Slightly Skeptical View on Health insurance

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It's hard to find products, services and companies that provide honest health service, good monitoring devices and, in general, quality products. This is especially true about medical insurance. Everything (or almost everything is spoiled by obsessive, destructive marketing). Not only USA health system is drug obsessed and test driven to the extent that serious mistakes are possible, it is based of strange symbiosis between doctors and health insurance companies in which each party tries to fool the other. In addition, many doctors became more pharmacy salesmen then real health specialists.  This father complicates the picture. 

In fact, anybody with health problems need to participate in complex poker match between insurance and doctors where you just a minor card.  There are several dangers here

Distortions created by the US healthcare model

This is a very complex issue but some visible problems are as following:

None of these key issues is addressed by the new legislation, hence the support from the Pharmaceutical Companies and Insurers. Nothing will change and the US will continue to pay double the share of GDP with worse outcomes in comparison to other developed countries.


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[Apr 05, 2019] Pelosi Accused of Deploying 'Most Dishonest Argument' Against Medicare for All by Jake Johnson

Pelosi: Sock Puppet For the Insurance Industry
Apr 05, 2019 | www.commondreams.org
described as "probably the most dishonest argument in the entire Medicare for All debate."

"People who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time. It is a complete nightmare."
-- Matt Bruenig, People's Policy Project

In an interview with the Washington Post , the Democratic leader said she is "agnostic" on Medicare for All and claimed, "A lot of people love having their employer-based insurance and the Affordable Care Act gave them better benefits."

Matt Bruenig, founder of the left-wing think tank People's Policy Project, argued in a blog post that Pelosi's statement "implies that, under our current health insurance system, people who like their employer-based insurance can hold on to it."

"This then is contrasted with a Medicare for All transition where people will lose their employer-based insurance as part of being shifted over to an excellent government plan," Bruenig wrote. "But the truth is that people who love their employer-based insurance do not get to hold on to it in our current system. Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare."

To illustrate his point, Bruenig highlighted a University of Michigan study showing that among Michiganders "who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months.

"This means that 28 percent of people on an employer plan were not on that same plan one year later," Bruenig noted.

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"Critics of Medicare for All are right to point out that losing your insurance sucks," Bruenig concluded. "But the only way to stop that from happening to people is to create a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that. Our current system offers the exact opposite. If you like losing your insurance all the time, then our current healthcare system is the right one for you."

All On Medicare -- a pro-Medicare for All Twitter account -- slammed Pelosi's remarks, accusing the Democratic leader of parroting insurance industry talking points:

The Speaker's alternative to the Medicare for All legislation co-sponsored by over 100 members of her caucus is a bill to strengthen the Affordable Care Act (ACA), which she introduced last week .

"We all share the value of healthcare for all Americans -- quality, affordable healthcare for all Americans," Pelosi told the Post . "What is the path to that? I think it's the Affordable Care Act, and if that leads to Medicare for All, that may be the path."

The nation's largest nurses union was among those who expressed disagreement with the Speaker's incrementalist approach.

In a statement last week, National Nurses United president Zenei Cortez, RN, said Pelosi's plan would "only put a Band-Aid on a broken healthcare system."

"National Nurses United, along with our allies, will continue to build the grassroots movement for genuine healthcare justice and push to pass Medicare for All," Cortez concluded.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

[Mar 25, 2019] 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

Highly recommended!
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%.

[Mar 21, 2019] We can spend endless amounts of money on the NSA, wars overseas, political campaigns and bailing out banks, tha we canaffort single payer healthcare system

Highly recommended!
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.

[Mar 05, 2019] On origin of the phase There ain't no such thing as a free lunch

Mar 20, 2017 | economistsview.typepad.com

RC AKA Darryl, Ron -> mulp ... "...TANSTAAFL" March 20, 2017 at 04:59 AM

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

"There ain't no such thing as a free lunch" (alternatively, "There is no such thing as a free lunch" or other variants) is a popular adage communicating the idea that it is impossible to get something for nothing.

The acronyms TANSTAAFL, TINSTAAFL, and TNSTAAFL, are also used. Uses of the phrase dating back to the 1930s and 1940s have been found, but the phrase's first appearance is unknown.[1]

The "free lunch" in the saying refers to the nineteenth-century practice in American bars of offering a "free lunch" in order to entice drinking customers.

The phrase and the acronym are central to Robert Heinlein's 1966 science-fiction novel The Moon Is a Harsh Mistress, which helped popularize it.[2][3]

The free-market economist Milton Friedman also popularized the phrase[1] by using it as the title of a 1975 book,[4] and it is used in economics literature to describe opportunity cost.[5]

Campbell McConnell writes that the idea is "at the core of economics".

[I was a bigger fan of Robert Heinlein's than I was of Milton Friedman and even then it was "Stranger in a Strange Land" and "The Unpleasant Profession of Jonathan Hoag" rather than later works that appealed to me.]

[Feb 26, 2019] It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures.

Feb 26, 2019 | www.unz.com

Bragadocious , says: February 26, 2019 at 2:49 pm GMT

@animalogic I don't know if you live in the US, sounds like you don't, but one could argue that the healthcare system has already been nationalized. Consumers must shop for policies that meet Obamacare standards which include coverage for gender reassignment and other things that 10 years ago no private insurer would dream of paying for. This is a direct result of government's boot on the market's throat. (And the market likes it, based on HMO stock prices)

It is illegal for any insurer to offer a bare bones catastrophic plan that doesn't cover Obama's hopey-changey list of progressive surgical procedures. 15 years ago, those catastrophic plans were everywhere, and very affordable.

And to your point about providing healthcare to people who can't afford it. We already have that, it's called Medicaid. When those receiving it die, the government comes in and grabs all of their estate's assets, because they used a government program that was forced on them. Like I said, it's been taken over.

[Feb 22, 2019] How Stupid Do They Think We Are - Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo

Notable quotes:
"... I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement). ..."
"... Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay. ..."
Feb 22, 2019 | www.nakedcapitalism.com

How Stupid Do They Think We Are? – Plutocrats Using Logical Fallacies to Defend the Health Care Status Quo Posted on February 22, 2019 by Yves Smith By Roy Poses , MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal

In the early 21st century, the debate about health care reform in the US ramped up. The result ultimately was the Patient Protection and Affordable Care Act (PPACA, ACA, "Obamacare"), which arguably improved access to health care, made some reforms in the regulation of health care insurance, but did not affect the fundamental reliance of the US on employer-paid, for-profit health care insurance to finance health care for many patients. Nor did it really affect the issues we discuss on Health Care Renewal (look here for details).

After the tumultuous election of President Donald Trump, the debate started up again with his and his party's attempt to "repeal and replace" Obamacare. Arguably, Obamacare ended up damaged but not repealed. Once again, the issues we discuss on Health Care Renewal were ignored, including threats ot the integrity of the clinical evidence base, deceptive marketing, distortion of health care regulation and policy making, bad leadership and governance, concentration of power, abandonment of health care as a calling, perverse incentives, the cult of leadership, managerialism, impunity enabling corrupt leadership, and taboos, or the anechoic effect. (Look here for a detailed discussion. )

It is time once again to discuss health care reform in the US. Now the push is from the Democrats and the left, with the stated goals of making care more universal, and perhaps decreasing or even ending the role of for-profit commercial health care insurance companies.

It is no surprise that those who benefit the most from the current system (even as modified by Obamacare) are rushing to its defense.

Dark Money to Defend Commercial Health Insurance

We already discussed how large health care corporations, including pharmaceutical and biotechnology companies, have been using dark money to funnel money for distinctly partisan purposes, to defeat whom they perceive as too left-leaning politicians, almost all Democrats. They seem to fear such politicians might promote health care reform efforts that would be based on "anti-free-market, anti-business ideology," that is efforts to decrease the role of commercial, for-profit health insurance in financing health care.

More recently, the focus has shifted to Democratic proposals for government run single-payer, or "Medicare for all" health insurance. In early January, 2019, the Hill reported

Thomas Donohue, the president and CEO of the Chamber of Commerce, on Thursday vowed to use all of the Chamber's resources to fight single-payer health care proposals.

'We also have to respond to calls for government-run, single-payer health care, because it just doesn't work,' Donohue said during his annual 'State of American Business' address.

The US Chamber of Commerce historically has had many executives of big health care corporations on its board. We listed 10 such members in 2015. It also historically has received financial support from some corporations. We listed 17 in 2018.

Then later in January, The Hill reported that a group called Partnership for America's Health Future started digital ads attacking "Medicare for All." The Hill stated its

members include major industry players such as America's Health Insurance Plans and the Pharmaceutical Research and Manufacturers of America

So here we have the leaders of big health care corporations funneling corporate money into propaganda campaigns to defeat government run single payer health insurance, an old policy idea that suddenly is looking politically credible. Current US regulation and practice allows them to hide the exact amounts spent on such campaigns by processing them through dark money organizations.

Such stealth health policy advocacy is now not new. What is surprising now is how some top leaders are willing to jump into the debate themselves, rather than just trying to manipulate public opinion through public relations/ propaganda proxies. Here are some telling examples. in chronological order.

Quest Diagnostics CEO Attacks "Medicare-for-All" Using an Appeal to Authority, an Argument by Gibberish, the Non Sequitur Fallacy, (and an Incomplete Comparison)

On January 24, 2019, Yahoo Finance reported

A top health care CEO is sounding the alarm on 'Medicare for All,' an idea gaining steam in political circles, including from newly-elected Rep. Alexandria Ocasio-Cortez (D-NY).

' Most people don't understand the basics of health-care economics in the United States ,' said Steve Rusckowski, chairman & CEO Quest Diagnostics (DGX), in an interview with Yahoo Finance editor-in-chief Andy Serwer at the World Economic Forum in Davos, Switzerland .

Mr Rusckowski implied that he knows a lot more about health care economics than most people, so most people should listen to him. Thus, he began with an implied logical fallacy, the appeal to authority .

He then presented the justification for his argument.

'The majority of people get their health care from their employers, and the majority of healthcare costs are paid by employers and employees,' he said. 'If you look at the $3.5 trillion spent on healthcare costs, that portion is actually funding the Medicare and Medicaid programs throughout this country.'

The syntax was fractured, and so this was incoherent and confusing. In particular, it was not clear to what "this portion" referred. $3.5 trillion? Health care costs paid by employers and employees?

The context of his use of that phrase did not help. Note that US total health spending was reported to be approximately $3.5 trillion in 2017 by the US Center for Medicare and Medicaid Services (CMS) . However, that was total health spending, not just the amount spent by Medicare and Medicaid. Furthermore, Medicare and Medicaid are funded by sources other than employers and their employees. While employers and employees pay tax on employee income to fund Medicare, general funds from the federal government, and from state governments funds Medicaid. Furthermore, many employers pay parts of their employees' private health insurance premiums, while the employees make up the difference in premiums. Self-employed people may may for their own insurance, etc, etc.

Mr Ruskcowski, not to put to fine a point on it, seemed to speaking gibberish, and would use this gibberish to justify his next point. So in formal terms, he used the logical fallacy of an argument by gibberish .

When incomprehensible jargon or plain incoherent gibberish is used to give the appearance of a strong argument, in place of evidence or valid reasons to accept the argument.

In any case, Mr Rusckowski went on to argue that he

remained skeptical of a Medicare-for-all plan funded by corporations and employees. ' I don't think [corporations and employees] can afford to provide that access as described.'

However, not only were his earlier statement gibberish, they were not clearly arguments in support of his contention that corporations and employees cannot "afford to provide that access as described." So this appeared to be an example of the logical fallacy of the non-sequitur .

Mr Rusckowski's total compensation as CEO of Quest was over $10 million in 2017, as estimated by Bloomberg News . So it is perhaps not surprising that is self-interest in preserving the status quo was strong enough to motivate him to jump into the debate. One would think, however, that someone who managed to become a rich CEO of a medical diagnostic company could manage to be a bit more logical.

Anyway, he has some strange bed-fellows in this cause, including two billionaires who are not directly involved in health care corporations, but who have obviously benefited from the current economic status quo.

Michael Bloomberg and Howard Schultz Used the Incomplete Comparison Fallacy

Two billionaires provided striking examples of one logical fallacy.

First, from t he New York Times, January 29, 2019 :

Mr. Bloomberg, the former New York City mayor who is considering a 2020 bid on a centrist Democratic platform, rejected the idea of 'Medicare for all,' which has been gaining traction among Democrats.

'I think you could never afford that. You're talking about trillions of dollars ,' Mr. Bloomberg said during a political swing in New Hampshire, which holds the nation's first primary in 2020.

'I think you can have 'Medicare for all' for people that are uncovered,' he added, 'but to replace the entire private system where companies provide health care for their employees would bankrupt us for a very long time .'

Second, from CNN on January 30, 2019 :

'Why do you think Medicare-for-all, in your words, is not American?' CNN's Poppy Harlow asked Schultz on Tuesday.

'It's not that it's not American,' Schultz said. ' It's unaffordable .'

'What I believe is that every American has the right to affordable health care as a statement,' Schultz said, lauding the Affordable Care Act, otherwise known as Obamacare, as 'the right thing to do.'

He added, 'But now that we look back on it, the premiums have skyrocketed and we need to go back to the Affordable Care Act, refine it and fix it.'

He argued that the Democratic progressive platform of providing Medicare, free college education and jobs for everyone is costly and as 'false as President Trump telling the American people when he was running for president that the Mexicans were going to pay for the wall.'

So both billionaire Bloomberg and billionaire Schultz stated that Medicare-for-all would cost too much. Yet neither addressed how much our current health care system costs. However, as a subsequent op-ed in the Washington Post by Paul Waldman pointed out, it only makes sense to talk about affordability in the context of a comparison with a reasonable alternative, say, the current health care system:

there is one thing you absolutely, positively must do whenever you talk about the cost of a universal system -- and that journalists almost never do when they're asking questions. You have to compare what a universal system would cost to what we're paying now.

there have been some recent attempts to estimate what it would cost to implement, for instance, the single-payer system that Sen. Bernie Sanders (I-Vt.) advocates; one widely cited study, from a source not favorably inclined toward government solutions to complex problems, came up with a figure of $32.6 trillion over 10 years.

That's a lot of money. But you can't understand what it means until you realize that last year we spent about $3.5 trillion on health care, and under current projections, if we keep the system as it is now, we'll spend $50 trillion over the next decade.

Again, you can criticize any particular universal plan on any number of grounds. But if it costs less than $50 trillion over 10 years -- which every universal plan does -- you can't say it's 'unaffordable' or it would 'bankrupt' us, because the truth is just the opposite.

These are text-book examples of the fallacy of incomplete comparison .

By the way, buried amongst his use of gibberish and non-sequiturs, Quest Diagnostics CEO Rusckowski also opined that Medicare-for-all would be unaffordable without any reference to the costs of the status quo, and hence also provided an example of an incomplete comparison.

The Waldman op-ed noted

The fact that these two highly successful businessmen -- whose understanding of investments, costs and benefits helped them become billionaires -- can say something so completely mistaken and even idiotic is a tribute to the human capacity to take our ideological biases and convince ourselves that they're not biases at all but are instead inescapable rationality.

Maybe. However, it may also be a tribute to their arrogance bred by decades of public relations (which Bernays thought sounded better than "propaganda ") and disinformation meant to soften up the minds of the public so that they will follow the lead of the rich and powerful.

Schultz Also Added an Appeal to Tradition (or to Common Practice)

Also on January 29, the Washington Post reported that

Schultz referred to a town hall hosted Monday night by CNN in which Harris embraced a 'Medicare-for-all' single-payer health insurance system and said she would be willing to end private insurance to make it happen.

'That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

' That's not correct. That's not American ,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

Presumably, by saying "that's not American," Schultz means that is not what we have always done, that is not what has been traditional American practice, begging the question of whether that practice could be ill-advised. Thus Schultz appeared to ladle on an appeal to common practice, otherwise known as an appeal to tradition .

As an aside, the quote also suggests that Schultz's real concern is not with the affordability of Medicare-for-all, particularly in comparison with that of the current system, but with the financial health of the insurance industry. But that is for another day .

Summary

So, to protect against the dread "Medicare for all," that is, proposals for a government single-payer health insurance system to replace our current practice of financing health care through large, mainly for-profit insurance companies, we see an acceleration of public relations/ propaganda paid by undisclosed donors, that is, via dark money. We also see prominent multi-millionaire and billionaire executives laying down a barrage of logical fallacies to support the status quo.

It is hard to believe that the defenders of the current system are not mostly self-interested. That status quo has made some people very rich.

It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

In 2011, we wrote ,

Wendell Potter, author of Deadly Spin , has provided a chilling picture of health care corporate disinformation campaigns and the tactics used therein.

In particular,

Mr Potter recounted how deceptive PR campaigns subverted the health care reform plans of US President Bill Clinton, reduced the impact of Michael Moore's movie, 'Sicko,' and helped to remodel the recent health care reform bill to reduce its threat to commercial health insurers. He further noted how PR distracted public attention from the growing faults of a health care system based on commercial health insurance, and how practical and legal safeguards against abuses by insurance companies were eroded.

Furthermore, Mr Potter

described 'charm offensives;' the deliberate creation of distractions, including the planting of memes for short-term goals that went on to have long-term adverse effects; fear mongering; the use of front groups, including 'astroturf,' (faux disease advocacy and/or grass roots organizations), public policy advocacy groups, and tame (and conflicted) scientific/professional groups; and intelligence gathering. He provided some practical advice for detecting such tactics. For example, be very suspicious of policy advocacy by groups with no apparent address or an address identical to that of a PR firm, or with anonymous leaders and/or anonymous financial backing.

Now it is 2019, once again health care reform is in the air, and once again the defenders of the status quo are hard at work. Now, they are even wealthier than they were 10 years ago, and have even more sophisticated tools, like social media and its hacks, at their disposal. Still, however, their arguments are ultimately built on sand.

