Donald Trump & 2016 Election

[pilferk]

Pilferk, whether it's Bernie or Hillary, I don't think we're going to see single payer anytime soon.  Assuming we're stuck with private insurance, what would be the most effective measures to reduce costs?

Republicans have often supported allowing insurance companies to sell across state lines.  First of all, I've never been entirely clear on why that's disallowed to begin with.  Second, at least on the surface, I don't see how allowing that would be incompatible with Obamacare.  And theoretically, it seems that providing more choice/competition would help reduce premiums.  I don't often agree on Republican platforms, but this one doesn't seem unreasonable.  How about we do away with state licensing completely and have just a single federal insurance license?

As for tort law reform, I can see how that would reduce costs, but wouldn't a limitation on damages just punish victims and reward wrongful conduct?

The single payor thing was meant more as a glib response on the "careful what you wish for" side of the street.  I think they'd like to do it...don't get me wrong...but I think there are incredible logistic and financial ramifications that....while not insurmountable...would require more of a public mandate than I think they're likely to get.  They'd literally have to gut an entire industry...hard to do in the most stable of economic times.  Really, though...you are about as likely to get single payor as you are to get Obamacare repealed.

I'm a supporter of the ability to sell insurance across state lines. It happens, now..but each insurer has to purchase, maintain, and comply with each individual states licensing laws.  That, really, benefits the larger companies who can afford to do that...or a more agent focused sales force.  Either way, anything that forces a bit of price competition is a good thing.  The only caveat is: I think you have to maintain the "tax is paid on the revenue in the state that it's generated" tenet.  I suspect thats why there has been longstanding objection by the states, in terms of federal interstate commerce laws.  But...it also perpetuates HUGE rate discrepancies, state to state.  Interesting, eh?

It's not incompatible with Obamacare at all.  Besides the tax issues, the reason it's been maintained is that they wanted HMO's (back in the 60's and 70's) to be accoutable to the states.  It was easier to shuffle litigation, oversight, and such off to the smaller, more focused, entity.  Interstate sales would change that, though, and open the process up to FEDERAL oversight. I think that's good. YMMV.

For torte reform...no, not as such.  You would see standardization. I don't think that's punative.  You'd essentially create a chart saying "In cases like this, and circumstances like this, with an outcome like this..you get this".  The issue in torte law isn't, actually, the real world damages, per se (ie: medical costs, lost wages, etc). It's the punative and "pain and suffering" that's out of control.  Because there's literally NO guidance.  If you get a good lawyer....you'll get millions for something that, in actuality, cost you very little.

Here's an example: Complicated birth.  There is a tool that OB's can use that's sorta like a vacuum.   Actual risk is relatively low, but it can lead to a mishapen skull. This can be fixed, surgically, but...it's purely a cosmetic complication (and often not a noticeable one).

There was recently an award of $12 million, for exactly that.  The parents sued because their son was delivered via Vacuum assist, and had a mishapen skull.  Now, it was a more extreme case of the complication.  But it caused no other anatomic issues.  His brain was fine, his apgar scores were normal. He just had, not to be indelicate, a bit of a conehead.  Essentially, a cosmetic complication that COULD BE FIXED once the child aged (and, likely, some of it would be fixed as the skull plates grew and rearranged), and the hospital agreed to cover costs for the fixation.  No actual monetary damages. There wasn't really any evidence of pain (or suffering).  Why? They had a good lawyer and a sympathetic jury.

THATS the problem.  And that's why premiums are so high in certain subspecialties.  Not so much because of the risk of actual occurance, but because the risk that a jury will find the victim so sympathetic, that they award a huge sum of money for no substantive reason.  And it happens more than you think, honestly.  I provided an extreme case, but it's not JUST high dollars, it's overall volume.  We're a litigious society.  So the insurance companies are also paying legal costs for every suit coming their way.

There are ways to enact "make sense" torte reform laws that don't actually significantly effect the victims.  They just standardize the awards they can get, instead of turning it into "Let see if we can win the malpractice lottery".  And I think there needs to be better oversight, from the courts, over what constitutes a valid claim, and what doesn't.  Both those things were promised, as part of the health care reform package "after we get this done".  I'm not saying, by any means, the limitations should be draconian on awards. I don't think anyone expects or plans for that, not even the providers/physicians.  But they should be reasonable and standardized.  And so long as that doesn't happen, and docs are left paying 6 figure malpractice premiums....those costs are going to remain a SIGNIFICANT piece of the indirect costs that health care consumers have to offset.

