those overhead figures as accurate, as in they are comparing like to like? Why?
http://www.forbes.com/sites/aroy/201...trative-costs/

Indeed i do.
Look at the last chart in the Forbes article.
It shows that Medicare delivered $8500 of treatment for $509, 5.8%,(2005)
while private delivered perhaps $3500 for $ 453, 13.2%.
It is somewhere between bad arithmetic and sophistry to claim 13% is more efficient than 6%

First: Do you concede the 23% figure you referenced earlier for private insurance is way high, or not? That the 3% you referenced for Medicare is way low, or not?

Second:

.

By Mr Roy's logic, one should ship by trailer truck instead of rail because the fuel cost is spread out over many trucks instead of one locomotive.

I do not think such is the logic proposed by Roy or his sources. That aside, I note there are different different figures of merit for overhead costs. One method I grant is overhead per treatment dollars spent. Another is overhead dollars spent per patient, in this case $509/patient for Medicare and $453/patient for private insurance according to the article. Are you dismissing the latter as irrelevant? While I don't know for a fact that the latter per patient figure is the most important, I surely do not dismiss it.

Forbes-Roy/Book make the case (with sources) that Medicare spends more treatment dollars per patient because it attends to the elderly who have higher medical costs:

...because Medicare patients are older, they are substantially sicker than the average insured patient — driving up the denominator of such calculations significantly.

I don't know how all the admin costs are spent with either system, though I have some insights. But consider the naive case that most all the costs are up front in the initial admission of the patient to the system, e.g. say for computer system costs that are all per patient, with a negligible difference in computer system cost between patients that are in/out in one day and another with three years of cancer treatment. IF such an assumption was valid, then the financial consequences of moving the entire US health system to 100% Medicare (single payer) would mean an *increase* in overhead costs, not a decrease.

Further Mr Roy's article in Forbes is a near bolt-for-bolt copy of this Hertiage Foundation article two years earlier, whose author Roy mentioned (Robert Book)
http://www.heritage.org/research/re...e-higher-not-lower-than-for-private-insurance
observe the chart is identical and content is on same compass heading.

Note i did take your remark to heart and looked into it a little.
When i saw Heritage Foundation my eyebrows raised, they have been dunning me to join ever since i wrote my senator blasting her for supporting Obamacare as written(namely by the insurance lobby, Cigna to be specific, see PBS Frontline episode "Obama's Deal".)
From Heritage Foundation's homepage:

I believe Heritage Foundation is probably as unbiased and unlikely to spin facts as Sean Hannity or Thom Hartmann.

Heritage is a think tank, they like anyone can be wrong, and they have a politically conservative view point. They also have a large staff of experts that publish frequently and testify in Congressional hearings, like a Brookings, like a Cato. You think that's the same as a TV talking head? That said, we're not asked to trust simply reputation as references are provided. Some of the key figures are taken directly from CMS accessible references [7] and [8].

...
[6]Benjamin Zycher, "Comparing Public and Private Health Insurance: Would a Single-Payer System Save Enough to Cover the Uninsured?" Manhattan Institute for Policy Research, October 2007, at http://www
.manhattan-institute.org/html/mpr_05.htm (June 25, 2009); Mark E. Litow, "Medicare Versus Private Health Insurance: The Cost of Administration," Milliman, Inc., January 6, 2006; at http://www.cahi.org/cahi_contents/
resources/pdf/CAHIMedicareTechnicalPaper.pdf (June 25, 2009).
[7]Centers for Medicare and Medicaid Service, "National Health Expenditure Accounts," Table 12, at http://www.cms.hhs.gov/NationalHealthExpendData/
downloads/tables.pdf (June 25, 2009).
[8]Centers for Medicare and Medicaid Services, "Justification of Estimates for Appropriations> Committees, Fiscal Year 2009," February 2008, p. 27, at /static/reportimages/542AA7F3C79882DB4513785E91472515.pdf (June 25, 2009)...

One other point: I don't see the issue of fraud mentioned in either article, but I expect it figures heavily off the books. According to the current US Attorney General, Medicare fraud is in the tens of billions of dollars per year. If Medicare is doing less than due diligence with respect to fraud, that fact might explain why some report Medicare billing practices to be easier than those of private insurers. Regardless of the reason, I suggest fraud dollars should be counted towards Medicare admin costs.