As I did in 2011 , it makes sense to quote Wendell Potter

onslaught drastically weakened health-care reform and how it plays an insidious and often invisible role in our political process anywhere that corporate profits are at stake , from climate change to defense policy.
[Potter, Huffington Post]

So,

The onslaughts of spin will not stop, the distortions will not diminish, and the spin will not slow down. To the contrary, spin begets spin, as the successes of corporate PR functionaries increase the revenues of their employers, further funding their employers' efforts to create a more hospitable climate for their business interests. Americans are thus being faced with increasingly subtle but effective assaults on their beliefs and perceptions. Their best defense right now is to understand and to recognize the sophisticated tactics of the spinners trying to manipulate them.

Most important is a singular mandate: Be skeptical .
[Potter, Huffington Post]

I still hope that summarizing some of Mr Potter's amazing points will help us all to be much more skeptical.

You heard it here first.


Disturbed Voter , February 22, 2019 at 4:26 am

Can any system of incentives work, for both the patients and the care providers? The tendency is for patients to seek professional help over over-the-counter remedies when it is unnecessary (hypochondria) and for care providers to over-test and over-medicate (avoid malpractice and promote snake oil). Either you use market-based incentives or bureaucratic incentives. And the bureaucratic incentive can be public or outsourced to commercial enterprise. There is no spontaneously self regulating system, it has to be designed-in.

Yves Smith Post author , February 22, 2019 at 6:26 am

Bullshit. Every other advanced economy had a fully or heavily government funded system. Their costs are 50-60% in GDP terms compared to ours with generally better health outcomes.

Hypochondria is present in only 1-5% of the population. That isn't a "tendency". The overtesting is due mainly to bad norms and bad economic incentives like it being perceived to be normal to have an EKG every year with your annual physical (another questionable practice in healthy people) when only people at heart disease risk need an EKG. MDs own the EKG equipment, so this is a profit center for them. Similarly, I knew instinctively that annual mammograms and annual Pap smears were overkill and I'd refuse those tests and get lectured for that. My take has now been confirmed. But those MDs were driven by bad collective beliefs as to what good medical practice was at the time, and not some personal liability fear.

As for overprescribing, again my perception is that this is more patient that MD driven (save possibly for elderly people who tend where they should be taken off certain meds for a month or two and tested to see if they are still needed). You forget that Big Pharma now advertises on TV and tells patient to ask their doctors about their wares! But the real sins like prescribing antibiotics for flus comes (as in with other cases) with patients wanting the doctor to Do Something.

I lived in Australia and MDs were very much of the "let's monitor this" (as in do nothing right now) school, which says that patients are perfectly fine with that if the doctor seems confident and also make clear that he'll change course if warranted.

MDs ought to be allowed to prescribe placebos or aspirin at real med prices with some mystery med name and have the pharmacy plan quietly rebate virtually all the price months later for the patients with real problems where meds are indicated (the problem need to run its course and the most that is called for is palliatives).

Redlife2017 , February 22, 2019 at 6:54 am

+1000
From my own experience I completely agree. In particular with your point about the Doctors being in the "let's monitor this" school of thought outside of the US.

I've lived in the US and the UK for extended periods so can compare and contrast. I actually think that due to the structure of the US system that the US medical system builds a dependency on subscribing more and more drugs to people because MDs and pharmas get the money (not a shocking statement).

In the UK a doctor will never overprescribe – even if you want them to. It's just not a thing at all since there is no incentive except to be a, uh, doctor. They are trying to make sure you either get or stay healthy.

The system is built to make sure people have healthcare without weird profit incentives. They even have signs at the GP stating that if you have flu you should just rest, drink lots of fluids and stay home – don't get other people sick.

And to pre-empt someone noting that the NHS is having lots of problems – that is completely the choice of the current government (and the government in their ConDem days of 2010 – 2015). The NHS would be in much better shape if they

  1. stopped all the stealth privatisation (it's shocking what is going on) and
  2. just made sure local services were properly funded.

Amfortas the hippie , February 22, 2019 at 7:55 am

aye. the stealthy neoliberal colonisation of NIH, and all the scandinavian happy places is studiously ignored.

with my own experience with healthcare -- 6 1/2 years to get a hip to replace the literally dead one i was hobbling around on and now, all the time i've spent in and around the gleaming medical center for my wife's cancer .talking to all and sundry listing to all and sundry from wastrels at the bus stop to suits riding the elevator with me healthcare is a Right, dammit. there is no place at all for markets, privatisation or profit. it is immoral to profit off the suffering of a human being, period.

that moral argument is what will win the day even the suits acknowledge it, before passing off responsibility to the System("well, yes but we can't do anything, because the Great God Moloch must be appeased")

I am a sacrificial victim to that cruel deity. I'll be in pain for the rest of my life because i couldn't get timely care i still walk around on an ankle that is an enervated bag of gravel, since no ankle guys in texas take medicaid (and i'm kicked off that, now, too,lol)

I am thankful for my hip, hard won as it was. and i am more than grateful for the level of care my wife is getting but damn.

let these ceo's walk a mile or two in bloody shoes before they lecture about affordability and access.

their sin is gross indifference to suffering in the service of their own greed.
fie.

Susan the Other , February 22, 2019 at 12:18 pm

Exactly. The phrase "providing access" is nauseating. It really means "preventing access" unless you pay.

This is nothing more than an obfuscation of blatant extortion. Do any of these patriotic capitalists understand capitalism? I don't think so. Too much liike a priest understanding god. Is god otherwise unaffordable, if you don't have a pious priestly middleman to do spiritual arbitrage? For a small fee, of course.

They really do think we are stupid. But they forget The Reformation. There just comes a point in time when you can't politely ignore the lies and destruction. It takes on a life of its own and is unstoppable.

This post is encouraging because there is a guy out there named Roy Poses who is connected with something called Health Care Renewal and there is another guy, Paul Waldman who works for the WaPo; and we are reminded of the wonderful Mr. Wendell Potter. And a whole nation on the march. Hope your hip and your wife are feeling better.

GF , February 22, 2019 at 12:29 pm

Here's a retweet from Bernie about the latest big pharma price gouge:

"Bernie Sanders
‏Verified account @SenSanders
Feb 20

Bernie Sanders Retweeted CNN Health

Catalyst's decision to raise the price of a life-saving drug from $0 to $375,000 is causing patients to suffer and ration their medication. Outrageous! Catalyst must immediately lower the price of Firdapse."

PlutoniumKun , February 22, 2019 at 10:37 am

A relative of mine is actually nearly through research on exactly the topic of prescribing differences between Europe and the US. He says he found a very different culture among US doctors (if and when its published I'll certainly let Yves know, it might make an interesting article or link here).

As you and Yves says, there is very little evidence of overprescribing or overtreatment in 'free' or heavily subsidised health systems. On the contrary, there is evidence of massive overtreatment in the US for people willing to pay and / or with good insurance.

Here in Ireland there were problems in hospitals because it used to be free to be an out-patient, so the poor/hypochondriac, etc., would clog up waiting rooms instead of going to their local doctor where they would have to pay. They introduced a charge solely to stop this. It was crude, but it worked. It would of course have been much better to co-ordinate charges or put a better system in place to triage real patients from those who just want a bit of sympathy.

Most GP's will tell you that about 5% of their patients represent 90% of their workload. Some people either need lots of care, or they are just demanding and go to the doctor for every little ache and pain, while others practically have to have a limb falling off before they'd go. That's just the way it is, and all systems come up with ways to deal with it.

Nearly all doctors will give prescriptions even when not needed, because they know people feel better for it. The doctors I know invariably give mild painkillers on prescription for minor things like colds and backaches. Its really a form of acceptable placebo. I'm lucky to have a really good local doctor who runs a small team who are very firm on explaining to people why they don't always need treatment or prescriptions, even to the point of it being a little annoying sometimes – he refused to burn off a wart I had some time ago, telling me just to go to a pharmacy and buy an over the counter freeze tab. And when I had a diagnosis for mild arthritis in my hip he told me to walk lots and eat natural anti-inflammatory foods – again, no prescription, even something very mild. He seemed surprised that I didn't argue the point.

That said, being strict on prescriptions can backfire. I know of a young man who died from a rare bone cancer. He was from a very poor background and looked like a typical junkie – pale skin, skinny, Nike sweat pants (he wasn't, he just looked like one). His doctor thought he was trying to scam opiates and told him the pain was all in his head.

He was a little bit innocent and believed her.

It was when he literally collapsed while visiting his girlfriend in hospital that he was examined and diagnosed – it was too late by then.

Carla , February 22, 2019 at 12:05 pm

Yves, thank you so much for calling bullshit on Disturbed Voter's comment. After spending more than two decades as a single-payer supporter, I cannot improve upon your response.

Disturbed Voter , February 22, 2019 at 12:33 pm

i work in medicine, do you? Mind you, you can have single-payer or Medicare-for-all but it isn't free (not free in Cuba or other locations).

And medical care will always be triaged on some basis so expect delay or denial of care.

What you see is dishonest accounting, moving costs from one column to another, and hiding the change.

And providers won't work for free either, unless you intend to enslave them. I am happy France etc has good open access care. You might ask how that is done, it isn't magic. The answer is, they pay high taxes, and don't spend that on things they don't want (like endless warfare). As far as drug prices go, Americans subsidize the cheaper prices found elsewhere (not that I agree do this).

AdamK , February 22, 2019 at 12:35 pm

+100000. It is also very common to create a package of services that are provided by the government insurance and leave the rest to private insurance. This package is revised every few years according to scientific reviews and adds or drops services. Plastic surgeries are out unless there's significant affects to the person'e quality of life. If a patient is interested in an experimental, or not proven, innovation, he can shop for it himself as long as there's solution that is covered. The same way private insurance deals with such cases presently. As for meds, with big data you can pinpoint to a patient that over uses or a physician who over prescribes, and use this info for integrative medicine purposes to optimize the use of meds to better results. Those methods do not go well with the healthcare industry of course. No one now has an incentive to cut services or meds.

In general every method has it wastes and frauds which cannot be quantified in advance, the issue here isn't just cost, it is first and foremost MORAL.

Mark , February 22, 2019 at 6:04 am

As a non American, I find it quite bizarre when claims like this are made. Universal health care and free/affordable quality education is available in many countries that are far less prosperous than the United States.

If only the US could look outside it's bubble and take a few hints from how things are done elsewhere. However being the "leader" of the "free world" seems to make the USA blind to looking outside its own sphere for how things could be done better.

(Not that the US is alone here. But it probably is one of the stronger examples.)

notabanker , February 22, 2019 at 7:30 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

Americans do live in bubbles, and within the US there are bubbles, the country is so vast and it's media is captured. I find it encouraging when people like yourself speak up and call bullshit. I've seen some of Sanders healthcare threads on twitter completely ratio'd with Canadian, British and Aussie's calling BS on the US propagandists that try to attack their systems. We need more of that.

Kurtismayfield , February 22, 2019 at 9:49 am

The isolation that Americans live in is a problem when it comes to this. I use the Alice in Wonderland on the other side of the lookinglass metaphor frequently to describe my expat experiences. Being immersed in a different culture, you see first hand how 'normal' is so relative.

You have to consider their news sources as well.. my theory is that the only point of the 5 and 6 O'clock news is to feed into middle class anxiety or advertise a product. The corporate run media wants people scared and to buy buy buy. I would love to see a politician start a campaign where they discuss 20 different country's health care systems that are better and cheaper than ours, and see how deafening the silence will be from the corporate media.

As I have said here many times before, just get someone to propose the Swiss system . Anyone that argues that the Swiss are some bastions of communist thought can be laughed at entirely.

notabanker , February 22, 2019 at 11:36 am

I did mention the media being captured. And unlike the UK, there is no European influence to counter / add breadth to the BBC. Brits and Europeans have a far more global-centric view of things, if for no other reason than geography.

Phacops , February 22, 2019 at 10:01 am

Having to work in other countries provides a swift reality check regarding ways of social organization and doing things. I count such experiences as saving me from believing conservative propaganda here in the US.

notabanker , February 22, 2019 at 11:54 am

I am so very glad my kids spent crucial formative years outside of the US. It's the best possible gift I could have ever given to them.

Phacops , February 22, 2019 at 9:53 am

What do you expect for a people who actually hate to travel except for pre-programmed experiences or resorts walled off from the surrounding community? That, and the lack of adequate holiday time to even enjoy their own country. I don't wonder at the ignorance of the American public about better ways of providing human services and better health outcomes, though I think some such ignorance is deliberate.

Buzz , February 22, 2019 at 12:02 pm

How very, very true Mark. I've yelled and screamed this same meme over and over to no avail. Look around, we're not the only country on this planet and we DON'T always have the right answers !

Grant , February 22, 2019 at 12:40 pm

On so many issues though in this country, when we talk about the "US", we should be clear about what we are talking about. The opinions of rich people in the media, rich and corrupt politicians, strongly ideological people with a class bias that are appointed by politicians, and paid propagandists and "think tanks" don't constitute the country. I don't think that those groups have anything to learn about other countries because I think most of them are fully aware that they are not being logically factual or honest in what they say on healthcare, the critiques they give of single payer, etc. Some people maybe are (willfully) ignorant, but I think most of it is gaslighting. It doesn't matter that every single payer system has lower overhead, is more efficient, has far less social costs, is cheaper as a percentage of GDP and on a per capita basis. It doesn't matter the reasons why this is the case. There was a WHO study in 2010 that showed that administrative overhead in private systems around the world is three times higher than overhead in public systems, and why that is the case. It doesn't matter how many studies show massive aggregate savings from adopting single payer here. The data on overhead with traditional Medicare versus private insurance, polls showing that the public parts of the healthcare system (the VA, Medicare, Medicaid) are all more popular than private insurance or things like the Rand study showing that care at VA hospitals are often better than the care veterans get at private healthcare providers. None of it matters, if any person on TV actually cared about factual accuracy on stuff like this, they wouldn't be on TV. Someone else that was willing to manipulate people and lie would be in their place, and they would be paid well to do so instead of them. You can't tell me that Jake Tapper isn't fully aware of what he is doing when he "fact checks" single payer like he has done.

The public, however, does seem to get it, especially when things are described accurately to the public. Kaiser does polls, they are opposed to single payer, and so they frame their questions in really biased ways. For example, they will ask, would you support single payer if it raised taxes? Well, some respondents say not, although there is still majority support. Beyond the MMT arguments of not needing to raise taxes, let's just assume that we are trying to make single payer as revenue neutral as possible, for arguments sake. Wouldn't a more accurate question be, would you support single payer if it raised taxes, but the tax increases were more than offset by a reduction in out of pocket expenditures? Polls show strong majorities of the country support single payer, and that is with very little of those in power and with big microphones supporting the idea. We all know the studies showing the large gap between popular opinion and what the state does on policy. Like every other issue, people want one thing, and worthless people in power want another, and our system doesn't make it so that those worthless people are really directly controlled by us collectively nearly as much as donors and other interests control them.

greg , February 22, 2019 at 6:34 am

Since it is becoming increasingly obvious that our current management team of wealthy white males are both too venal and too incompetent to sustainably manage a global economy, perhaps we should start looking for alternatives.

It is delusional to think that US healthcare, or any of the problems which beset both the United States and the world, will be effectively dealt with as long as they are in charge.

It is unreasonable to expect that the over exploitation of natural resources, or sustaining the environment, addressing global warming, and so forth, will happen under their management. This is simply because they are the ones who control the earth's resources, and they are the ones who most profit from their unregulated exploitation and destruction.

It is unreasonable to expect that pollution will be effectively dealt with, because the wealthy make a profit from every ounce of pollution, and every scrap of litter, that has ever been, or will ever be, produced.

Every ounce of CO2 produced, is profit for some wealthy businessman.

Overpopulation is profitable for the wealthy. It both expands their market for goods and services, and lowers their price for labor.

Have you not noticed that we have been aware of all of these problems for over 50 years, and nothing has actually been accomplished with any of them?

Nothing effective will be done, with any of these problems, while they are in charge. It's all been talk, talk, talk, and from the wealthy, always the seeds of confusion and division.

Once a problem has been solved, it is no longer an opportunity for profit. As long as a problem festers, there is money to be made.

Every cost imposed on society is a profit opportunity for someone with wealth and power. There is money to be made, as civilization declines and collapses.

Mac na Michomhairle , February 22, 2019 at 9:23 am

You seem to start of suggesting that things would be fine, if it were not for wealthy white males being in charge.

That is a peculiar perspective that appears to attempt to divert attention from the actual horrifying system itself, and divert potential energy from attempts to change that system, to focus on a mere feature of the system.

As though, if an investment house screwed over my parents, I devote myself to bettering the world by fighting the men of Connecticut wherever I encounter them, because the house agent who was point person was from Connecticut.

If individuals in the system stand to profit from it, of course they have a stake in its continued existence; any individuals do.

Mike Mayer , February 22, 2019 at 7:39 am

Why don't businesses in the USA want to have the burden of providing health insurance taken away from them? It is a cost they bear because they need to find, negotiate, buy and administer the health plan. I am surprised most businesses are not lobbying to have the government provide it.

voteforno6 , February 22, 2019 at 9:44 am

On the other hand, the system of employer-based health insurance does offer additional ways for employers to keep the serfs in line.

rd , February 22, 2019 at 10:50 am

I tend to align with incompetence and neglect in lieu of conspiracy theories if the former can explain it, because it takes a lot of effort and smarts to pull off a conspiracy and both of those are usually in short supply across a large population.

I think we have most companies for whom the health insurance system is just something they have to have and they just go along with the flow because their competitors based in the US have similar costs.

The one organized group on this is the healthcare industrial complex that are lobbying against any nationalization type of change and even want to get more into the VA and Medicare than they already are. This IS their business and they are focused on it like a laser beam. so the conspiracy theory works for their sector.

BTW – I am surprised that the inexpensive healthcare in the rest of the developed world hasn't been a talking point of Trump's as a "subsidy" to their businesses justifying retaliatory tariffs by the US. The difference between what the US and the rest of the developed countries spends on healthcare is bigger than the entire US military budget as a percent of GDP, never mind the delta between US military spending and the other G-20 countries. So if we could drop our health care per capita spending to a bit below Switzerland's (next highest), we would have paid for the entire US military budget. If we could drop it down to Canada's level, we would have saved a year and a half's US military budget every year.