There are other cost cutting measures, too.  State governments have, of late, started to visit the taxing of non-profit hospitals to balance their budgets (ie: fund the state employee pensions they've mismanaged).  The Fed needs to step and and see that for what it is: An abuse of the matching funds doctrine (ie: we'll take money from you, but give it back to you, funded in part by the fed).  That's becoming an issue in terms of costs.

Supply costs are the kicker.  Without interfering in the free market, or instituting the same kind of price restriction you proposed (which the fed could do...I mean, technically, they are supplying a federal contractor, in most cases, sooooo.....), I don't know what you can do.  There's probably some tax benefits you can work in to suppliers, or tax levies you can wield short of direct price controls.  This is the one we struggle with most.  BUT, I think if you get a handle on the rest of it, the supply stuff becomes LESS of an issue in the sum total.

The collusion between insurers, in terms of both reimbursement rates and in terms of premium prices has to be cut off.  There needs to be an actual run at letting the free market be...well...free.  That will help at least help the CONSUMER see a reduction, even if costs aren't actually reduced for care.

[GeorgeSteele]

Thanks a lot, appreciate the thoughtful response.

I still have trouble getting entirely comfortable with standardized penalties for medical malpractice.  Going with your example, assuming they standardized penalties for improper vacuum assisted births.  I may be overly paranoid here, but perhaps a hospital determines that frequent vacuum use is more profitable than using it only as a last resort.  With limited damages, they know their worst case cost scenario and may also get more business out of it with the future fixation surgery. 

That would be my concern, not that I'm completely against tort law reform, but I'd want to make sure any reforms maintain the delicate balance of reducing frivolous claims and outlandish punitive awards while still being strong enough to deter malpractice. 

[pilferk]

Thanks a lot, appreciate the thoughtful response.

I still have trouble getting entirely comfortable with standardized penalties for medical malpractice.  Going with your example, assuming they standardized penalties for improper vacuum assisted births.  I may be overly paranoid here, but perhaps a hospital determines that frequent vacuum use is more profitable than using it only as a last resort.  With limited damages, they know their worst case cost scenario and may also get more business out of it with the future fixation surgery. 

That would be my concern, not that I'm completely against tort law reform, but I'd want to make sure any reforms maintain the delicate balance of reducing frivolous claims and outlandish punitive awards while still being strong enough to deter malpractice. 

In your example, though...the hospital would still be responsible for covering the costs of the fixation (as they had agreed to, in my example, before the suit even made it to court)...so that's not future business. It's future cost for the facility.  Because that piece is actual damages.  Its the more subjective areas of the malpractice segment that needs reform.

And, in actuality (in this particular case) the use of the vaccuum equipment constitutes additional cost, not a reduction of cost. There are supplies involved, additional training to use the equipment (not just by the physician), and the cost, itself.

I do get your point: You don't want the provider to go cheap, just to go cheap, or to maximize profit over care.  BUT...here's the thing: There is additional oversight that prevents that. JAHCO (the Joint Commission) ensures things like that are not done during a review process.  Likewise, additional subspecialty accrediations (like the American College of Surgeons) do clinical reviews and will not renew you status if they see things like that.  So..in essence..there are other checks and balances to assure that kind of thing doesn't happen.

[Thorned Rose]

In general, a more conservative... less "do what ya want when you want, and how you want" mentality would be great.

Freedom has limits. Common sense and nature govern those.