 

[ThinkToday]

First: Do you concede the 23% figure you referenced earlier for private insurance is way high, or not? That the 3% you referenced for Medicare is way low, or not?

http://www.factcheck.org/kerry_paperwork_ad_accurate.html The range of the paperwork cost in the NE Journal of Medicine study are 7.6%-31%. However, as noted in the article, it's unlikely a reliable estimate is achievable. For example, paperwork includes admission papers, pre-authorization, examination paperwork (dictations, etc.) required for the doctor to get paid, paperwork to get lab work down, paperwork to get x-rays done, insurance billing paperwork, appeals (seems like something is always getting rejected or questioned), resubmissions, etc. We have some serious documentation requirements that must be met to get paid.

It's kind of funny. I remember when I was very young going to the doctor. My "file" was a small stack of 4x6 index cards with a date, what I had (cold, flu, broken finger), what was done/given, and a notation of the charge (usually $5). Each time I saw the doctor, it added 1 or 2 lines to my "medical record", when one side of the card was full, he wrote on the other side, when the card was full on both sides, I got another 4x6 card added to the pack. Over the past 5 decades, I see little improvement in basic care, yet cost and paperwork are through the roof. As a parent that has taken my children to the doctor many times, the reasons I go are largely the same as they were 5 decades ago, it just costs more, takes longer, more paperwork, etc., and doctors still treat the same things the same old ways. Not much is any more high tech than it was back then for most things I needed them for.

 

[jim hardy]

First: Do you concede the 23% figure you referenced earlier for private insurance is way high, or not? That the 3% you referenced for Medicare is way low, or not?

no, not at all to both.
Figures are adjusted by individual authors to suit their hypoththeses.
But i'll allow that they could represent upper and lower bounds of reasonable estimates.

I do not think such is the logic proposed by Roy or his sources. That aside, I note there are different different figures of merit for overhead costs. One method I grant is overhead per treatment dollars spent. Another is overhead dollars spent per patient, in this case $509/patient for Medicare and $453/patient for private insurance according to the article. Are you dismissing the latter as irrelevant?

irrelevant to discussion of efficiency, yes. It's an interesting statistic though.
IIRC the $509 includes an apportioned part of gov't's cost to collect taxes which, i believe is not correct. IRS is incredibly efficient and would exist irrespective of Medicare. So if Medicare does drive up cost of tax collection it's not significant and probably immeasurable.

Heritage is a think tank, they like anyone can be wrong, and they have a politically conservative view point. They also have a large staff of experts that publish frequently and testify in Congressional hearings, like a Brookings, like a Cato. You think that's the same as a TV talking head?

Ahh exaggeration is sometimes a useful tool of communication. And i didn't mean to disrespect the highbrow world of think tanks.

But it is their mission to influence public thought and government policy.
To a considerable extent they propagandize
and the talking heads are by and large their useful idiots.

Reading Eric Hoffer's "True Believer" changed how i look at mass media. That book is a study of mass psychology and how one can manipulate it, and how it was done in 1930's Europe. When you go to those thinktank websites and look at who's their directors it becomes apparent they all have a mission. Well the ones i have checked into, anyhow. I don't remember looking into that Manhattan Institute.

So i try to take in a variety of news sources and take just their observations, make my own conclusions.
Had you told me when i was a kid i'd be watching Russia Today's newscasts (280 on Dish) and finding their coverage superior , i'd have beaned you.
But their proselytizing is as flagrant as FoxNews.

old jim

 

[BobG]

I do think putting some limits on the Commerce Clause is a good idea.

Inherently, an individual mandate forcing people to buy insurance should be unconstitutional. Historically, cases such as Gonzalez vs Raich and Wickard vs Filburn seemed to make it unlikely the court would strike down the individual mandate. Historically, Congress has been able to use the Commerce Clause to do whatever it darn well pleases.

If the Commerce Clause allows the federal government to overrule state laws on medical marijuana for private consumption and allows the federal government to outlaw growing wheat for private consumption (by the growers' chickens), then it seems like the Commerce Clause can pretty much control anything.

I think an individual mandate is unconstitutional, but I'm still surprised the court said it was unconstitutional.