And "American Exceptionalism" pretty much ensures that nobody will look outside the US borders for solutions. If we are doing it, then it must be the best way. End of story. No further research required.

jrs , February 22, 2019 at 1:03 pm

besides the fact that it only makes a little bit of sense even as a conspiracy theory, a few people work just for healthcare and would retire otherwise (they are of course comparatively well off it goes without saying, and yes they SHOULD be able to retire, make room for those who actually NEED to work!).

But most work for survival day to day and if healthcare comes with it that's great, but many work without any form of employer provided healthcare at all (because they still need money to survive). I've heard 30-40% of the working population has NO employer provided healthcare. The serfs are still kept in line just by even more basic needs like food, shelter, and climate control, or they wouldn't show up for such jobs, but of course they do.

tegnost , February 22, 2019 at 9:59 am

IMO it's because they like the captive employees who won't quit because health care

Jim Thomson , February 22, 2019 at 12:51 pm

Bingo.

antidlc , February 22, 2019 at 10:18 am

As mentioned by other posters, companies want to use healthcare to keep employees captive. They don't want employees to leave for smaller firms or start their own companies. It's a way to limit competition.

Companies also have a vested interest in keeping the employer-based insurance model:
https://www.wsj.com/video/why-big-tech-wants-access-to-your-medical-records/F9C51DC8-5238-4D0C-B8BD-73F0FAC92048.html

They want to be able to use your medical history to decide whether to hire or fire you. The video is quite alarming.

oaf , February 22, 2019 at 8:00 am

" the financial health of the insurance industry"

Perhaps Government should mandate the profitability of all sectors of the Economy
..or justify why they pick *favorites*

Got to keep the trough full; that's an important pig!

oaf , February 22, 2019 at 8:17 am

lest we throw out the Baby with the bathwater; let's bathe in it a while longer!

zagonostra , February 22, 2019 at 8:19 am

> It is also hard to believe they are stupid. However, a close reading of their arguments suggests they may think we are stupid, or at least befuddled by repeated public relations/ propaganda/ disinformation campaigns.

Unfortunately, I think in the aggregate both are true: They are not stupid, rather cunning and evil, we are stupid, or rather easily manipulated by a very sophisticated propaganda machine that goes back to Edward Bernays. If you repeat a lie often enough it doesn't matter if it's true or not, and by the processes of association (socialism/Venezuela) we are wired in ways that makes us susceptible to blaring lies (some of Koestler's works come to mind).

There has to be a tipping point where enough people have built up defenses to the propaganda that enable "we" to go after the bloody bastards.

tegnost , February 22, 2019 at 10:16 am

I think it's less a matter of defenses and more the numbers game, the PTB have been pretty successful winnowing the field. Say a 1000 people work in an industry, someone of those 1000 figures that 100 of those can be replaced (h1b, computers, undocumented immigrants) but the amount they charge stays the same, or more likely is increased to reflect the leaner machine being more productive. Big bonus to top guy. Then it's well we have 900 employees, we could do the same with 700 employees etc and on down the line. This has worked really great for the 40 years since reagan. Add crippling student loan debt, winnow out some more people as they have been effectively neutered, basically only able at best to maintain as a steadily depreciating labor unit (hmmm, we need that persons shoes to touch the ground in a medical establishment so the gov can pay us, since that poor schlub obviously can't, thanks ACA, and once again imo, the whole reason for the medicaid aspect of the ACA) the end result is fewer and fewer successful lives being led, and more and more precarious lives being led. In 2016 the dogs wouldn't eat the dogfood. Nothing about the numbers have changed so the dogs are going to be more grumpy and indeed some of those dogs which sat on the sidelines last time might be grumpy enough to vote in 2020.

katiebird , February 22, 2019 at 8:39 am

It seems like there is a logical fallacy somewhere in this story. .

Arizona college student could die because she can't get copies of her medical records

The files are locked away in a repossessed electronic-records system while creditors of bankrupt Florence Hospital at Anthem and Gilbert Hospital bicker over who should pay for access to them.

.

The medical records are the only thing standing between her and a lifesaving surgery by a top physician at Johns Hopkins Hospital.

The doctor has refused to perform the operation without a complete understanding of Secrist's health history, including what her pancreas looked like when she was originally diagnosed, she said.

Every week that goes by, the danger increases of another attack of acute pancreatitis that could cause her organs to shut down.

"Without those records, we can't go forward. We can't make me better," said Secrist, who lives with her parents in Florence. "Having my life, practically, in the hands of a judge and people I don't even know, who don't even know my situation, it's upsetting."

Secrist and her primary-care physician sent letters this week to Maricopa County Superior Court urging swift release of her records. Federal and state law require medical facilities to send patients copies of their medical records within 60 days of a request.

taunger , February 22, 2019 at 9:00 am

Thank you for this post that clearly identifies the logical fallacies. This can be useful in conversations #fieldwork

Norb , February 22, 2019 at 9:04 am

In the long run, Medicare-for-all lays the groundwork for a more healthy and productive society. Healthy citizens require less healthcare, so there is potential savings over time. Healthcare is most efficient when built around a healthy society. But healthy citizens must be the primary goal, not some abstract argument about affordability and jobs protection. The jobs created by the system must be oriented toward societal health, not the profit generation for a few plutocrats. No wonder they are bemoaning the cost- they have been impoverishing the citizenry for 40 years and sooner or later that bill has to be paid.

The plutocrats, always attempting to hide their true motives, now seek to obfuscate their abject disdain for working people by using arguments of cost to continue restricting access to healthcare. Their inhumanity must be driven home and called out, but the social discourse is still in "polite" mode. Using the term 'stupid' to describe the plutocrats falls in this category. They know exactly what they are doing, and are given a social pass to continue acting in an inhumane and antisocial manner. Chants of USA USA are obscene in this context. The longer this trend continues, only decline can result.

If people are not responsive to a moral argument, the argument for comparative costs is the strongest one that needs to be constantly driven home. We are already paying- and as pointed out, will be paying much more in the future for less. Everyone can understand that and can see it in their own pocketbooks.

The moral bankruptcy of the current leadership must be called out. The propaganda bubble that Americans live enshrouded in is showing signs of weakness. That bubble will burst when pricked from forces outside the impirum- and there are many- failure is everywhere and the rest of the world is not as delusional as most Americans.

a different chris , February 22, 2019 at 9:19 am

Do these billionaires realize that, in this case the word "unaffordable" specifically means "go die"? Wow.

bassmule , February 22, 2019 at 9:27 am

As Lambert has frequently pointed out, NeoCon policy regarding health is this:

1. "Because markets!'
2. "Go die!"

voteforno6 , February 22, 2019 at 9:46 am

That's NeoLib The NeoCons are the ones who want to bomb everything, everywhere, because America.

polecat , February 22, 2019 at 11:19 am

Put the two together, and you have two wretched greedy fingers locked in avaricious embrace !

JBird4049 , February 22, 2019 at 12:15 pm

The two sets have been merging to where they would be almost the same in a Venn diagram. Almost the entire Washington establishment agrees on what is call the Washington Consensus which is cutting taxes, reducing regulations, free trade, and now apparently the Forever Wars.

Most of the differences that remains are cosmetic and focus on the social issues so that the selected base will organize, donate, and vote for them.

For example, gun control, LGBT rights, and pro-choice (abortion) for the Democratic Party and gun rights, religion, and pro-life (anti-abortion). Note that the goal is not to solve or even ameliorate any issue, but rather to inflame them so that they can be used as cover, distraction, and agitation.

Carolinian , February 22, 2019 at 9:46 am

It's all about the Benjamins–logic has nothing to do with it and never has. The largest business in my county is the hospital system which also has the highest paid CEO. And they just became even larger by buying a smaller competing hospital. Yves has pointed out how fearsome the DC health lobby is and, as cited above, the Chamber of Commerce is fully on board. There's been some excitement because announced Dem pres candidates support Medicare for all but Dem candidates always say they are for reform whereas in reality we get Hillary care in the '90s or Obamacare after both he and Hillary campaigned on the issue. Probably none of this will stop unless the economy crashes to the point that the medical complex has to accept reform and reality.

justsayknow , February 22, 2019 at 10:14 am

''That is the kind of extreme policy that is not a policy that I agree with,' Schultz said on 'The View,' adding that doing away with private insurers would lead to major job losses.

'That's not correct. That's not American,' Schultz said on CBS. 'What's next? What industry are we going to abolish next? The coffee industry?'

I'd say Shultz gives the game away as he reveals he sees the current "system" as a make-work-make profit center.
I imagine he and Bloomberg et al have significant investments in the health industrial complex. Otherwise wouldn't it benefit all other commerce sectors to have customers with lower health costs thereby freeing up money that could be spent with them.

Eclair , February 22, 2019 at 12:22 pm

"What industry are we going to abolish next?"

Great question, Schultzie! Where were you (or your ilk) when we 'abolished' the US textile industry? Or our furniture industry? Or our electronics industry? Or our clothing industry? Or our rail car manufacturing industry?

And the jobs that went with them.

antidlc , February 22, 2019 at 10:23 am

More from Wendell Potter:

How to be ready for the health care industry lie factory
https://www.tarbell.org/2019/02/be-ready-for-the-health-care-industry-lie-factory/

antidlc , February 22, 2019 at 10:26 am

Meet the propaganda outfit fighting against Medicare for All (podcast)

Why do we believe the things we do? Whistleblower, New York Times best selling author and Tarbell.org founder Wendell Potter, along with millennial co-host Joey Rettino, are joined by politicians, activists, journalists and pretty much everybody else to figure it out.

https://www.tarbell.org/2019/02/the-potter-report/

Summer , February 22, 2019 at 10:26 am

I laugh when they say they are worried about "jobs" of people in the health insurance industry. They aren't worried about the jobs, but exec pay. Everytime I look up there are articles about more automation and tech in the administrative and medical pafts of the industry.
It's like Uber claiming to worry about drivers while claiming their future is driverless cars.
So a good number of people that staff the health insurance industry (talking to you non-wealthy execs) need to get on board now and get their health care covered.

There aren't too many industries that aren't salivating overways to have fewer employees and then you hear all this BS from the same industry "leaders" touting how employer based system is the only thing imaginable.

rd , February 22, 2019 at 11:12 am

BTW – latest number I can find

Canada military spending 1.0% of GDP; healthcare spending 10.4%: Total military + healthcare = 11.4% of GDP

US military spending 3.5% of GDP; healthcare spending 16.9%: Total military + healthcare = 20.4% of GDP

So between those two economic sectors, Canada has an extra 9% of GDP to spend on other priorities. No wonder they can have an inflated housing market as well as paid parental leave.

Disturbed Voter , February 22, 2019 at 12:41 pm

Exactly. To reallocate resources, you have to look at the whole picture, not just the health industry. That is a huge question. What you do with a particular allocation, is pertinent.

D , February 22, 2019 at 11:13 am

i always wonder if they are really thinking through when the say that the government (us) but that if we let patients and insurance can pay for it?? Really????

Susan the Other , February 22, 2019 at 12:45 pm

Thanks for this post, Yves. It was really good. It did all the demolishing for us. Deconstructing the whole building. I love the phrase (whether facetious or not) "argument by gibberish." I mean, it could be a necessary part of a logic curriculum – please analyze this argument for gibberish – because we were once so oblivious. So, more accurately, the pushers are now the oblivious ones. The full court press against "socialism" and "unaffordable health care" and holding up the decrepit free market isn't going to work much longer.

Hepativore , February 22, 2019 at 12:58 pm

One thing that I also hope that gets changed in the US, is combining dental care with a Medicare For all Program. It is ridiculous that people have to carry both dental and health insurance as good dental care and physical well-being are related. Left untreated, oral maladies can quickly become serious and more expensive to treat. Effective dental care is far from a vanity service.

[Feb 22, 2019] Angry Bear Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

Feb 22, 2019 | angrybearblog.com

Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals

run75441 | February 21, 2019 10:00 pm

Healthcare Hot Topics This should come as no surprise as I have written on the topic of Healthcare Costs and Its Drivers before. In particular, the overriding statistic from an earlier post was 50% of the increase in healthcare costs was due solely to price increases between 1996 and 2013 (JAMA, Factors Associated With . . . . Adjusting for inflation, "annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased from $1.2 trillion to $2.1 trillion or $933.5 billion between 1996 and 2013." This was broken down into 5 fundamental factors contributing to rising healthcare costs.

– Increased US population size was associated with a 23.1% increase or $269.5 billion
– An aging population was associated with an 11.6% increase or $135.7 billion
– Changes in disease prevalence or incidence (inpatient, outpatient, ED) resulted in spending reductions of 2.4% or $28.2 billion
– Changes in service utilization (inpatient, dental) were not associated with a statistically significant change in spending
– Changes in service price and intensity were associated with a 50.0% increase or $583.5 billion.

Five fundamental factors (Population size, Population aging, Disease prevalence or incidence, Service Utilization, and Service Pricing) were collectively associated with a $933.5 billion increase in annual US health care spending between 1996 through 2013. Represented pictorially, stated objectively, and categorized numerically, I can not make it any more obvious.

Some Explanation

The change in disease prevalence or incidence was associated with a spending reduction of 2.4%, or $28.2 billion while the change in service utilization did not result in a statistically significant change in spending. Said another way, these two factors had little or no impact on the rising cost of healthcare.

The increased healthcare costs from 1996 to 2013 were largely related to Healthcare Service Price and Intensity and secondarily impacted by Population Growth and Population Aging in order of impact. The bar chart reflects all of the impact in changes.

So the aging tsunami of baby boomers has not hit yet and population growth has not greatly impacted the results of this study. In patient stays at hospitals are down as well as out patient use of facilities. The big issue is the change in pricing for inpatient hospital stays and pharmaceuticals. Hospital/clinic consolidations leads to the former even though insurance has been fighting for a reduction in stays. Pharmaceutical has instituted new pricing strategies which we have all read about in the news. Old drugs such as Humalog, Viovo, and the infamous Epipens as well as others are now more expensive. This study points to pricing for pharma and service as the issues.

An example?

There is a tendency to challenge the lifestyle practices of people who indulge in too much. One factor did come out in the increased cost of healthcare. The increase in annual diabetes spending between 1996 and 2013 was $64.4 billion of which $44.4 billion of this increase was pharmaceutical spending. Said another way, two-thirds of the increase in treating diabetes was due simply to the increased pricing of pharmaceutical companies.

And yes, there should be time spent on changing habits where it can be changed and providing the means to do so. However, in 1996 Eli Lilly's Humalog was $21 per vial. By 2017, the price increased to $275 (700%) for a vial which equates to a one-month supply.

Why has the cost of Humalog increased? "The truth is the improvements in new formularies of old versions which are marginally different, and the clinical benefits of them over the older drugs have been zero." Just like slapping "new and improved" on the labels of food products with a change of ingredients (which qualifies under USDA and FDA labeling regs)., pharmaceuticals can play the same game and they do.

As the article ("Eli Lilly Raised U.S. Prices Of Diabetes Drug 700 Percent Over 20 Years ") explains, "most patients do not pay the full cost/price of a drug up front and absorb their portion of the cost via an increase in monthly healthcare premiums." This leads to pharmaceutical companies charging as much as the U.S. insurance companies will let them. Both parties profiting from increased prices. Perhaps Alex Azar the Secretary of Healthcare can explain it better as he was an officer of Eli Lilly when Humalog began its ascend?

Another Study via Health Affairs

A shorter time period extending one year longer than the Jama study, the Health Affairs study supports what is being said in the JAMA study. According to data from the Henry J. Kaiser Family Foundation, total health spending on the privately insured in the United States increased in real terms by nearly 20 percent from 2007 to 2014.

A more recent study funded by the Commonwealth Fund and published by Health Affairs examined other costs impacting healthcare. Commonwealth Fund supported researchers recently analyzed hospital and physician prices for inpatient and hospital-based outpatient services as well as for four high-volume services: cesarean section, vaginal delivery, hospital-based outpatient colonoscopy, and knee replacement. Its findings were as follows:

– From 2007 to 2014, hospital-prices for inpatient care grew 42 percent compared to 18 percent for physician-prices for inpatient hospital care
– For hospital-based outpatient care, hospital-prices rose 25 percent compared to 6 percent for physician-prices
– There was no difference in results between hospitals directly employing physicians and indirectly employing physicians
– Hospital prices accounted for over 60 percent of the total price of hospital-based care.
– Hospital prices accounted for most of the cost of the four high-volume services included in the study. The hospital component ranged from 61 percent for vaginal deliveries to 84 percent for knee replacements.

Sound familiar? The JAMA study looked at both in and out patient costs/prices associated with hospital services and said they were up. The Health Affairs study looks at in patient services for four high volume inpatient services stating they have increased significantly from 2007 to 2014.

What the Health Affairs study Showed

The Health Affairs study also presents a comparison of hospital pricing growth rates as compared to physician pricing growth rates. The study is only a few weeks old and I am surprised I am able to access as much information as I have. While Health Affairs admits the study is a start and more work differentiating other aspects must be done, the study suggests there are significant growth in the bargaining leverage of hospitals as compared to physicians.

If you recall Rusty "Tom" and I engaged in a number of different conversations on healthcare with one of them being hospital consolidations (2013). It is a power grab, as Rusty pointed out, for more market segment and pricing control with those having name-recognition gaining the most. Maggie Mahar also referenced the same issue.

In my own commentary On the Horizon After Obamacare (2014): As it stands and even with its faults, the ACA is a viable solution to many of the issues faced by the uninsured and under-insured; but in itself, it only addresses the delivery-half of the healthcare problem. The other half of the problem rests with the industry delivering the healthcare and the control of pricing through the inherent monopolistic power coming and pushing the industry into greater integration of delivery. As Longman and Hewitt posit,

"the message from Department of Health and Human Services stresses the vast savings possible through a less 'fragmented and integrated' health care delivery system. With this vision in mind, HHS officials have been encouraging health care providers to merge into so-called accountable care organizations, or ACOs"; "while on the other side of the Mall, 'pronouncements from the FTC are about the need to counter the record numbers of hospitals and doctors' practices merging and using their resulting monopoly power to drive up prices."