[Drew]

As long as the U.S. has leaders that don't enforce immigration laws, illegals are going to continue to enter this country and use emergency health care facilities and other facilities much more often which will only make that small percentage rise over time and cause a strain on the system. Why can't the immigration law be enforced? Why should someone here illegal and breaking the law be able to receive emergent free health care when millions of Americans who are paying insurance, high premiums, high co-pays to get the same emergent care illegals receive for free? Of course the medical industry is going to pass this cost on to the paying consumer. It's outrageous! So you have people like Obama, Clinton, and Sanders wanting to continue to give illegals all this "free" stuff. If immigration laws were enforced  it would have an effect on the cost the medical industry takes on by giving to people who are here illegally. People play God every day in this world. People make a personal choice to break the law and cross into the U.S illegally. Why should the American people take on the responsibility for providing medical and government services paid for by the U.S. tax payer to deal with illegals breaking the law? I don't think it's my responsibility or the U.S. citizens responsibility to pay taxes to take care these people. The immigration problem just didn't start, it's been going on for a long time. Who's going to pay for "free" healthcare to illegals who don't want to buy insurance? Who's going to pay for the "free" education given to illegals? Obama, Clinton and Sanders don't want to answer that question. The answer is...the U.S. tax payer is going to pay that cost.

Yup, thanks for completely making my original point for me 

So are you saying, don't fix the problem with illegal immigration? And vote people into power who will let anyone break the law and come into this country illegally?

This to me is the problem. You going to continue to have an influx of people who cause a strain on hospitals, emergency care, and other entities. You seem not to care that the working citizen who pays there taxes are going to have to pay for this influx. Why should hard working legal citizens be responsible for taking care of people and providing services to people who break the law in the first place?

Yes, it's always the illegal immigrants, if not for them, our lives would be so much better.  I'm reminded of the story where the banker and the worker have 12 cookies, the banker takes 11 and says to the worker, "watch out, an immigrant is going to take your cookie."

Is this like reality where  the government makes the U.S. tax payer pay for benefits given to illegal immigrants while having a difficult time making ends meet for their own families and who are only pouring fuel on a fire welcoming more people to break the law and enter this country illegally? Again, why should hard working legal citizens be responsible for taking care of people and providing services to people who break the law in the first place?

[GeorgeSteele]

In your example, though...the hospital would still be responsible for covering the costs of the fixation (as they had agreed to, in my example, before the suit even made it to court)...so that's not future business. It's future cost for the facility.  Because that piece is actual damages.  Its the more subjective areas of the malpractice segment that needs reform.

And, in actuality (in this particular case) the use of the vaccuum equipment constitutes additional cost, not a reduction of cost. There are supplies involved, additional training to use the equipment (not just by the physician), and the cost, itself.

I do get your point: You don't want the provider to go cheap, just to go cheap, or to maximize profit over care.  BUT...here's the thing: There is additional oversight that prevents that. JAHCO (the Joint Commission) ensures things like that are not done during a review process.  Likewise, additional subspecialty accrediations (like the American College of Surgeons) do clinical reviews and will not renew you status if they see things like that.  So..in essence..there are other checks and balances to assure that kind of thing doesn't happen.

OK, understood.  If tort reform were to be implemented, however, I think it would have to go hand with government imposed price controls.  Why should the industry have government protection for liability but free market for its profits?  

The same should apply for the pharmaceutical industry.  If a company is asking the government to grant it a patent (a government artifice that does not exist in the free market) for the drugs it invents, then the federal government is well within its rights to attach conditions to that patent, including price controls.  If it doesn't want the patent, fine then, go out in the free market and get your prices undercut by copycat competitors.  

[pilferk]

So are you saying, don't fix the problem with illegal immigration? And vote people into power who will let anyone break the law and come into this country illegally?

This to me is the problem. You going to continue to have an influx of people who cause a strain on hospitals, emergency care, and other entities. You seem not to care that the working citizen who pays there taxes are going to have to pay for this influx. Why should hard working legal citizens be responsible for taking care of people and providing services to people who break the law in the first place?

I'm saying "fixing" (whatever that means) the illegal immigration problem that you're talking about has very little to do with healthcare costs. VERY LITTLE. An amount so small, that even implementing the most draconian measures proposed wouldn't have a noticeable effect on your insurance premiums, or taxes.  It's a talking point, and a scare tactic, that is meant to rabble rouse, and get you to act in a very specific way.  I don't care, honestly, how you vote...because, for this election, all the options suck balls. Godzilla 2016.

Here's the heart of the issue: I seem to understand the entire issue, in relation to healthcare.