Or, in a more cynical vein, does this precendent only apply when an alternative justification for action is available, such as calling it a tax - an option that would have been impossible in the medical marijuana and the wheat for chickens cases?

A lot of times, it seems like justices decide on a decision and then search for legal justification rather than start with a set of legal principles that apply to a case no matter where that leads (both Kennedy and Scalia switched from the pro-Commerce Clause position they held in Gonzalez vs Raich to an anti-Commerce Clause postion).

I'm less convinced with their argument on Medicare, even though I think limiting Congress's use of federal funds to force states to adopt federal 'suggestions' is also a good idea. The proper solution for the problem is to reduce federal taxes, increase state taxes, and let states handle more issues on their own; not declare the practice unconstitutional (which I don't think it is). And in this case, Medicare is a federal program (rightly or wrongly) and I would think the federal government is perfectly within its right to set the rules.

I'm really surprised that went down 7-2.

 

[Windowmaker]

What happens if the family of four makes like 40,000 a year and don't have insurance? Do they get subsidized insurance premiums or tax credits?

http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/General%20DHS/FPL.pdf

This means at 130 percent above the poverty line a family of 4 is just below 30,000. So at 133 percent would mean almost at 30k a year. What if a family of four makes 32000 a year? If both parents are working, they are each earning 16000 a year. That's about 8.33 an hour, doubt they have benefits or work at a large company.

Sounds like a tax increase to me.

 

[Evo]

What happens if the family of four makes like 40,000 a year and don't have insurance? Do they get subsidized insurance premiums or tax credits?

http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/General%20DHS/FPL.pdf

This means at 130 percent above the poverty line a family of 4 is just below 30,000. So at 133 percent would mean almost at 30k a year. What if a family of four makes 32000 a year? If both parents are working, they are each earning 16000 a year. That's about 8.33 an hour, doubt they have benefits or work at a large company.

Sounds like a tax increase to me.

Here you go, the information on the act. Instead of guessing you can actually read it.

http://www.healthcare.gov/law/full/index.html

You do know that what you are referring to is "medicaid" which is handled differently by each state. Under the ACA, many more people will be eligible for medicaid than before. And yes, if they work, but can't afford premiums, they will get subsidies.

Consumers

Although "nothing will change tomorrow," some consumers will see big changes by Jan. 1, 2014, when more aspects of the law take effect, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. Those changes include:

•Insurers will no longer be allowed to turn anyone down because of a pre-existing medical condition, such as cancer, Pollitz says.

•More patients will be eligible for Medicaid, a federal insurance program administered by the states that serves the poor and disabled. Today, people can qualify for Medicaid only if they are poor, pregnant , disabled or a child. Each state sets different financial standards to qualify for Medicaid, and some states have required that people be not just poor but "subpoor," with incomes substantially below the federal poverty level.

By 2014, however, people will become eligible for Medicaid based only on their incomes, Pollitz says, meaning single adult men with incomes up to 130% of the federal poverty level will also qualify.

•Also by 2014, the "working poor" — many of whom are eligible for employer-sponsored health care but can't afford the monthly premiums — will be eligible for subsidies to help them pay for their health insurance, said Mary Grealy, president of the Healthcare Leadership Council.

•Federal standards for health insurance plans will eliminate "junk" plans with huge deductibles that provide little to no real benefits for consumers, Pollitz says. That means consumers will have more confidence that any plan they buy on the private market will provide at least a minimum standard of quality that includes drug coverage, hospital care, maternity care and other essentials.

http://www.usatoday.com/money/indus...6-28/health-care-ruling-whats-next/55900370/1

 

[Alfi]

What happens if the family of four makes like 40,000 a year and don't have insurance? Do they get subsidized insurance premiums or tax credits?

http://www.dhs.ri.gov/Portals/0/Uploads/Documents/Public/General%20DHS/FPL.pdf

This means at 130 percent above the poverty line a family of 4 is just below 30,000. So at 133 percent would mean almost at 30k a year. What if a family of four makes 32000 a year? If both parents are working, they are each earning 16000 a year. That's about 8.33 an hour, doubt they have benefits or work at a large company.

Sounds like a tax increase to me.

That's about 8.33 an hour, doubt they have benefits or work at a large company.

back this up ... please ... it would be a good point.