Two different messages from government, greater efficiencies in healthcare through consolidations as ACOs versus monopolistic pricing control in healthcare by large hospital and pharmaceutical corporations an unintended result. There is large amounts of inefficiencies, waste, and rent-taking in healthcare as well as in Medicare which is touted as the go-to by politicians and advocates of it. Lets not make a similar mistake, the creation of any forthcoming healthcare system must first address the costs of healthcare and then the delivery of it not ignoring the quality of the product and its outcome after treatment. Again Maggie Mahar was big on promoting this result emanating from any new system.

While Physician fees grew at a compounded annual rate of 6% for baby deliveries and 1% for office visits between 2003 and 2010, hospitals fees during a similar period grew at 17%.

A measurement of the competitiveness of a hospital within a certain area of the country is done utilizing the Herfindahl-Hirschman Index (HHI) . It has been used to measure competition in and around cities. The results of the HHI revealed an increase in the concentration of hospitals from mergers and acquisitions, going from moderately concentrated in 1990 with an HHI numeric of 1570, to more concentrated in 2009 with a HHI of 2500, and with some cities purely monopolistic at 10,000.

Rigorous action by the FTC would certainly go a long way in improving compositeness; however, the FTC has been purposely understaffed by cutting its funding. In place at the FTC is a staff 22 lawyers and economists to monitor a $3 trillion healthcare industry. It is too understaffed to take on such a large industry which would overwhelm it with legalese and paper. Maybe in the next election will bring forth the right person to take on healthcare.

Resources

Hospital Prices Grew Substantially Faster Than Physician Prices For Hospital-Based Care In 2007–14, Zack Cooper, Stuart Craig, Martin Gaynor, Nir J. Harish, Harlan M. Krumholz, and John Van Reenen, HealthAffairs, February 2019

Zack Cooper Hospital Care Prices Rose Faster Than the Cost of Physician Services, February, 2019

After Obamacare Phillip Longman and Paul S. Hewitt, Washington Monthly, January – February 2014


Mike Kimel , February 22, 2019 5:46 am

I have the impression that it has gotten harder to see a doctor or get a prescription filled over time. A couple of decades ago either your insurance paid or it didn't. Now it seems to me that most people have stories about arguing with insurance companies. It is sort of expected to be a part of the process. Time costs like this aren't counted with a dollar value but they surely contribute to the negative experience, and they require additional admin people at both medical providers and insurance companies. That in turns leads to more documentation and paperwork, requiring even more admin people. It's one thing if the extra personnel are a force multiplier allowing more people to be serviced. It's another if they are an impediment and an added cost.

Denis Drew , February 22, 2019 11:28 am

The political forum is too "understaffed" on all topics to fight back against (a nation of) scams because of (you know what I'm going to say) the disappearance of labor unions. Late Dean of the Washington press corps, David Broder, told a rookie reporter that when he came to DC the lobbyists were all union.

Nice to get real -- math broken down -- info beginning to tell why we pay twice as much for health care as any other country. When you add the hospitals overcharging, the drug companies bleeding us literally to death and the private insurance paper work overload, maybe we are finally sorting it out, at least a bit.

likbez , February 22, 2019 3:35 pm

The relationship between hospitals and heaths insurance companies currently somewhat resembles criminal cartel.

Often hospitals perform on the patient procedures that are best paid by the insurance companies, even if they are unnecessary, or even harmful.

An epidemic of unnecessary cardiac stents insertions in the USA is a nice illustration of the trend for costly and unnecessary (or even dangerous for the patient) procedures . Hospital cardiologists are pushed by financial incentives

"chief cardiologist Steven Nissen at the renowned Cleveland Clinic noted that doctors are paid per procedure rather than on a salary basis, while the Mayo Clinic's chief of cardiology, Raymond J. Gibbons, also cited the financial incentive of performing procedures."

And only few cardiologists that practice this racket went to jail.

That somewhat resembles relations between the car insurers and the body shops ;-)

[Jan 11, 2019] Health Insurer Greed or Desperation An Odd Data Point From Cigna naked capitalism

Notable quotes:
"... It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not. ..."
"... The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home. ..."
Jan 11, 2019 | www.nakedcapitalism.com

Health Insurer Greed or Desperation? An Odd Data Point From Cigna Posted on January 9, 2019 by Yves Smith I sometimes give personal Consumerist-type anecdotes about dodgy vendor behavior in case readers have had similar experiences.

Admittedly, health insurers being difficult about paying claims is so common that they fall in the realm of "dog bites man" stories. But the elements of my latest arm-wrestle with Cigna suggest that the insurer is so eager to maximize profit and burnish its financials that it is doing the equivalent of pulling up the sofa cushions to collect change.

I've had this plan a very long time, since the early 1990s. Cigna in theory has not changed the terms (to do so, it would have to notify me and New York State) save approved rate increases. In practice it has, by among other things a few years back requiring that claims be submitted within 120 days of service. That has allowed it to engage in a new form of mischief: simply not processing some claims. No doubt the hope is that consumers won't notice, or will notice too late to get duplicate documentation and resubmit before the 120 days are up.

Mind you, for well over 15 years, I never had a single claim go astray. Now it happens with sufficiently high frequency for it to be implausible that the US Postal Service is losing so many of my letters, when other envelopes virtually never go missing. So every time I submit a claim, I have taken to recording the details necessary to locate the items in Cigna's system, as well as the mailing date.

Last July, Cigna sent a letter about a "pharmacy claim". It was a remarkably content-free document, with no reference to dates of service or any clues to allow a customer to figure out what they might be referring to, particularly since I do not have a pharmacy plan. A "pharmacy plan" is when the doctor sends a scrip to the pharmacy on behalf of a patient, and the pharmacy bills the insurer, with the patient responsible for any co-pay. My plan covers prescription drugs, including ones I get overseas (I've submitted prescription drug claims from England and Australia). I pay for the drugs and I submit for reimbursement. And until the mysterious July letter, I never had any problem with them being paid (provided, of course, Cigna didn't try claiming it had never gotten the claim).

Fortunately, because I keep good records, I could see I had sent in a claim in late June for four dates of service for less than $400 worth of meds total. The only reason the amount was that high was three of the four items were 90 day supplies.

I called Cigna and got a rep who found the four items and confirmed they were in a payment limbo and ought to be paid.

When no check had arrived by September, I called again, had the agent say that there was not reason for the claim not to have been paid, and put it in for reprocessing.

On November 28, with still no payment, I insisted on speaking to a supervisor, which it took an ungodly amount of time to reach. I started making noise about external appeal to New York state (my plan is a New York state regulated plan). She confirmed like everyone else that it should have been paid, and said the check would go out in three to five days.

Two weeks later, nothing from Cigna.

I called again. I got an agent who said the payment is pending.

By this time, steam was pouring out of my ears. I asked again to speak to a supervisor. After a 30 minute wait, I was told one would call me back. I should have known from long experience with Cigna that promises to make calls or follow up are empty, as this proved to be.

I decided to have one last go on the phone before writing the state for an external appeal. I called over the weekend. The agent said that the payment was issued on January 3, but she saw only three of the four drugs in the scans of the claims. Mind you, this was the cheapest scrip, and a shortfall versus what I should have received of about $13 (assuming that check finally arrives). But this is what this incident says about Cigna:

1. Recall that on the first call, and if my recollection serves me right, on at least one of the later calls, I confirmed the dates of the claims. The one that disappeared was the most recent in the date range, making it almost certain that I cited it most if not all calls.

This strongly suggests that the original Cigna hope was that I would not follow up adequately on their bafflegab letter, and when I did, someone went and scrubbed my record to reduce the amount Cigna would have to lay out. This is such a small amount that it would seem hardly worth the effort .which further suggests that Cigna has this sort of records-doctoring highly enough routinized to be able to do it cheaply. 1

2. Cigna has supposedly initiated payment right after the new year. Even though Cigna ought to be on an accrual as opposed to a cash accounting basis, it's not hard to infer that they kicked the payment back into a new fiscal year to flatter some sort of metric. It might not even be a financial reporting metric but some other measure that senior management and/or analysts follow.

As we said at the outset, in terms of abuses, this is small beer. But that's the point. Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me, knowing in this era when class action suits are virtually dead, that they can grift with no fear of being held to account.

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

____

1 The last agent checked my records for the date of the gone-missing drug claim to see if it had somehow gotten separated from the other three and was being handled separately. She came up empty-handed. Recall that I now have a not-approved, not-noticed-as-required change to my contract of a 120 day submission limit, so disappearing that item so late in the game makes it impossible for me to resubmit that item.

Geo , January 9, 2019 at 4:09 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Well said. You're much more thorough and persistent than I am. I'm their target dupe that won't notice such things and just accept that it was my fault when I do notice. Very insightful read. Thanks so much!

WestcoastDeplorable , January 9, 2019 at 3:17 pm

Sorry to read of your problems, but Insurance companies aren't the only category screwing with the details; I recently transferred a balance to U.S. Bank on one of those "zero interest for 12 month" deals. In about 2 months after the transfer, all the sudden I get a late notice from them, then realize I didn't receive a statement (which was about 10 days late). And they laid a $39 charge on the account, which I was able to get waived with a trip to my local bank. Little did I realize this "late pay" also resulted in nixing the "zero interest" deal, and they levied the full interest on the balance.
Needless to say, I transferred the balance elsewhere, but seems to me lots of companies are gaming the mailing of statements to pad their coffers.

campbeln , January 9, 2019 at 3:53 pm

I had a good one with Macy's we bought a ton of stuff for the new house back here in the US and got the 0% interest for 12 months on their credit card for the first purchase or some-such. What the lady at the counter did was to run 2 separate transactions on the card so the second, much smaller, transaction fell outside of the "first purchase" and incurred the minimum monthly interest charge. Over the course of the 12 months, I'd have been in a slight deficit thanks to these additional charges, so I paid the damned thing off in full and threw it in the drawer.

So Macy's went from having a part-time AmEx card user to one that never uses it all because they didn't want to uphold their own promo Picking up pennies in front of a steamroller

Barbara , January 9, 2019 at 5:55 pm

Some years ago, I got such a 0% offer from a bank which issued one of my credit cards. This one was for existing debt and lasted until the debt was paid off. I was happily paying off my debt in reasonable monthly installments. After I paid my 6th monthly installment, I got a letter from the bank saying that they needed to raise the interest rate and would appreciate if I would concede. They added that if I continued to insist on 0%, as was my right to do, my credit card would be discontinued on the last payment. I chose to continue the 0% deal and, as promised (the only promise they kept), my credit card was cancelled thereafter.

Fast forward several years, I regularly get credit card offers from said company. Needless to say, I don't think much of people (or businesses – corporations are people too!) who renege on deals. You can guess what is not in my wallet!

The Rev Kev , January 9, 2019 at 4:18 am

Excuse for for asking but just to clarify a point. When you send mail to Cigna and you say that you record the details, are you talking about certified mail and registered mail then? The reason that I ask is that by using the same in Oz, it has saved both my daughter and I individually over a thousand dollars each when the recipient tried at first tried to deny receiving what we sent until confronted with tracking numbers that can be checked online.

Arthur Dent , January 9, 2019 at 9:15 am

More and more I am going to tracking numbers with signature required for things that have any sort of value.

The joy of focusing on shareholder value is that all other stakeholders are subservient to it. Ultimately, the sheer greed of the corporations is likely to force the general population to demand a government-run single-payer system where at least they can vote the politicians out of office instead of having unaccountable executives making their lives miserable. The inability to repeal the Affordable Care Act was just the first shot across the bow.

Spent more time in Canada over the past few weeks. Everybody I spoke to up there is utterly baffled by what is going on in the US and is seriously wondering if the US is officially insane. They cannot understand why we continue to live down here. BTW – many of these people are white people over 50 with military backgrounds and little to no college in the demographic that would have been probably voting for Trump in the US.

Octopii , January 9, 2019 at 1:05 pm

Have considered moving but they don't want us up there.

Yves Smith Post author , January 9, 2019 at 9:44 am

It takes $3+ per envelope to send something certified and a half hour tax on my time to go to the post office.

And sending a letter certified does not prove what was in the letter. It's useless from an evidentiary standpoint. Cigna could claim the envelope had no claims in it, or that the claims were "unscannable" (another "dog ate my homework" they've tried now and again). It's useless in proving a submission.

monday1929 , January 9, 2019 at 4:22 pm

Yves, you might try video-taping the mailing process, including video showing the papers as legible etc as they are sealed in envelope and handed over postal counter and showing tracking numbers.
Include in the envelope a letter explaining you will post video on you-tube if they claim "unscannable" or that envelope was empty.
United Healthcare broke dozens of promises to "call back"- they never ONCE did so. Hopefully not to far off topic, I would like to keep NC updated on current complaint with NY Office of Professional Discipline regarding a dentist who possibly hid about 100 bad (as in semi-criminal) Yelp reviews by establishing a phony company name and shifting reviews there. So far, after one month not a peep from Port Chester regional office where referred to.

beth , January 9, 2019 at 7:35 pm

Alert to United Healthcare Medicare Supp. retirees. I'm sure the UH did this not just to me but to all of those who carelessly pay all bills sent to them. When I signed up for AARP United Healthcare insurance, the rep told me that he would have to accept a check for the first month and then had to put me on a ckg acct withdrawal plan. I had never done that before and didn't like the idea. It turned out that that saved me in the long run for two reasons. First they billed me for the first month after accepting my check. I did not pay it and by the time I received it they had already taken money out for the second month. I am sure there are many seniors who just paid the bill anyway. Slick trick & sick trick.
And then a year later I was finally diagnosed with my genetic disease after all these years. I began getting the only medicine specifically for this disease which since it is an orphan drug is expensive. They rejected the first bill from the provider and told them I was not a member of the plan. I was thrilled that I had had the money taken out of my acct. so they could not say the check was late.

Kradek , January 11, 2019 at 12:25 am

Why won't these companies let us email the claims? Cheaper for all, content and dates verifiable

run75441 , January 9, 2019 at 11:00 pm

Yves:

Green Card works in court and I have used it with Ocwen

flora , January 9, 2019 at 11:17 pm

By 'green card' do you mean the usps certified return receipt green card?

vlade , January 9, 2019 at 4:33 am

Hmm.. I haven't seen "the cheque will be issued" excuse for ages now, courtesy of pretty much all European payments being direct and settled on T+1 latest.

I guess having netflix and Facebook (the "great innovations" coming out of the US) is more important to a number of US residents than a working payments system like say the EU has.

mle detroit , January 9, 2019 at 10:12 am

I've been trying unsuccessfully to decode your first sentence. What is this payments system, where can a neophyte learn about it, does the UK use it, and what how Brexit affect it?

Kpl , January 9, 2019 at 4:36 am

When bad behaviour and fraud go unpunished this is what one should expect.

Disturbed Voter , January 9, 2019 at 5:27 am

Stick to your guns, and make them meet your business performance metrics!

Heath insurance is inherently un-profitable in the long run, unless service is denied.

oh , January 9, 2019 at 3:58 pm

Not really. Denial of claims is yet another way for them to pad their profits.

Louis Fyne , January 9, 2019 at 6:32 am

cigna bought express scripts and the deal closed in december.

it could be cost-cutting-induced incompetence. it could be intentional revenue padding. could be both.

and ya, compared to the daily/weekly neoliberal microaggressions, no wonder why after 3weeks a lot of people shrug when it comes to the government shutdown

Spring Texan , January 9, 2019 at 11:06 am

Love your phrase "neoliberal microaggressions." We need to start using that more!

Very descriptive.

rd , January 9, 2019 at 12:22 pm

This government shutdown is going to get very interesting as the Trump Administration tries to expand what are "essential services" requiring workers to come in without pay. So far it hasn't interfered with my travels because the TSA and ATC workers are all there working without pay. I believe tax refunds are going to be declared "essential" so those workers will be called back to process them without pay. This will likely be occurring in numerous other areas as the Administration gradually discovers that government workers actually do something.

Thad Allen had an interesting interview on NPR this morning as he discussed the Coast Guard working without pay: https://www.npr.org/2019/01/09/683501454/coast-guard-members-may-have-to-work-without-pay-during-shutdown

The GOP may have finally figured out how to pay for tax cuts: you still provide the services but you don't pay the workers!

Octopii , January 9, 2019 at 1:08 pm

Reminds one of the old Soviet saying, "They pretend to pay us and we pretend to work."

ambrit , January 9, 2019 at 1:10 pm

This dynamic is beginning to resemble the joke attributed to Lenin. "The Capitalists will sell us the rope with which we hang them."
I cannot think of a better way to energize a general strike than this.

Oh , January 9, 2019 at 4:02 pm

The TSA is just a pretend act anyway. It's all for show.

Larry , January 9, 2019 at 7:01 am

Perhaps the plan is to fatigue customers over small amounts to condition them to give up appeals over larger disputes.

Homard Mard Hankee Ospetsua , January 9, 2019 at 7:05 am

For most of the year 1982, I worked as a parlegal for a workmen's comp law firm representing petitioners (the sick or injured workers). Almost all of the cases we handled were from workers whose disability checks had stopped after six weeks. Always six weeks. That's the point at which the insurer would stop sending the checks and the worker would call us. Then, someone (like me) from the law firm would call the insurer. There would be one of a a stock set of about half a dozen responses, ranging from "my desk is so messy haha, but I know I saw that check in these papers somewhere" to "we don't have the proper medical documentation" (even though of course there needed to be medical documentation for them to send the first 6 weeks' worth of checks). After one or two phone calls from us, the checks would begin to flow again in a week or two (including checks for any week that the insurer had missed).

Oh, and 95% of these cases were from workers whose first language wasn't English.

The theory of the folks who'd been at this business for awhile was that, by having a built-in delay at the six-week mark, the insurers were making a little extra interest.

cnchal , January 9, 2019 at 7:17 am

> . . . in terms of abuses, this is small beer . . .