You want to theoretically rail against a problem, while offering no REALISTIC solution, and spout talking points. You want to take leaps of logic without any actual evidence.  And every time you do, as above, you further and further make my point for me.  I guess, for that, I should thank you. You seem, above, to be espousing the "Let them die" position.  Which, of course, is not only impractical, but impossible.  Which you would know, if you actually had a clue what you were talking about.

Again, you want to rail against the "evil" of illegal immigrants, specifically, and I'll bow out.  I have no interest in that topic, specifically.

Bring up healthcare, and I'll point out you don't know what you're actually talking about.  As I have. Because you don't.  Maybe just admit that part and Mo Vaughn....or don't.  And keep proving my point.

[GeorgeSteele]

Is this like reality where  the government makes the U.S. tax payer pay for benefits given to illegal immigrants while having a difficult time making ends meet for their own families and who are only pouring fuel on a fire welcoming more people to break the law and enter this country illegally? Again, why should hard working legal citizens be responsible for taking care of people and providing services to people who break the law in the first place?

In the words of Hyman Roth, they are "small potatoes".  We can do everything you're proposing regarding illegal immigrants and it wouldn't make a dent in our health insurance premiums or our tax dollars.  There are much bigger fish to fry, but immigrants, who can't vote or make campaign contributions, are the perfect scapegoats.  

[pilferk]

OK, understood.  If tort reform were to be implemented, however, I think it would have to go hand with government imposed price controls.  Why should the industry have government protection for liability but free market for its profits?  

The same should apply for the pharmaceutical industry.  If a company is asking the government to grant it a patent (a government artifice that does not exist in the free market) for the drugs it invents, then the federal government is well within its rights to attach conditions to that patent, including price controls.  If it doesn't want the patent, fine then, go out in the free market and get your prices undercut by copycat competitors.  

I agree, BUT not for the same reasons.  

Keep in mind, providers (aka practices, healtcare facilties, etc) are CONSUMERS of supplies, not manufacturers.  So the price controls are on another section of the industry. That section is actually not liable for malpractice.  Device failure, for example, is covered under different jurisprudence.  Those manufacturers, interestingly, are NOT required to carry malpractice insurance. Things that make you go hmmmmmmm.  Price controls on supplies would likely make healthcare facilties do figurative backflips.  Especially the large non-profits (which, FYI, are pretty much the best known, best regarded facilities in the country).

And I agree on almost everything you're saying in terms of price controls, up to and including the drug companies.. To my mind, they are indirect federal contractors, since most providers get a sizable portion of their revenue from the fed (directly or indirectly).  But to get there, you would almost HAVE to engage in some sort of universal health care system, if not outright single payor.  And then you're messing with private industry (or so the Repubs will argue). That's a tough mountain to climb given the current makeup of the legislature.  Honestly, though, this was one of the things "promised" to be addressed after Obamacare was enacted.  And yet......nada.

As an aside: I always find that ironic: Repubs want to tell you what you can, and can't, do in your personal life, but woe be to anyone who want to control what's going on in a corporations "life".  I mean, the Dems are pretty much the opposite, so they're not much better. But that's a dogma discussion I should probably let lay.

[pilferk]

Is this like reality where  the government makes the U.S. tax payer pay for benefits given to illegal immigrants while having a difficult time making ends meet for their own families and who are only pouring fuel on a fire welcoming more people to break the law and enter this country illegally? Again, why should hard working legal citizens be responsible for taking care of people and providing services to people who break the law in the first place?

In the words of Hyman Roth, they are "small potatoes".  We can do everything you're proposing regarding illegal immigrants and it wouldn't make a dent in our health insurance premiums or our tax dollars.  There are much bigger fish to fry, but immigrants, who can't vote or make campaign contributions, are the perfect scapegoats.  

EXACTLY!

George, I want to give you a cigar, or a turn buckle..or maybe revive Miss Elizabeth for you, for the night.  This, exactly.

[pilferk]

The same should apply for the pharmaceutical industry.  If a company is asking the government to grant it a patent (a government artifice that does not exist in the free market) for the drugs it invents, then the federal government is well within its rights to attach conditions to that patent, including price controls.  If it doesn't want the patent, fine then, go out in the free market and get your prices undercut by copycat competitors.  

Another thing on the drug companies: What gets me most is that those same, exact drugs (where allowed..you know there is no such thing as an OTC PMS drug in Europe?) are sold, in other countries (the one's with single payor, specifically) for a FRACTION of the cost they are sold for in the U.S.? AND they're still making a profit on them?

Do you know for ANY other product, there are federal (and international) laws PROHIBITING the sale of a product for significantly less than you do in your "home country".  They're called "Dumping" laws.  And the drug companies managed to lobby to get a specific exemption for pharmaceuticals?

More things that make you go hmmmmmm

[Drew]

You want to theoretically rail against a problem, while offering no REALISTIC solution, and spout talking points. You want to take leaps of logic without any actual evidence.  And every time you do, as above, you further and further make my point for me.  I guess, for that, I should thank you. You seem, above, to be espousing the "Let them die" position. Which, of course, is not only impractical, but impossible.  Which you would know, if you actually had a clue what you were talking about.

The solution is you fix the immigration problem. Look at the strain immigration has caused on European nations as we speak. You won't have to let them die if there not here illegally in the first place. As I said, people make personal choices every day. They have to take responsibility for those choices. I don't think someone should be able to break the law and be taken care of. If you have security forces on the border you will slow down the burden the U.S. tax payer has to take on for people breaking the law.

Small potatoes more often than not grow into bigger potatoes. At one time, illegal immigration was small problem and noting was done. Now, the problem has grown to measures that are out of hand and continue to grow at a fast pace. It's like cancer. If you don't do anything the cancer will grow until it kills you. Why do you think people don't balk at cancer at any stage?

[GeorgeSteele]

George, I want to give you a cigar, or a turn buckle..or maybe revive Miss Elizabeth for you, for the night.  This, exactly.

Yes!     (By the way, RIP)

[GeorgeSteele]

I agree, BUT not for the same reasons.  

Keep in mind, providers (aka practices, healtcare facilties, etc) are CONSUMERS of supplies, not manufacturers.  So the price controls are on another section of the industry. That section is actually not liable for malpractice.  Device failure, for example, is covered under different jurisprudence.  Those manufacturers, interestingly, are NOT required to carry malpractice insurance. Things that make you go hmmmmmmm.  Price controls on supplies would likely make healthcare facilties do figurative backflips.  Especially the large non-profits (which, FYI, are pretty much the best known, best regarded facilities in the country).

And I agree on almost everything you're saying in terms of price controls, up to and including the drug companies.. To my mind, they are indirect federal contractors, since most providers get a sizable portion of their revenue from the fed (directly or indirectly).  But to get there, you would almost HAVE to engage in some sort of universal health care system, if not outright single payor.  And then you're messing with private industry (or so the Repubs will argue). That's a tough mountain to climb given the current makeup of the legislature.  Honestly, though, this was one of the things "promised" to be addressed after Obamacare was enacted.  And yet......nada.

As an aside: I always find that ironic: Repubs want to tell you what you can, and can't, do in your personal life, but woe be to anyone who want to control what's going on in a corporations "life".  I mean, the Dems are pretty much the opposite, so they're not much better. But that's a dogma discussion I should probably let lay.

I see how that can be a problem with respect to the disconnect as far as liability vis a vis providers and device manufacturers, but I would envision something where a provider would document all of its costs (including what it pays for devices) and then be permitted to charge only X% above that amount for its health care services.

[pilferk]

The solution is you fix the immigration problem. Look at the strain immigration has caused on European nations as we speak. You won't have to let them die if there not here illegally in the first place. As I said, people make personal choices every day. They have to take responsibility for those choices. I don't think someone should be able to break the law and be taken care of. If you have security forces on the border you will slow down the burden the U.S. tax payer has to take on for people breaking the law.

Right...so...you don't understand, or choose not to understand, what you're talking about.  Again, thanks for making my point for me.

THEY ARE HERE.

THEY NEED EMERGENT CARE.

THEY ARE PEOPLE.

So...are you going to amnesty everyone currently in the country?

Or do you plan to try to round them up and deport them all (good luck with that...the costs of that enforcement squad will dwarf the costs you're looking at eliminating...and your healthcare costs will drop such a tiny amount, you likely won't notice it, and it will disappear in about 16 months)?