Tens of millions of small beers ends up being a gigantic vat of beer for Davos Man running Cigna. This is the result of Davos Man purchasing laws to prevent class action suits, which was paid for by stealing small beers from the peasants for decades.

I do pity the human capital at Cigna. Their worth to Davos Man is how well they steal small beers, the more they steal the higher in the organization they go, aspiring to be the next Davos Man.

Brenda Pawloski , January 9, 2019 at 8:33 am

If you are able to send your pharmacy claims online and keep an electronic copy, you can resubmit easier, faster and more often. I have done this with Cigna. I agree it is odd how they choose to ignore random claims, but it happens enough that it seems to be intentional.

BRUCE STONE , January 9, 2019 at 8:36 am

Have you tried sending the mailed correspondence by priority mail? Like Certified Mail–you get a tracking number– and documentation of delivery–but it's half the cost and my insurer will routinely refuse to accept certified mail to the claim's PO box number.
They can't refuse to participate in the priority mail tracking systems -- and it's as good in court as certified mail–although it does lack the signature credo from return receipt.

Also–my insurer routinely loses my docs and has a similar time limit on claims–but I have successfullly re-submitted based on documenting the previous sent item and the tracking data from USPS–most such systems require them to accept a resubmit when you can prove you sent it within the timeframe .

Yves Smith Post author , January 9, 2019 at 9:47 am

See the comment above. Won't help. Only proves I sent a letter in, not what was in the letter. They can say they got the earlier letter but the claim was not in it or was unscannable.

Questa Nota , January 9, 2019 at 8:54 am

Expecting reimbursement is a pre-existing condition and is not covered by the Plan for which you have eligibility. Refer to paragraph x.xx in section q.qq of user agreement #.##.

Yves Smith Post author , January 9, 2019 at 9:48 am

Not germane. Please don't offer irrelevant comments.

Kiwi , January 9, 2019 at 10:35 am

The comment was a joke

mle detroit , January 9, 2019 at 10:17 am

Good one, QN. Hope you didn't get scorched when you poked the Dragon.

RMO , January 9, 2019 at 4:39 pm

"You've chosen the 'never pay" plan option which clearly states (in this microdot that also serves as a period at the end of paragraph 4) that no claims you make will be honored. It's a good choice if you never get sick. Oh I hate to see a grown man cry Rev So get out of my office!" (adapted from the Pythons)

beth , January 9, 2019 at 7:40 pm

Do I sense a little hostility? Maybe you can be more explicit with what you are angry about.

Medical Quack , January 9, 2019 at 9:25 am

Well I gave a speech last year to a big doctors group about a lot of this and have written about it for years, it's called the Healthcare Algo Cartel. What folks can't see and don't want to believe is that there's tons of quants (called non traditional actuaries in healthcare) modeling policies and finding new areas every day where coverage for certain items can be "scored" to reduce the amount the insurer will pay.

I just don't know how long you all want to keep living in virtual perceptions and not realize this has been going on for years, just like the stock market, algos and their query results are running everything, and folks are too busy on Facebook or screaming at a box (Alexa) to take time out and learn up. Cigna is basically emulating United Healthcare and using the same models, but they don't own a PBM like United does or they don't own a bank like United does (an industrial bank). That bank by the way holds a lot of HSA money and United a couple years ago bought all the Wells Fargo HSA accounts, that's how they grow.

Nobody mentions an exit fine either for Cigna and Express Scripts. There's 5 years left for Cigna to be required to OptumRX as a PBM, contract signed with Catamaran, which OptumRX bought. Those folks with OptumRX as their PBM with Cigna have 5 more years before a switch to Express Scripts can be facilitated unless Cigna takes out another bond sale to pay it off.

People need to learn up and see what's going on, insurers are big data people and nobody seems to get that but just hang around long enough and more will come out about United Healthcare and what they and Apple are doing together, you already have United pimping Apple watches and all Apple employees are given an Optum Bank HSA account with one scratching the others back already.

Cigna by the way has Express Scripts hitting the big coupon savings route to compete, you can search that one up. Did you know that if you use a coupon to save money on your RX that that money can't be applied against a deductible? Time to learn up folks and see what the healthcare algos are doing, they're denying your care and access and there's more MBA quants on their way to be hired at insurers to model even more ways to profit by "scoring" consumers into oblivion, it's how you don't qualify done by queries and predictive models. The more complex they make it, the more insurers profit off of consumers not understanding the game and we don't have the ability to fight back (we don't have the algos and computer code).

Kris Alman , January 9, 2019 at 12:21 pm

The Cigna-Express Scripts merger is brilliant financial engineering to further consolidate insurance companies with PBMs in the fight between them and PhRMA over price gouging.

The coupons that you can get through Good Rx is a scheme of Express Scripts. https://www.biopharmadive.com/news/express-scripts-goodrx-roll-out-cost-savings-program/442197/

Now that Trump has signed bills lifting pharmacist 'gag clauses' on drug prices, the pharmacist can point you in the direction of drugs cheaper than your co-pays, which you pay-out-of-pocket and can't claim toward your deductible. What a win for Cigna/ExpressScripts!

Yves, I can't believe you have been so patient with Cigna! Complain to your insurance division. Though, I will add that while this may work at the individual level, it does nothing to create systemic changes.

JerryDenim , January 9, 2019 at 12:48 pm

Sorry to be so dense, but can you elucidate a bit more on "scoring" and how health insurance companies are using your personal data they've purloined or surreptitiously obtained to deny care? If you're not self-insured but receiving subsidized insurance through an employer plan are you still affected by "scoring"?

I would never knowingly register any health monitoring device with a health insurer or employer and I've always thought those who do are foolish, but recently I was considering buying an Apple Watch solely for the express purpose of being able to surf while being on call for my job. I believe there may be other waterproof, cellular-enabled wrist devices in the consumer space now besides Apple, but they all seem to be equipped with health monitoring sensors as well. I would never voluntarily register such a device with any programs in exchange for discounts, but it seems like linking a watch/wrist-phone to my cell phone account would be an iron identity shackle. I would really like a tiny robust cell phone reciever to screen calls while I'm in the water, which has the ability to increase my quality of life, but I don't want my heart rate and vitals logged and sold. I modified a song lyric a couple of decades ago to coin my own phrase; "Never mind what you're buying, it's what you're selling" – It becomes more true each passing year.

jfleni , January 9, 2019 at 9:31 am

RE: Health Insurer Greed or Desperation? An Odd Data Point From Cigna.

The "Nitty-gritty" A Scam wrapped in a Swindle, with a Fraud right on top!
Run -do not walk – to Medicare for ALL!

jefemt , January 9, 2019 at 9:58 am

Not fun to do the work, but imagine a few million Cigna clients at $13.00 a pop. Will pay for attorneys and accountants.

As to Priority Mail/ tracking/proof, why do we tolerate such a byzantine battle-prone system? Think of the man-hours Yves and countless others spend on running down this hors*#t. If she and others (doc offices/ care providers?) billed Cigna and others at a reasonable but market-based hourly rate for the collective man-hours spent on claims, Cigna et al would be out of business.

Its a level of complexity that is completely unnecessary. Our complacency, tolerance, and acceptance is pretty astounding. Must be the very real primacy of the threat and fear that personal health prompts. Immoral to lever off of this. Care versus insurance. Insuring a mortal being. Ridiculous premis only Wall Street could concoct. And we buy it because markets, capitalism, rugged individualism, American Exceptionalism.

Doc friends and family consistently state 35-40% of their costs, staff deals with billing, coding, reimbursement. There is huge savings to be gained in the process if we would go to a single payor system.

But you all know that- preaching to the choir.

I am still trying to figure out how to tie personal health choices, like diet and exercise, moderate alcohol use, etc.. and some incentivized skin-in-the game, some 'pain' disincentivises folks from over-using single payor and insisting on the highest dollar cost latest most expensive treatments -- how can this be institutionalized?

But , no need to reinvent the wheel- countless other nation-states have figured it out. For a nation of business-persons, we appear to be, as my old dad used to say, dumberthanwhaleshit

hunkerdown , January 9, 2019 at 12:04 pm

If they're overusing the system, what's the underlying reason? Probably loneliness or neurosis, either treatable on an outpatient basis as a mental/community health matter. If they demand heroic treatments or frivolous diagnostics , what's the underlying reason? Probably the consumer model of medicine and direct-to-patient marketing of interventions, also easily treatable (through restriction of advertising) and known to work well in other nation-states. If they eat crap, what's the underlying reason? The standard American diet is a consequence of national policy to grow grain instead of vegetables, which can be changed slowly and with effort as a public health hazard. If they don't exercise, what's the underlying reason? Built environments and lifestyles that are hostile to pedestrian traffic, which is not necessarily such an easy problem to solve due to the private interests and investments in the status quo, but whose opposing public interests would grow much stronger under a single-payer system.

Yet, all of these solutions, however difficult and world-changing they might be, are more effective over the long term and less resentment-inducing than having citizens pay to be individually scourged as a service in the name of individual incentive.

Yves Smith Post author , January 9, 2019 at 3:10 pm

The overwhelming majority of people do not elect to overconsume medical care.

People who don't exercise often don't have the time or money to do so (gym membership). Do not say "Anyone can run." Running on pavement is knee replacement futures. And there are people like me who could never jog even when young.

The ones that do fall into a few categories:

1. Ones with "lifestyle" diseases, like diabetes due to overweight/poor diet and smoking-related diseases. Problem is that these are typically the result of stress. Very hard to get off cigarettes and harder if you are subject to stress/use nicotine as a performance drug. Obesity significantly due to American portion sizes. too many refined carbs, and again, stress. And once people get fat, it is very hard for them to take and keep the weight off. I have managed to do so by virtue of seriously undereating for 40 years (<1200 calories/day, and that includes when I was exercising vigorously pretty much daily). Most people can't do that for social reasons. It is hard to be a meager eater when you are eating with other people.

2. People who are already have a problem and have been marketed to to demand tests and treatments. The classic version of this is doctors prescribing antibiotics to people with flus. The patients demand a treatment and the MD does not want to get in an argument. More extreme is patients not wanting to hear that there aren't any good options for what they have and shopping for an MD who will intervene anyhow. Another is all those new pricier drugs marketed on TV "Ask your doctor about..."

beth , January 9, 2019 at 8:15 pm

The best information about obesity is still the UCSF researcher Robert Lustig. He now has his own website but it not organized well to my taste and fails to keep the best long lectures there. Actually the best information in the shortest time is his first lecture that has been seen millions of times by geeks like me is "Sugar: The Bitter Truth" a one hour and 29 minute lecture he did in 2009. Youtube cuts it up and wants me to pay for it. But each time I have seen it has been on UCTV or UCSF. For those of us who want to understand the science this one is a must. There is good videos after that, but this is the foundational scientific information.

I can't give you a link because Google and the sugar industry makes it maddingly hard to find and moves it around.

flora , January 9, 2019 at 9:46 pm

It's a very good presentation. Thanks for the reminder. From UCTV:

https://www.uctv.tv/shows/Sugar-The-Bitter-Truth-16717

bob , January 9, 2019 at 3:21 pm

"I am still trying to figure out how to tie personal health choices some incentivized skin-in-the game "

You're trying to noeliberalize it. "How do we build in the need for 18 layers of very well paid bureaucrats who deal out spite, and lack of care, as part of their job descriptions?"

I can't imagine any more 'skin in the game' than all of the skin, and literally all of the person.

Do you ghouls even read what you write?

k. , January 9, 2019 at 9:59 am

As someone who managed a medical billing office in the 80s and 90s I can assure you that insurance companies losing claims is nothing new. That's why the advent of electronic billing to Medicare and Medicaid and BCBS and others was so wonderful. Finally, Medicare stopped "losing" all those claims we offices had to refile all of the time.

Sometimes it helped me to envision the office I was sending the paper claim to, imagining a constant turnover of new employees who didn't know what they were doing, or throwing away a stack of bills at the end of the day because they hadn't met their quota.

It's like borrowing "your" money longer, not paying what's owed in a contract.

EoH , January 9, 2019 at 10:38 am

Thanks for sharing.

This seems reminiscent of bank ATM fee scams. A dollar here, $2.50 there – systemwide – and soon you're talking about real money. It also matters whose budget the costs or income are shifted to, which is often a highly-competitive internal game. Same with the now ubiquitous and easily incurred penalty charges, which banks use to generate the outlandish returns they now consider their due.

Coincidentally, I was recently helping a friend with her latest medical bill. Always good sport if it's not your bill. It was "only" for about a thousand dollars. Her insurer paid the amount, minus her deductible.

The hospital system sent her a follow-up bill for the same service. It was for the deductible the insurer did not pay – routine – AND for another thousand dollars, which was not.

Here's the hospital's argument: It had billed the insurer and the patient only a thousand dollars. But the insurer considered bills for up to two thousand dollars for that service. Having, in effect, underbilled the insurer, the hospital added the difference between its first bill and the maximum amount the insurer would consider.

But the hospital did not bill the insurer for the higher amount, only the patient. That routine also happily avoided any reasonable and customary cap the insurer and hospital had agreed to.

The hospital does this routine systemically. Its "customer service" operators have a canned response for outraged patients: You'll pay it in the end and we'll dock your credit score in the bargain. Film at eleven.

Steven Hoel , January 9, 2019 at 10:39 am

I have found this letter (or to be used as script to be read over the phone) to be 100% effective so far. I suspect it gets kicked up to a supervisor who wants to get rid of the crazy customer:

"To: "Big Corporation"
Regarding Inv #

Hello,

You have issued your fourth notice. Please note that this is now my third notice to you of whom to bill. If I must spend more time on this issue, I will be billing out at $200 per hour in ½ hour increments. Sending a further notice without contacting "XYZ Healthshare" for payment will indicate acceptance of my terms.

This blood work was for my annual Physical. I am covered under "XYZ Healthshare" and they cover one physical per year.

Please submit above referenced invoice for payment to:

"XYZ Healthshare"
Payor ID:
P.O. Box 1234
Anytown USA 12345

Insured: John Doe
Policy # 123456789

It is not acceptable to simply send me another payment notice when you are not billing as I instructed. I will send my billable hours in return and submit a copy to my attorney.

Best Regards,

John Doe"

NotTimothyGeithner , January 9, 2019 at 10:44 am

The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home.

Perfect.

jrs , January 9, 2019 at 12:56 pm

Of course Trump's misdeeds are becoming abuses much closer to home, having one's government closed becomes real impractical even on the day to day level.

Spring Texan , January 9, 2019 at 11:08 am

Wow, this makes me very happy I work for a self-insured employer which unfailingly pays bills in good faith. Awful.

California Bob , January 9, 2019 at 12:10 pm

I was with United Healthcare in the private sector for years, with good coverage and no serious issues (PPOs only). When I went on Medicare, I stayed with AARP-endorsed UHC; I figure the last thing UHC would want is a bunch of angry retirees with time on their hands. So far, so good.

Jimmie Q , January 9, 2019 at 5:40 pm

I don't know about that. I've not been able to login to the AARP/UHC website for 2 months.
They admit that there is a problem. After 2 months I'd say they are correct.
You'd think they would go back to the last working version of their log-in software.
What kind of testing was performed before inflicting this crap on their users. None, by the looks of it.
It's pretty obvious when you can't login. How stupid are these people ?

Oregoncharles , January 9, 2019 at 12:17 pm

Not medical, but a similar penny-ante scam that we encountered from a car rental, which I will name: it was Dollar/thrifty – they're the same company. Ironically, we were happy with their service, given the price, UNTIL we turned the car in at the Indianapolis airport. The agent claimed the system was down, so couldn't give me a receipt; foolishly, and feeling time-pressured, I walked away without one (don't do that).

The company first claimed the car had not been turned in, then discovered that it had been re-rented the next day, so charged us for an extra day. I refused to pay it, since an agent had agreed that our boarding passes from the airline proved when we'd turned it in. In fact I got the credit card company to reverse the extra amount (their service was exemplary). Attempts to clear it up on the phone led to hangups at their end, and ultimately they sent the $50 difference to collection. When I got a call, I started yelling about it being a fraudulent charge and making legal threats; never heard from them again – not worth it for such a small amount. I felt that principle was involved.

And now the oddity: Dollar/Thrifty belongs to Hertz, but we've had no trouble renting from Hertz. Go figure.

JerryDenim , January 9, 2019 at 1:21 pm

One scam I've seen Hertz attempt on me twice, was claiming a car wasn't returned completely full, like 1/16th shy of full, then they proceed to charge you for a full tank of gas (15, 20 gallons or whatever that means based on the vehicle) at some outrageous price like $9.00 a gallon. It's a scam that is always going to add up to over a hundred dollars. It's a quick, vicious one-time burn (sharp practice as Yves would say) they try to pull on customers they figure may never rent from them again anyway. Algos I'm sure. Always document, document, document with rental cars. Cell phone cameras are great in this regard. Photos of the odometer with gas gauge displayed work great for refuting such charges.

beth , January 9, 2019 at 8:32 pm

I was definitely scammed by Dollar/Thrifty. I have switched to using Enterprise but they sometimes don't have an airport location. So far so good. I usually take only one trip a year.

Oregoncharles , January 9, 2019 at 12:21 pm

Afterthought: Insurance is a service business, which would normally depend on providing reasonably good service – granted, in this case Yves is locked into an old contract, so they might be trying to get rid of her.

I wonder if this sort of behavior means they see the political handwriting on the wall, figure the business can't last much longer, and are trying to extract the last dime, because it IS the last?

EoH , January 9, 2019 at 3:13 pm

Standard business model. Nothing special.

I question whether insurance is any longer a service, at least for the customer. Health insurance used to be a business that offered a reasonable service, service tracking and payment processing for employers, who purchased the service for their employees as a form of deferred compensation, in exchange for a reasonable fee.

The model seems to have changed to one of open and notorious self-dealing. The intermediary has become a principal, and no fee and no level of profit is too great. The intermediary makes decisions that look to the lay person like practicing medicine – not seemingly in the interest of savings its employer customers money, but it making it for themselves. The model is a major reason for the extraordinary cost of medical care in the US.

Synoia , January 9, 2019 at 12:26 pm

Small claims court?

ambrit , January 9, 2019 at 12:57 pm

That would be a tax on her time, she has to physically show up in court for the 'trial', and money, as in, filing fees. A small claims judgement does not guarantee payment. That could take a second suit. (I had to go for a second filing to get my judgement paid.)
This is a systemic problem. The remedy in that elusive "perfect world" is to change the system.

AdamK , January 9, 2019 at 12:55 pm

"Corporate America has been institutionalizing penny-ante scams "

Don't get me started. 24 hour fitness sold membership for super sport facilities at a higher price promoting the deal that gives free towels to members while at the gym. 3 years after, towels are gone. Price was raised several times, and there is no difference between regular facility and super sport. No one complained. They simply got the news and adjusted. Saying something is not considered appropriate, so we continue to pay more and more and getting less and less.

ambrit , January 9, 2019 at 1:05 pm

Same dynamic used for Internet services, telecom services and cable services. Life is legally an "ethics free zone" today.
Reminds me of one of the more vulgar posters I once saw. A mid range shot of a woman's "private parts" with a 'tattoo' above the mons pubis saying; "Abandon all hope, ye who enter or exit here."

WheresOurTeddy , January 9, 2019 at 2:32 pm

seems germane:

"The political crisis we are facing is simple. American commerce, law, finance, and politics is organized around cheating people." – Matt Stoller

https://twitter.com/matthewstoller/status/893848256769171458

JerryDenim , January 9, 2019 at 1:10 pm

This story is strangely similar to the battles I used to wage years ago with Sallie Mae to pay down my student loan principal ahead of schedule. I would send checks that would never be cashed. If they ever were the amount would always be applied to interest and never principal. Tons of emails, phone calls and letters stretching out over months all about one check or another.

"Oh you sent the check to that address? No that's all wrong, try this one." "Oh, no, you have to write a letter stating you want the amount to be applied to principal. Oh, you did already? Oh, well send one to this department at this address instead and your next one should be be applied to principal."

Absent an aggressive regulator corporations can play infuriating games like this for years until the consumer gives up or lawyers up. Lawyering up is no guarantee of victory and doesn't make financial sense for small penny-ante grievances. Most people stuck dealing with hassles like these don't have the money to lawyer up anyway and corporations know it. I remember back in 1995 when my phone service was changed without my permission and I received an outrageous bill. I placed one phone call to the FCC that lasted a few minutes and I received a $250 credit and my phone service was free for the next year. I miss those days.

"The punditocracy wonders why more Americans aren't worked up about Trump's misdeeds. The great unwashed public is beset with abuses much closer to home."

Absolutely. It's really tough for working class Americans to shed a tear for Central American border jumpers having a rough go of things with ICE when their own government refuses to protect them from thousands of small capitalist depredations that they are subjected to on a daily basis.

tongorad , January 9, 2019 at 1:11 pm

Corporate America has been institutionalizing penny-ante scams like the one Cigna ran on me
I received an errant charge when I chose to cancel my account with a phone-carrier giant. Lots of time on the phone speaking to different people, demanding to be sent an invoice/bill.
In the end, I just paid. I was losing sleep over it.
I have a feeling that these kinds of extractions are commonplace.
What a world

beth , January 9, 2019 at 8:41 pm

If we are discussing scams, I had an earthlink account for about a year when I noticed that rather than billing me monthly, they were billing me every 20 days and when I noticed it, they said they would refund my money at my request.

And what do you think happened?

M Morrissey , January 9, 2019 at 1:20 pm

File a complaint with your state insurance department. Most departments have dedicated staff who will follow up on such issues. If you one of many victims, it can lead to a "Targeted Market Conduct Examination" of the company.

Once that happens, the insurer will readily settle claims such as yours because besides fines, the impact of an examination damages their reputation. Also, if there is a pattern of misconduct, the complaint information is shared between the 50 states, who may also initiate targeted examinations. Don't get mad–get even.

monday1929 , January 9, 2019 at 6:06 pm

You are kidding, right?
And ."damage their reputation"- thank you, I needed a laugh.

JBird4049 , January 9, 2019 at 1:37 pm

The more people are in need of medical care the less likely they are to have the time, energy, or even money to maintain their records, read all their letters and emails, and write and call enough times to finally get their money. The sicker are the less likely you will get paid. Truly vulture capitalism.

Dan , January 9, 2019 at 1:57 pm

I tend to agree that these 'billing mistakes' are a conscious strategy on the part of insurers. For several years Kaiser (Northern California) would attempt to bill me $15 every time for routine physical visits (which my physician had requested!). Routine physicals, of course, are meant to be free under the ACA. Every time the receptionist would request payment in advance, I would decline an tell them that the appointment should be free. They then would proceed to bill me by mail, and I had to spend time calling them to resolve the issue. Unlike Yves' experience with Cigna, Kaiser customer service was always friendly and promptly resolved the 'error'.

Since we changed from a Covered California plan to a small business plan this practice appears to have stopped, at least for me. Nonetheless, this annual ritual was a ridiculous tax on my time, and I wonder how many people who were less informed/hostile to their insurer than I am have just paid these false and illegal fees up front. The consistency of this practice over a period of years makes it hard for me to believe that there is really error involved, as opposed to a subtle fraud by the insurer.

monday1929 , January 9, 2019 at 6:13 pm

It is never an "error", and it is always in their favor (proof it is not an error).
They target the sickest, least likely to fight back. There is an MBA somewhere who wrote an algorithm designed to screw the old and sick. My nightmare with United "healthcare" (why are they allowed to call themselves or imply they are healthcare providers?) was on behalf of someone else who never could have fought these scammers.

tiebie66 , January 9, 2019 at 3:31 pm

So, they legislate to permit disruption against you and not against them, but year after year – figuratively speaking – you send the same people back there. The system is beyond reform, is that not clear by now? Vote for anyone –except– a Democrat or Republican. It would create upheaval at first, like spring cleaning, but it is as necessary. If you are too timid to make changes, you will only get weaker and weaker until you are too weak to resist. Don your yellow jackets!

But on a different level – where does this originate? My sense is that it is a failure of education. The nation can neither read, nor write, nor think. This makes for easy victims. Do teachers really deserve better pay? Is teaching not a 'calling' rather than a career? Should teachers not do better? But perhaps the failure of education is also, in part, institutionalized?

Big Tap , January 9, 2019 at 4:55 pm

Speaking of insurance scams some involve a PPO type policy. More and more often I'm told at the time of service of a doctors visit to pay up front. With a PPO policy you usually don't know exactly what you owe till after the insurance company tells you what your co-pay is and then you're billed. When you pay up front bring overcharged intentially is the scam. Getting a refund of your own money can time consuming.

Pft , January 9, 2019 at 6:49 pm

Not only health insurance. Good luck if your house burns down and you want them to honor the contract in a timely fashion. They hold off until you accept less hoping you hate living in 2nd rate accomodations enough to cave. My sisters contract called for full replacement of all contents regardless of age. She paid a hefty premium for that. They held out for months offering less saying some of the contents were older and not worth the replacement cost which is what she wanted to avoid by paying the extra premium for the upgrade. Came to an agreement somewhere between but took 15 months before she could move back in.

EoH , January 9, 2019 at 7:37 pm

There is the basic problem that with almost every medical service, the customer does not know the price until the bill(s) show up in the mail. (Nor have they any training or experience that would enable them to choose alternative treatments or vendors.) Only later still does an insured customer find out what portion of that bill is her responsibility. And that's without errors and intentional mis-billing, which are common.

The usual conservative refrain that patients need more skin in the game studiously ignores that patients always have all their skin in the game, even though no one tells them the game or the rules until it's too late. It is an environment that could only make predatory behavior flourish.

Katherine , January 9, 2019 at 9:57 pm

This is one of the most unsettling posts I have read on NC since becoming hooked about 6 months ago.

cat sick , January 10, 2019 at 2:44 am

Live a healthy lifestyle and self insure

I am sure not dealing with insurance companies is a sure way to lower stress levels and therefore require much less healthcare.

As a fairly healthy 50 year old I find that even though I have access to a good free first world healthcare system (Singapore ), never using it and paying doctors direct for all my needs is the way to go and probably costs me 10% of what a US citizen might pay for an insurance policy.

When I am in the US and so many people you meet have "meds" that they take on a daily basis it leads me to believe that not only are the insurance companies in on the scam but also the doctors and drug companies plying people with drugs that in most cases probably make them worse off

The first $20 of care I would reccomend is to buy one copy each of "how not to die" and "the case against sugar" read these and then do all you can to avoid both insurance companies and doctors .

[Oct 27, 2018] Surgery on a Sunny Afternoon Got Me Thinking About Healthcare

Notable quotes:
"... Millions young and old, caught up in the struggle for Healthcare and now there's a consensus. ..."
caucus99percent
span y divineorder on Sat, 10/27/2018 - 1:52pm Millions young and old, caught up in the struggle for Healthcare and now there's a consensus.

Yesterday we caught the bus downtown to the Dragon Room in the Santa Fe Plaza area for Happy Hour to meetup with friends we hadn't seen in a year. Heh. As happens with we seniors, part of the time was spent catching on health issues.

Our friend is facing knee replacement surgery with complications. Carpenter property manager by day, musician by night, he was worried about how things would turn out. But at least he had coverage through his wife's employment. Millions still don't have healthcare, and many who do, face denial of coverage and worse.

It clearly is a huge issue for some in the upcoming midterms.

Senior or no, perhaps you, too are worried about how things will turn out?.

Medicare Advantage vs. Medicare for All https://t.co/EFG1G4QKCS

-- Alice Marshall (@PrestoVivace) May 31, 2018

For those who followed the healthcare debacle during Empty Suit era it has been gratifying to see the coverage and movement toward single payer.

But there are still serious obstacles.

Dr. @awgaffney details the barriers to #SinglePayer reform: "Obstacle number one is the corporate opposition, obstacle number two is the potential that #MedicareForAll could be co-opted or sort of mutated into a lesser thing." https://t.co/E4xTSBPx2E via @businessinsider

-- PNHP (@PNHP) October 26, 2018

Here's another link for those who want to educate themselves on MA vs IMFA.
http://healthoverprofit.org/2018/03/27/medicare-advantage-vs-medicare-fo...

Over the last few decades, insurers participating in Medicare Advantage have schmoozed Congress into compensating them with more money per person than is allocated to traditional Medicare. Don McCanne of Physicians for a National Health Program writes:

"Each year the administration, whether Democratic or Republican, uses quirky arcane rules to ensure an adequate revenue buffer so that private insurers can compete favorably with the traditional Medicare program by offering lower premiums and cost sharing and expanded benefits Once a critical mass has enrolled in private plans, Congress will gradually reduce the relative value of the voucher-equivalent, reducing the government component of the funding of Medicare by shifting more costs to the Medicare beneficiaries."

We see this happening right now, with top leaders of Republican Party expressing a strong interest in cutting Medicare. In response, physician advocates argue that the private Medicare Advantage HMOs should be isolated as a source of wasteful government spending, and that benefits offered by these plans should be expanded into traditional Medicare. Physicians for a National Health Program (PNHP), the doctor-led think tank for single payer policymaking, has been putting forward a strong case against Medicare Advantage for some years.

PNHP points to a number of studies that show the Medicare Advantage HMOs cherry pick healthy patients and lemon drop expensive, unhealthy ones. This is done through narrow coverage networks and poor access to specialized care , driving patients with heavy medical burdens into traditional Medicare – where they can choose their own providers. A 2015 Brown University study showed that of Medicare Advantage patients who had long-term stays in nursing homes, 17% switched to traditional Medicare the next year. The report's lead author, Momotazur Rahman, told NPR news that there are incentives, including "steep cost-sharing as patients need more expensive care" and "limitations on expensive treatments",that because sick patients to drop out of Medicare Advantage plans. A 2017 Government Accountability Office (GAO) report found that of 126 Medicare Advantage plans, 35 plans saw disproportionally high numbers of sick enrollees dropping out into traditional Medicare.

In 2017, a Kaiser Family Foundation (KFF) study found one out of every three Americans enrolled in Medicare Advantage plans were given narrow physician networks. It concluded that plans offering broader networks tended to have much higher premiums than narrow-network plans. KFF also found that one out of every five plans do not include a regional academic medical center in their networks, and estimated that 40% of Medicare Advantage networks included top-quality cancer centers.

The Medicare Advantage insurers can also increase their profits by upcoding the severity of the diseases that their patients have. HMOs are paid per capita based on the number of patients they cover. The payments are also risk adjusted according to the severity of the illnesses of those covered: the more severely ill, the higher the compensation. So it is to the Medicare Advantage plans' advantage to upcode, to make patients seem sicker. Investigations by the Center for Public Integrityand the work of academics show that there is both direct and indirect evidence of massive upcoding in Medicare Advantage, costing the government and taxpayers tens of billions of dollars.

While Medicare Advantage is not an efficient or an equitable means of offering care to senior and disabled Americans, it's important to look into some of the benefits that satisfied patients (who tend to be healthy) are grateful for. All of these benefits would be offered (and enhanced) through a national health insurance system like National Improved Medicare for All (NIMA).

Sorry for leaving out the extensive hot links in the above quote.

So as before its a crapshoot that the Dems and their Repub buds won't screw this up for us.

My wife C99er jakkalbessie and I rode our pedal assist bikes down the Arroyo de Chamisa Urbano to the grocery store this morning, and it is one beautiful fall day here in
The City Different. Leaves are changing, there's a little snow up on the mountains east and west. Such a glorious day to be alive, and able to pedal around still!

I got to get my butt in gear and get ready for MOHS surgery. Spending too much time out in the sun, I guess.

Running through my mind are thoughts like " How much will I have to end up paying? Will my Medicare Advantage Employer group coverage try to deny it?"

What if I were like millions, with no coverage at all? My brother has a much larger problem on his face and no insurance what so fcking ever.

It's all but guaranteed that Trumpco will finally strangle ACA to death and soon. And then there's the worry about how corpadems can fck everything up.

What are people going to do? All the best to you and yours, good health to all.

Of course its not just we mouldy odies that care about this sheet.

AP-NORC/MTV Poll: Young people back single-payer health care https://t.co/pnBGhCq0Pq

-- Health Care For All (@HCASFV) October 26, 2018

Young Americans called health care a very important issue in deciding how to vote. Sixty-two percent of those who will be old enough to vote in the midterms rated it as such. That's the most who said the same of any issue in the poll, including... https://t.co/K2oMRAXPRz

-- Big Easy Magazine (@bigeasy_mag) October 27, 2018


More power to us all.

Wish me luck! Hoping to be in the 94% success rate for this surgery. Divineorder.

[Oct 25, 2018] Is Medicare for All the Answer to Sky-High Administrative Costs? by Lambert Strether

Oct 25, 2018 | www.nakedcapitalism.com

"Is Medicare for All the Answer to Sky-High Administrative Costs?" [New York Times].

The answer will surprise you! "Medicare's direct administrative costs are not only low, but they also have been falling over the years, as a percent of total program spending.

Yet the program's total administrative costs -- including those of the private plans -- have been rising. 'This reflects a shift toward more enrollment in private plans," Mr. [Kip] Sullivan said.

"The growth of those plans has raised, not lowered, overall Medicare administrative costs.'" • It is very gratifying to see a single payer stalwart like Kip Sullivan quoted as the authority he indeed is.

And, contrary to the headline, it does look like Medicare has a bad neoliberal infestation that needs to be dealth with. "Free at the point of delivery" is a good starting point, because that strikes a deathblow at the complex eligibility determination process so beloved by markets-first liberals.

[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?

[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.

[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......

[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 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/

[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 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 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....

[Nov 05, 2015] Fake herbal supplements are more common then you think

observer.com

observer.com

Earlier this year, the New York AG investigated supplements at major retailers and found that four out of five didn't contain any of the labelled herbs. They contained "cheap fillers like powdered rice, asparagus and houseplants, and in some cases substances that could be dangerous to those with allergies." We're not talking fly-by-night Internet products; these are glossy bottles of so-called Gingko Biloba and Echinacea and Garlic, sold in stores like GNC and Target and Walgreens, with relaxing names like "Herbal Plus" and "Spring Valley":

1-rMEC1moEKkOBfuiGvH8Czg

When you buy a supplement, then, you're effectively on your own - not just in determining whether the supplement is safe and effective, but even in deciding whether you're eating what you think you're eating. Reload's packaging suggests it's an "herbal blend" full of plants like Gingko Biloba and Saw Palmetto, but tests show that it actually contains sildenafil, the strong prescription chemical found in Viagra itself.

This is a much freer market than people are accustomed to when they purchase anything from a reputable retailer, let alone something they plan to swallow. Absent stricter regulation, busy citizens count on the media to inform.

[Oct 28, 2013] OBoZoCaRe BoNaNZa!

Zero Hedge

Below is Kunstler's description of our medical situation. All that needs to be pointed out is that the republicans are primarily the ones responsible for opposing the kinds of fixes that would have gone a long ways to remedy the situation. A single care provider approach means cutting out the sleazy tribe of middle-men who make our way of fleecing the ailing public so profitable. The prime directive of the republican party is at all costs protect the unholy wealth of those who already have most of it...

The ObamaCare piece of the picture is a mere pathetic soap opera compared to the first two quandaries. The 2000-page law did nothing to address the core tragedy of medicine in America - namely, that it has evolved into a hideous hostage racket. You go to a hospital with a terrifying illness and you are susceptible to fleecing by the so-called "care-givers" for the promise that you may get to live. No prices for treatment are never discussed. They are presumed to be astronomical - but who cares if you end up dead, and if you do get to live, you'll figure that out later. If you hold an insurance policy, these charges will be subject to a fake negotiation between grifting insurance companies and grifting hospitals, physicians, and drug companies. The price "settlements" are only slightly less a joke than the actual charges, and are obfuscated in documents designed to bewilder even well-educated policy-holders.

Even if you are insured, the charges may bankrupt you. A typical one-day charge for "room and board" in a non-specialized hospital in-patient bed runs $23,000 at my local hospital. For what?

Half a dozen blood-pressure checks and three bad meals? You can be sure that ever-fewer families will be able to fork over $12,000-a-year for basic coverage.

The ObamaCare legislation and its laughable rollout of a useless website is just a punctuation mark at the end of the soap opera script.

The result eventually will be the complete implosion of the medical racket and a return to a very primitive clinic system, with payment in chickens or cords of stove-wood. The smaller number of surviving humans will surely enjoy better health, and greater piece of mind, when this monster racket expires of inertia, bad faith, and deceit.

[Nov 03, 2011] The profit in keeping you ignorant by Wendell Potter

iWatch News

Health insurance industry and its corporate allies are fighting requirement that policies be understandable By Wendell Potter6:00 am, October 31, 2011 Updated: 1:21 pm, October 31, 2011 PrintE-mail6 inShare. Columnist Wendell Potter Robin Holland If you have no idea what you're paying good money for when you enroll in a health insurance plan, there's a good reason for that: insurers profit from your ignorance. And they're waging an intense behind-the-scenes campaign to keep you in the dark.

In my first appearance before Congress after leaving the insurance industry, I told members of the Senate Commerce Committee that insurers intentionally make it all but impossible for consumers to find out in advance of buying a policy exactly what is covered and what isn't and how much they'll be on the hook for if they get sick or injured. Insurers are quite willing to provide you with slick marketing materials about their policies, but those materials are notoriously skimpy when it comes to useful information. And the documents they provide after you enroll are so dense few of us can understand them.

In the months following my Senate testimony, lawmakers drafting health reform legislation included a provision requiring insurers to both provide comprehensible disclosures of health plan benefits and make that information available to anyone shopping for coverage. Despite repeated attempts by industry lobbyists to get that provision stripped out of the final bill, the Affordable Care Act as signed by President Obama last year requires that all private health plans provide consumers with a concise and understandable Summary of Benefits and Coverage (SBC) form. In addition, they must provide a uniform glossary of medical and insurance terms.

If you think that sounds like a reasonable request, you're not an insurance company executive who is rewarded more for meeting Wall Street's profit expectations than assuring that consumers know what they're buying.

Now the Obama administration is trying to figure out how to enforce this new requirement, and so health insurers and their allies have launched a full-court press to persuade government officials to gut it by exempting policies sold where people work. Because the vast majority of Americans who have coverage get it through their employers, this would mean that most of us would, for all practical purposes, continue to have to buy a pig in a poke.

Fortunately there are several organizations, including Consumers Union, publisher of Consumer Reports , that are fighting the good fight. They're demanding that Obama officials write the regulations to apply to all health plans, regardless of whether they are sold on the individual market or through employers, unions or other groups. They insist that Congress intended for the standard form, which would allow "apples-to-apples" comparisons of health plans, to apply across the board.

As Consumers Union noted in comments sent to the administration, the booklet describing benefits that most employers currently provide their workers "is a bulky, legalistic document that few consumers can understand." It cited one study which concluded that the typical benefit description document provided by employers is written at a college reading level. Most Americans have trouble understanding information written above the 6 th to 8 th grade level.

Insurers and their corporate allies, including the U.S. Chamber of Commerce and the National Association of Health Underwriters, are claiming in comment letters to the administration that providing a uniform, simplified and understandable version of those documents would cost so much money they would have to increase premiums.

America's Health Insurance Plans (AHIP), the lobbying and PR group for insurers that says it represents more than 1,300 health plans covering 200 million people, contends that the cost of implementing the proposal would be $188 million. In addition, AHIP says, the annual cost of providing the information would be $194 million. Would insurers consider absorbing those costs? Of course not.

"The benefits of providing a new summary of coverage document, in addition to what is already provided to consumers, must be balanced against the increased administrative burden that drives up costs to consumers and employers," AHIP said in its letter.

Nonsense. Consider this: the five largest insurers (UnitedHealth, WellPoint, Aetna, CIGNA and Humana) over the past week have reported profits exceeding $2.6 billion for just the three months that ended September 30, 2011. Over the past 10 years, those five companies have recorded profits of more than $50 billion. Imagine what the total would be if you added in the profits of the other 1,295 health plans AHIP says it represents.

The industry could even pass a hat among the CEOs of those big insurers and come up with the additional money without any one of them giving until it really hurt. UnitedHealth's Stephen J. Hemsley is the highest paid CEO in America, according to Forbes magazine. He hauled in more than $100 million last year alone. When H. Edward Hanway, my former CEO at CIGNA, retired at the end of 2009, he walked out the door with $111 million. When you consider the money those two guys have made over the years, they alone could cover the cost of providing consumers with information they can understand.

I'd advise everyone to keep their eyes on this skirmish. If the administration caves to the insurers' demands on this, we'll know who really is calling the shots when it comes to implementing health care reform.

[Feb 08, 2011] guest-post-why-small-business-isnt-hiring-and-wont-be-hiring

by cxl9
on Tue, 02/08/2011 - 12:49
#943358

$1000/month for health coverage? Really? I am a 43-year old man who pays $369/mo. for a Kaiser gold policy + prescription. A young person could expect to pay half that. Anyone who believes health care is overpriced or unaffordable is simply hoping the government will force someone else will pay his medical bills.

by docj
on Tue, 02/08/2011 - 13:01
#943378

Good luck finding a "state approved" health insurance policy in the People's Republic of MA for under $1K/mo. (Thanks for that, Mitt Romney.)

by ThirdCoastSurfer
on Tue, 02/08/2011 - 14:31
#943751

Thanks to QE2 I have High Blood Pressure and "suddenly" don't qualify for traditional insurance. I applied for and qualified for "Obama Care" through www.pciplan.gov.

For $400 a month it carries a $2,000 deductible and a $5950 Out of Pocket max (OOP). http://www.pciplan.com/forms/pdfs/2011BenefitsSummary.pdf

So, from Year to Year, I can expect to pay $4800 in premium and $2,000 deductible equaling $6,800 before coverage begins and then I'll pay 20% of the next $19,750 before the OOP max is reached.

It was hard for me to fathom why I would chose (or in 2014 be forced) to accept such terms rather than just pay cash in the hopes that no one annual bill would amount to more than $10,750 (Premium + OOP) until I looked at the cost of random things like an appendectomy or a ER visit for a broken bone, each of which can easily cross $20,000 in expense because of the way hospitals, and health care in general, "upcharge" and "unbundle" their charges. Apparently, no one pays the listed price, so why all the confusion? I have no idea but is it possible that for tax purposes the difference can somehow be applied as a taxable loss as a business expense?

"Talk about what a tangled web we weave"

by blunderdog
on Tue, 02/08/2011 - 15:54
#944043

If all this info is accurate, and you're not happy with the "Obamacare" option, why not just skip the health-insurance and pay the fuckin' tax penalty?

Who in the world even wants health-insurance?

It's the ultimate definition of a sucker bet: insurance against shit you could *never* want to happen in the first place. If it pays off, you lose. If it doesn't, you lose.

I *know* some of these folks, and I'd predict: if something horrible happens to you and fucks your world, you're really not going to give a shit whether you can pay your bills for the emergency surgery.

by Dr. Sandi
on Tue, 02/08/2011 - 17:56
#944520

Once you get on the actuarial bad side of 55, the odds look a lot different.

You can stiff the hospital and all the various hangers-on for the first visit. But you're screwed if you ever have to go back there and don't have cash or credit card in your drooping paw.

by blunderdog
on Tue, 02/08/2011 - 18:09
#944556

Yes, I do actually appreciate that, which is why I say "IF" it looks like a bad deal, fuck it.

What I can't get over is listening to folks bitching about health-insurance costs on the one hand, taxes on the other hand, and outrageous health care expenses on the third hand. No one HAS TO take BP medicine. No one HAS TO have dialysis (or their kidneys replaced) after a decade of *not* taking BP medicine.

The money either has to come from somewhere or it doesn't--if it doesn't, just stop paying and die already. It's no one's fault that people get old and die, right? Your health is going to fail you no matter who you are or what you've done. If you don't want to pay for health-care, DON'T.

Just don't whine about it if you choose to pay. And don't blame government for the fact that you want the best possible care available and "money is no object" as soon as you reach that point, but it's a waste of your tax dollars as long as you feel ok.

Most people I know are completely infantile on this subject. It's no wonder no one's happy with our "policies."

by braveneweconomy
on Tue, 02/08/2011 - 12:55
#943379

Same here. I'm an independent contractor mid-40's and pay about $400/mo. for great coverage. I'm always perplexed by the people who scream about health care being too expensive.

by minus dog
on Tue, 02/08/2011 - 13:26
#943496

Sure, you can get insurance for $250/mo (assuming you can afford that - many cannot) but it doesn't do you any damn good for the sort of routine medical care someone my age actually uses. I typically get a huge cash discount, so my bill is essentially the same as if I were paying for the services with insurance... and without the monthly overhead.

Even at 250 a month, I'd be paying about 10x as much per year for medical and dental expenses. Even with the occasional serious injury every 3-4 years (about $3k a pop) I'm still coming out ahead.

Complaints about "freeloading" are going to fall on deaf ears - two words: Social Security.

This article is spot on; the system exists to fuck us and empty our pockets, why the hell would be participate in it?

by RKDS
on Tue, 02/08/2011 - 13:37
#943517

It would've been interesting for you to provide a salary for comparison, because to someone making $30K and taking home less than $2K per month, $400 right off the top actually _is_ expensive. And it's even worse if your employer doesn't offer coverage and you have to pay even more on the individual market.

by minus dog
on Tue, 02/08/2011 - 18:24
#944590

And, as people seem to keep forgetting, median individual income is somewhere around $26K

by HungrySeagull
on Tue, 02/08/2011 - 14:00
#943602

I know one retired dentist who endured 1200 dollars coverage per month for the wife. The moment the wife hit 65, medicare kicked in and he pockets the 1200 dollars per month.

HOORAY!

And if anything happens beyond what medicare pays, cash paid to billing all done.

by Mercury
on Tue, 02/08/2011 - 12:57
#943391

The acid test isn't whether or not your premium checks get cashed but whether or not you get what you need when you blow a gasket.

by tmosley
on Tue, 02/08/2011 - 13:15
#943456

Exactly. My company changed insurance this year and I went to the dentist for a regular checkup+x-rays. The insurance only covered half of the cost! This policy was the same price (to me) as the older one.

I would hate to see what happens if I were to actually have to go to the doctor or have some surgery.

by TheDriver
on Tue, 02/08/2011 - 13:40
#943556

I'm happy to fill you in on those details. As a 40 yo with reasonably priced coverage who had to face 2 unexpected, unrelated surgeries in as many years, I can tell you how bad things really are. I'll leave the country for future surgeries and pay cash. Even with airfare and lodging costs, it would be cheaper than having the work done in the US.

by HungrySeagull
on Tue, 02/08/2011 - 14:04
#943615

I had two insurance policies.

Both of them fought over a 16,000 dollar Ride in a MRI machine some time ago. They paid it. Then they fight over several surgeries I have had. They paid that too.

The moment Obamacare became law, I canceled both insurance companies and go to cash. If my doctor can fix a boo boo, great! Otherwise I make do.

I learned a month after cancelling for myself and spouse, our premiums would have gone up from about 870 a month to 1450 a month and some services cut back or disallowed.

Sorry. I am not putting money after a company that is cutting back.

Oh the small details about hospice, burial, cremations and all of that is already prepaid and arranged. One phone call does it all.

by baserunr
on Tue, 02/08/2011 - 14:07
#943631

See, here's a disconnect. Insurance is to cover the cost of expensive, unexpected-type events that have a small chance of occuring. If you are going to the Dentist for a "regular" check-up, that doesn't meet the criteria of what "insurance" is designed to cover. Many insurers have found a way to earn additional premium by expanding the boundaries of what they will "insure". That doesn't mean it is such a great deal for the insured; it just means the company can earn additional premium. If you work to keep the insurance for large, unlikley, and calamitious expenses, you'll probably find it very affordable. Pay cash for the rest.

by cxl9
on Tue, 02/08/2011 - 13:44
#943565

Agreed. I have been with Kaiser for years, and I can say that the service has been great. I have no complaints whatsoever with the medical treatment. I plan to stay with them for as long as I possibly can, at least until private health providers are eliminated in the United States and all of us are waiting in line down at the Post Office to get our health care.

by Thunder Dome
on Tue, 02/08/2011 - 12:58
#943394

I'm covering a family of four in the great state of Illinois--$20,000/yr not including dental.

by Threeggg
on Tue, 02/08/2011 - 15:32
#943955

Thunder you are doing better than me. (by $18 dollars) I pay $1718.00 for a Blue Cross Blue Shield Policy in Illinois. (it includes dental) That is for 3 people that are healthy.

I am looking into a major medical policy with a large deductable as I will pay for the regular medical expenses out of my pocket.

The medical sham put forth by Bamy raised all the prices. Now that they have the prices up over the rainbow they now want to repeal it. !

Prepare yourselves peeps as this running financial shit-train is pulling into the station.

[Mar 29, 2010] Will the GOP Remain the Party of No?

This is from The Myrtle Beach Sun:
DeMint, Graham let S.C. down on health care overhaul, by Isaac Bailey, The Myrtle Beach Sun: Two South Carolina legislators had the opportunity to shape the historic health care bill President Obama signed into law on Tuesday... Because the Senate version of the bill was going to be the foundation of the law, Sens. Lindsey Graham and Jim DeMint were our only two politicians who could have forced even more conservative ideas into the legislation. ... Neither did. Both shirked their responsibility to the state to walk lockstep with the GOP.
There was little reason to expect anything different from DeMint, who represents the party's Rush Limbaugh-wing. He didn't begin the debate saying we must find a way to bring down S.C.'s high percentage of the un- and underinsured. He didn't say we must find a way to stem costs that are spiraling out of control, bankrupting hard-working people for the sin of getting too sick. He didn't say the days of uninsured families having to leave coffee cans decorated with a sick loved one's photo on convenience store counters must end. He didn't say that if reform included strong tort reform so doctors would no longer feel the need to perform unnecessary tests that he would vote for it.
Instead, he said reform's defeat would be Obama's "Waterloo", that it would break the president. Only after his comments ignited a firestorm did DeMint propose a policy that most experts considered laughable. He was focused on politics, not people.
Sen. Graham began the debate differently. He knew if nothing changed, our health care system would eventually bankrupt us, which is why he initially supported the bipartisan Bennett-Wyden bill. ... But the proposal went nowhere fast. Instead of Graham engaging in the fight to incorporate the best parts of Wyden-Bennett - or any other effective plan - he fell in line with the rest of the GOP caucus.
He, too, became more concerned about his party's positioning for November than the people he was sent to Washington to represent...
The most vulnerable South Carolinians ... needed Graham and DeMint to lead. ... They didn't. Instead, they stood for the petty and ignored the real needs of the people. History won't forget. And neither should we.

And, from the local paper this morning:

Move past 'repeal, replace', Editorial, Register Guard: Republicans are preparing to march into the 2010 election under the dubious banner of "Repeal and replace!"
It's a losing strategy, one that GOP lawmakers should rethink before venturing too far down that road. The health care reform bill has been signed into law. ... The Republicans should turn the page on health care if they want to shed the "party of no" label that served both the GOP and nation poorly in the debate over health reform.
That doesn't mean that House Minority Leader John Boehner and other Republican leaders should publicly embrace Obamacare. That's unrealistic; their philosophical differences with Democrats on reform are too deep and broad, and Republicans resentment over President Obama's historic achievement precludes even the pretense of a political truce.
But Republicans face long odds in any attempt to repeal and replace health care reform, and they know it. ... As Sen. Jon Kyl, R-Ariz., acknowledged, repeal "is not realistic because Barack Obama would veto the bill and we don't have the votes to override it."
For Republicans such as Boehner, Kyl and DeMint, "repeal and replace" is an election strategy and not a practical legislative goal. ...
Repeal-and-replace Republicans eventually must face the difficult task of explaining why their apocalyptic predictions - everything from the death panels to the dismantling of democracy - didn't come true. In the months and years to come, many Americans, even those skeptical about the reform effort, will come to see the scare tactics as hyperbolic depictions of a bill whose moderate approach incorporated many Republican ideas.
Republicans have just suffered a devastating legislative defeat, and they are entitled to nurse their wounds. But the GOP's political aspirations - and the nation's interests - would be best served by full engagement on the many critical issues facing Congress, from financial regulatory reform to immigration to unemployment. ... Republicans remain fixated on their loss on health reform - so much so that some, including Sen. John McCain, R-Ariz., have publicly ruled out any bipartisan cooperation for the remainder of the current session.
The American people need - and deserve - a legislative process in which both parties are engaged and bring competing views to the table. By clinging to the cold corpse of the health care debate, Republicans will miss an opportunity to express a clear, compelling vision on other issues - a vision that could do far more to sway voters to their side this fall than continuing to flail away over health care. ...
While there is still time, Republicans should repeal and replace their catchphrase, and substitute another that bodes better for their party's future.

There's an inconsistency between free market ideology and the need for reform in areas like health care and financial services. One of the first steps in reforming the system is to acknowledge that the market won't take care of the problems itself. Once that is acknowledged, i.e. that regulation is needed to fix these market failures, the only question is whether that regulation will be of the "market-based" variety or by edict (e.g. this is the difference between system of tradable carbon permits that allow least cost carbon reduction strategies to emerge and a government set emission limit for each industry which generally does not achieve ca4rbon reductions at least cost).

With Democrats mostly opposed to old fashioned edict style regulation -- with their willingness to embrace market-based solutions to regulatory issues -- and with Republicans unwilling to embrace anything that Democrats propose, there is little ground left for those Republicans who are willing to admit that markets sometimes fail to stand upon. Democrats have taken the middle ground -- market based regulation -- from Republicans. This leaves Republicans with a choice of going along and compromising (and thereby embracing proposals they have made in the past, e.g. the health care bill looks an awful lot like the health care program Romney put in place in Massachusetts), or standing in opposition simply because it is a Democratic proposal. The choice they've made, standing in opposition to everything, is a losing strategy that allows policy to be shaped entirely be the other side. It will be interesting to see if a fissure develops within the Republican Party over this.

Will Republicans be able to share the market-based regulatory ground Democrats have taken away? There are already signs that Republicans will work with Democrats on financial reform, but there were early signs of a bi-partisan effort on health care as well, so we'll see how this plays out. I think people are fed up with banks and want something to be done, and Republican attempts to block legislation won't play well with the public at all. So I expect the coalition of no to be broken -- some legislators will see that they cannot continue just saying no and expect public support -- but not without big fights within the Republican Party between the extremists and the centrists. If Republicans do move in this direction, and it's more likely they'll do so on financial reform than on climate change legislation, you'll see an attempt to reclaim these policies as Republican (here's a great example: Health Care Reform--A Republican Idea?). And given the administration's centrist tendencies, in many cases they'll have a pretty good argument.

Posted by Mark Thoma on Saturday, March 27, 2010 at 10:34 AM in Economics, Financial System, Health Care, Politics, Regulation Reblog Permalink Comments (32)

Comments

roger said...

MT, you write about the Dems "willingness to embrace market-based solutions to regulatory issues" - I'd read that a little differently: with the Dems "unwillingness to embrace regulatory solutions to market-based problems."

That, I think, is a more accurate index of the Democratic party's conservatism.

howard said...

we can only hope that the gop will go all-in on repeal....

jrossi said...

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

Get to work on this, politicians of America.

OhNoNotAgain:

The big question is: are the Medicaid rates for specialists enough for them to make a profit and cover their costs ? If so, then I think these specialists are going to find themselves in a lot of trouble if they keep up the practice of refusing to see patients because the payments aren't as high as they want them to be.

jrossi:

That is a big question. Profit is total revenue minus total expenses. What you're really asking is whether the marginal cost of seeing a Medicaid pt is greater than the marginal revenue you get from seeing the pt. Well, it depends on the practice's variable cost structure, doesn't it?
Another interesting question is opportunity cost. If you can see a private pt at $200 and a Medicaid pt at $75, the choice is easy, if you can pick and choose.
Will the specialists be in a lot of trouble? Again, it depends. If I send the ENT 9 paying pts for every Medicaid one, he risks losing a lot of money by pissing me off and refusing to see my Medicaid pt. If I send 2 paying pts for every 8 Medicaiders, well, he might not care for my business.
The devil is in the details in HC reform.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag.

For example, suppose a Medicaid pt comes to my practice who needs immediate specialty care (draining a peri-tonsillar abscess, for example), but who will be unable to see one because none of the local ENT docs will take the risible payment. So I"m stuck, with an acutely ill pt that I can't help. Well, I could spend a hour on the phone begging someone to take him, or I could send the pt to the ER and move on to my next pt, so I can actually stay in business and keep my practice open. This kind of crap happens every single day in poverty medicine and is one of the main reasons why it can be so hellish to take care of people without adequate insurance. Begging the GI guy to see your rectal bleeder, begging the surgeon to see your hernia case, begging the neurologist to see your headache pt. Make no mistake about it, insurance that specialists refuse is inadequate. Better for mental health and, usually, the bottom line of the primary doc to refuse to take part.

[I know, I know and this is quite important and especially worrisome since there are supposed to be further limits to physician payments to come and the limits are to be selective in terms of area of practice.]

Hal:

The GOP seems headless. One would think McCain would be the leader, but he is so weak and desperate he needs Palin to help him keep his senate seat. When Palin is the GOP's not so secret weapon you can be pretty sure the party is headless, or better, brainless. What is frightening is that brainless might win lots of votes in 2012 if Americans are still angry and uninformed.

anne:

J Rossi:

This bill has lots of problems from where I sit. One comes to mind immediately: Medicaid reimbursements will increase for us primary care docs, but will be cut for specialists. This essentially turns the primary doc's office into a Community Health Center (poverty medicine clinic), where the primary is left holding the bag....

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

March 25, 2010

More Doctors Giving Up Private Practices
By GARDINER HARRIS

The delivery of medical care is changing as more young physicians take jobs with heath systems and older doctors sell their practices to those same systems.

[Also, the nature of what a community doctor is and how much leeway such a doctor may have is changing and seemingly quickly.]

alan :

There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system. For example, I went to doctor to get finger stitched, was told I needed a surgeon and had to go to ER. All I got was 5 stitches! Maybe the primaries and nurse practitioners will have to get on with doing real care instead of referring, and maybe we'll have to figure out how to get the gun-for-hire lawyers to back off.

jrossi :

That's weird Alan. This family doc sews people up all the time, and so does my NP. You must live in the East or in a big city.

jrossi :

Anne, Independent family docs have been a dying breed for years, but now it's hitting the specialists--and quick. I don't know if it's good or bad. Interesting times.

Fred C. Dobbs:

I wonder, is there any other reason for this than specialists getting much better salaries?

It is true, apparently, that doctors are 'practicing differently' these days.

http://www.nytimes.com/2010/03/26/health/policy/26docs.html

NYT - March 25, 2010
More Doctors Giving Up Private Practices
By GARDINER HARRIS
WASHINGTON - A quiet revolution is transforming how medical care is delivered in this country, and it has very little to do with the sweeping health care legislation that President Obama just signed into law.

But it could have a big impact on that law's chances for success.

Traditionally, American medicine has been largely a cottage industry. Most doctors cared for patients in small, privately owned clinics - sometimes in rooms adjoining their homes.

But an increasing share of young physicians, burdened by medical school debts and seeking regular hours, are deciding against opening private practices. Instead, they are accepting salaries at hospitals and health systems. And a growing number of older doctors - facing rising costs and fearing they will not be able to recruit junior partners - are selling their practices and moving into salaried jobs, too. ...

jrossi:

It's the money, Fred. If PCPs could make a reasonable living we would not group up much. Actually, a small single-specialty group is fine, mainly because you can share on-call and overhead, plus a lot of us like a small group--two or three heads are better than one. But most docs, myself included, would avoid multi-specialty groups, where PCPs are low men on the totem pole, and hospital or health system owned groups, where a@@holes in business suits call the shots. Most docs like to be independent. But you can't make much of a living doing this, so we are forced to group up. There's a recent post at Kevinmd about a doc worried about cuts in Medicare putting him out of business (he's an internist so he should be OK at least temporarily with the 10% increase), but the details of the doc's practice finances are interesting. Revenue 800k, Costs 720k, take home 80k. He shoulda gone to nursing school, probably would get paid more.

Fred C. Dobbs:

I think it's interesting that doc's like to be businessmen, get the revenues, don't like the costs, complain about the net. Forget nursing; go be a (salaried!) hospitalist. On the other hand, you guys are heroes & life-savers. Deal with it!

You want $$$, go be investors.

Zephyr:

The healthcare system is being choked by the pressures of the insurance system. Insurance is the biggest problem with our healthcare system. We need to remove the insurance bureaucracy from the healthcare dollar. This applies to government insurance and private insurance.

We need publicly funded clinics and hospitals available equally to all.

We have public roads, public defense, public schools...
...why not public healthcare?

Fred C. Dobbs:

Just 4 years ago, Mitt Romney was getting along wonderfully with the Democrat-controlled MA legislature, famously establishing universal health care (which was good enough to become the model for the US plan). Things were looking up for him and the Republicans, sort of. Then the election campaign of 2008 happened and the Republicans soiled themselves. The question has to be, can they swallow their pride, clean themselves up, and return to rational political discourse? The country sorely needs to have two functional parties, for balance if nothing else. It's not looking good, yet.

Fred C. Dobbs:

'Things were looking up for him and the Republicans, sort of': aside from a furious
urgency to get past the Bush Jr years a.s.a.p.

anne:

Alan:

"There are a lot of strange distortions in the medical system right now - probably a lot to do with malpractice system."

The effect of malpractice concerns has been repeatedly studied and found to have a minimal effect on health care cost. A sense of this is that by the beginning of 2005, there were already a majority of states with malpractice suit limits in effect and the difference has been minimal if any. Nonetheless, there is a sense that malpractice makes a difference in costs even among doctors even in states with the strictest limits such a Texas. This would seem quite wrong.

Fred C. Dobbs:

It's arguably effective that doctors would have us believe that they need high pay to cover their
malpractice premiums, even if it's only anecdotal.

anne:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

June 1, 2009

The Cost Conundrum: What a Texas town can teach us about health care.
By Atul Gawande

"It's malpractice," a family physician who had practiced here for thirty-three years said.

"McAllen is legal hell," the cardiologist agreed. Doctors order unnecessary tests just to protect themselves, he said. Everyone thought the lawyers here were worse than elsewhere.

That explanation puzzled me. Several years ago, Texas passed a tough malpractice law that capped pain-and-suffering awards at two hundred and fifty thousand dollars. Didn't lawsuits go down?

"Practically to zero," the cardiologist admitted....

Fred C. Dobbs:

Interesting , but as the article says:

'McAllen has another distinction, too: it is one of the most expensive health-care markets in the country. Only Miami-which has much higher labor and living costs-spends more per person on health care.'

What does this 'teach us about health care'?
Don't do it like they do it in McAllen TX.

Fred C. Dobbs:

Even more interesting, the article says:

'The Medicare payment data provided the most detail. Between 2001 and 2005, critically ill Medicare patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received twenty per cent more abdominal ultrasounds, thirty per cent more bone-density studies, sixty per cent more stress tests with echocardiography, two hundred per cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and five hundred and fifty per cent more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. The primary cause of McAllen's extreme costs was, very simply, the across-the-board overuse of medicine.' ...

I believe I have read that this has to do with physician-entrepreneurs 'providing' (selling?) diagnostic testing to their patients. Very profitably too. Personally, I think testing is a great idea, when done ethically & cost-effectively.

Fred C. Dobbs:

By the way, many doctors think
'the world' of Atul Gawande, MD.
http://gawande.com/about
Brigham and Women's Hospital
Department of Surgery
gawande@gawande.com,
etc.

Reality Bites:

The cap instituted in Texas is not the malpractice reform that was proposed and rejected. Notice that only pain and suffering is capped at $250,000. A doctor could still get sued for millions if he fails to test for an obscure ailment that eventually leads to a loss of function or life. Thus the need to practice defensive medicine.

Republicans aren't on board on this bill. Their proposals voiced during the "debate" with Obama were rejected. There's no reason why they should lend support to a bill they believe will be very harmful to the country and end up raising health care costs.

ken melvin said...

If there really was a god, those who keep on yapping about malpractice would be among those who got their brains fried and the letter of apology cause see MO has a $250k cap.

beezer said...

The 800 lb gorilla in the room is the doctors, or lack thereof.

We don't graduate enough physicians because it's pretty much financially out of reach for most of those smart and talented enough to compete. Too few of anything is going to raise labor rates.

Also, we've turned physicians into businesspeople first. Got to make that real big "nut." Not really the right focus for medical care overall, and certainly not for producing affordable care specifically.

Too many doctors today got there in order to become wealthy. And as long as that is the primary motivation, health care will always be far too expensive.

Open up education by subsidizing medical education so all the bright young ones can compete, in return for guaranteed salaries. We'll get a stronger corps of physicians overall, as well as physicians who have the right motivation to begin with.

History:

Per Uwe Reinhardt, who knows about these things, US medical costs are too high because we pay too much for things. (Not that McAllen-style overuse isn't a problem also). The things are:
1) Medical bureaucracy, i.e. insurance companies.
2) Drugs
3) Doctors, who are paid about twice what they are in the rest of the world relative to prevailing incomes.

Our gross overpayment per year (compared to other advanced countries) is about $1T/yr,
split $300B, $300B, $400B.

We're discussing point three. The main reason (along with what beezer correctly said) for this situation is that Lyndon Johnson bribed the AMA into letting him pass Medicare. The bribe took the form of allowing arbitrary pricing for new procedures, under the rubric "usual, customary, and reasonable". In this scenario a procedure might cost $50 and a somewhat improved one $5000. I actually saw one instance of this apparently absurdly exaggerated increase cited; although I'm too lazy to look it up.

The doctors who are highly paid are the ones who do procedures. Hence, a lot of procedures.

Cutting procedure reimbursement rates is indispensable to cutting costs. The solutions to monopoly-based price increases are: 1) regulation, or 2) monopony; you take our business because there is no other.

[Mar 29, 2010] Booming business helps patients navigate medicine - The Denver Post

By MIKE STOBBE AP Medical Writer Article Launched: 07/24/2008 12:21:20 PM MDT NORCROSS, Ga.-After three surgeries, Judy Sherer still had chronic pain in her left shoulder. She'd lost faith in her doctors, and in despair tried a new health benefit offered by her employer.

The service, Health Advocate, is a call-in center that helps customers find the right doctor, haggle over insurance coverage and manage other medical system headaches.

An advocate helped Sherer find a new surgeon-one who found metal shavings left in her shoulder by a previous doctor. The advocate also negotiated the charge for her physical therapy down to $40 per visit from the $200 she was told initially.

"It saved me a ton of money," said Sherer, 63, of Norcross, Ga. "I'm very, very pleased."

Health Advocate is one of a growing number of U.S. companies offering some form of advocacy services to medical consumers. Revolution Health-the Web-based medical consumer services company overseen by AOL co-founder Steve Case-has been considering getting into the same business.

"It's a really interesting industry that's just taking off," said Carol Fischer, a spokeswoman for Pennsylvania-based Health Advocate, a 12 million-member organization.

Currently, the health advocacy business is an industry with about $50 million to $75 million in annual revenue but only about a dozen companies of any significant size, said Richard Rakowski of Intersection LLC, a Connecticut-based investment and development firm that has researched the field.

But those numbers have grown from a few years ago, and it may be on track to become a $1 billion industry based on the demand for the service, said Rakowski, the firm's principal.

The field is blossoming in the wake of cutbacks in corporate health benefits, an overhaul of Medicare and other changes that have forced medical consumers to shop more for medical care.

More than ever, people need help negotiating the medical system, said Jessica Greene, a University of Oregon health policy analyst.

"We're asking consumers to make more complicated decisions, but the numeracy and health literacy skills of many consumers are not at the level needed to handle this new responsibility," Greene said.

Though some consumers are savvy enough to beat a billing overcharge or probe doctors' litigation histories, they don't have the time for such labors, experts said.

Indeed, the largest customers of health advocacy services are companies, not individuals. "The employers are interested because it means their employees are not on the phone taking care of doctor's visits" during work hours, Fischer said.

The companies grouped into the health advocacy business range from small regional firms operating out of home offices to companies with national call centers the size of football fields. No one seems to have an exact count, but Flagship Global Health, Care Counsel and Enhanced Care Solutions are among the more visible names.

Health Advocate claims to be the largest. Founded in 2001, it now has more than 3,500 companies, unions and other organizations as clients, including Johnson & Johnson, American Express and The Home Depot Inc.

Altogether, about 2.6 million employees, or members, are signed up with Health Advocate. But the number who can use it is actually higher: Members can share the call-in number with spouses, children, parents and parents-in-law-including elderly kin who need help picking a Medicare prescription drug plan, finding a nursing home or arranging transportation for health care. With all relatives added in, Health Advocate's membership as roughly 12 million, Fischer said.

About 180 advocates staff Health Advocate's call center in suburban Philadelphia. It's usually registered nurses who talk to the patients, and each patient gets an advocate who stays with the case and is the recurring contact. The staff also includes behind-the-scenes workers who help with insurance claims and other administrative questions.

"I'd say 80 percent of (our) people call Health Advocate because they have trouble with billing," said Andrew May, a human resources vice president for Wells Real Estate Funds, the Georgia-based company that employs Sherer.

Initially, May said, he doubted Wells employees would use Health Advocate, thinking they would instead continue to come down to human resources for help rather than turn to a 1-800 number.

But some of Wells' 400 employees started using it and having great experiences, he said. Company executives appreciated the help, calling the $5,700-a-year cost a good deal.

"We're not billing specialists. We're not registered nurses. To have that resource is much more powerful-it gets to the bottom of things quicker," said Susanna Johnson, a Wells human resources manager.

Health Advocate in May began to sell its services straight to individuals, as a $365-a-year service.

Some other companies have always focused on individuals, especially rich ones.

One example is $10,000-a-year PinnacleCare, founded in 2002 by John Hutchins, who created a concierge-like service at the Cleveland Clinic. He later used his connections to build a national network of doctors for his private health advisory start-up.

The Baltimore-based company is essentially a club for millionaires and billionaires that puts nurses and social workers in touch with members. Not only will they help members find top-level care, they will get them moved to the head of the line. PinnacleCare advisers will even meet the patient at a doctor's office or hospital.

PinnacleCare has about 1,700 member-families. One satisfied customer is Kirk Posmantur, 45, the founder and chairman of Axcess Luxury & Lifestyle. His Atlanta-based company markets handmade watches, private jets and other luxury items to the affluent.

"It's a no-brainer for those who've got net worth of $5 million or more," he said. "You've got people who advise you on your taxes. You've got people who advise you on how to manage your money. But what's more important than your health?"

Not every health advocacy group is a for-profit business.

The Patient Advocate Foundation provides free help to people with chronic, debilitating and life-threatening conditions. Founded in 1996, the Virginia-based organization has 113 employees and an annual budget of about $8.5 million. It handled nearly 45,000 cases in 2007-most of them cancer patients.

The organization's founders initially expected many clients to be uninsured. As it turns out, about 80 percent have at least some health insurance but are dealing with pre-approval authorizations, medical debt from incomplete coverage or other problems, said Nancy Davenport-Ennis, the group's chief executive and co-founder.

Companies like PinnacleCare are a blessing "for those consumers that can afford to have a boutique service," she said.

She wishes, however, that companies would provide more pro bono service. "The concern is those that need help and can't afford something like that," Davenport-Ennis said.