Or are you going to let them die?

Those are your 3 choices. Pick one

And if you choose the last one, keep in mind, current laws say that non-profit providers (and there are lots of them, at least one in every state, and more like one in every urban area) MUST PROVIDE emergent care to anyone who needs it, with an ability to pay or not. You can't even ASK, for emergent care, at a non profit.

So...you give them permission to refuse service and let the patient die on their doorstep..you also give them permission to refuse service to ANYONE who can't provide evidence they can pay when they get there. So...if...for example...you're in a car accident, you're in rough shape and unconcious, and your wallet is thrown clear...and you happen to be..I don't know..a little too brown...they let you die? Right? Because they don't know if you are an illegal or not. And you're obviously going to cost a ton of money to take care of.

Again, you don't know what you're talking about.  You're talking out of your ass to try to support SOMEONE ELSE'S talking points. You're theory crafting a pie in the sky situation, instead of living in the real world. And every time you write another line, you keep proving my point.

As for breaking the law...do you go faster than the speed limit? So, if you are in an accident, and need urgent care...the provider should instantly disqualify you from being seen. Your care will be expensive, and increase premiums. Or at least triage you down the line...because the EMS report clearly shows you were speeding. C'mon, man.  At least live in the real world.

Small potatoes more often than not grow into bigger potatoes. At one time, illegal immigration was small problem and noting was done. Now, the problem has grown to measures that are out of hand and continue to grow at a fast pace. It's like cancer. If you don't do anything the cancer will grow until it kills you. Why do you think people don't balk at cancer at any stage?

I've been waiting for this one.

Actual data shows it hasn't changed much, % wise, in the past 25 years.  Between 6 and 9% of uncompensated care/self pay.

So, in relation to healthcare...no appreciable growth

Again, talking points vs facts.

[pilferk]

I agree, BUT not for the same reasons.  

Keep in mind, providers (aka practices, healtcare facilties, etc) are CONSUMERS of supplies, not manufacturers.  So the price controls are on another section of the industry. That section is actually not liable for malpractice.  Device failure, for example, is covered under different jurisprudence.  Those manufacturers, interestingly, are NOT required to carry malpractice insurance. Things that make you go hmmmmmmm.  Price controls on supplies would likely make healthcare facilties do figurative backflips.  Especially the large non-profits (which, FYI, are pretty much the best known, best regarded facilities in the country).

And I agree on almost everything you're saying in terms of price controls, up to and including the drug companies.. To my mind, they are indirect federal contractors, since most providers get a sizable portion of their revenue from the fed (directly or indirectly).  But to get there, you would almost HAVE to engage in some sort of universal health care system, if not outright single payor.  And then you're messing with private industry (or so the Repubs will argue). That's a tough mountain to climb given the current makeup of the legislature.  Honestly, though, this was one of the things "promised" to be addressed after Obamacare was enacted.  And yet......nada.

As an aside: I always find that ironic: Repubs want to tell you what you can, and can't, do in your personal life, but woe be to anyone who want to control what's going on in a corporations "life".  I mean, the Dems are pretty much the opposite, so they're not much better. But that's a dogma discussion I should probably let lay.

I see how that can be a problem with respect to the disconnect as far as liability vis a vis providers and device manufacturers, but I would envision something where a provider would document all of its costs (including what it pays for devices) and then be permitted to charge only X% above that amount for its health care services.

Yeah, device failure does not USUALLY come back and bite the provider in malpractice.  Especially if there was no way the doc could have known it would fail.  If it's FDA approved, and you use it in the manner prescribed, and implant it correctly..that lawsuit goes right to the manufacturer.  I didn't mean to imply otherwise. I'm just saying...that's a little convenient, no? They get a much more structured damages table in that section of jurisprudence.

And that last bit....well, that's pretty much how it's done.  Just not via actual price fixing, but by negotiated reimbursement rates with the commercial providers, and the fixed rates of reimbursement from the govt.

You're sort of set at a fixed level of revenue over costs (direct and indirect), because the commercial folks (aka blue cross, aetna, etc) get that information shared with them as part of the negotiations.  They know what charges vs costs are literally per case.  There's complete transparency, by design, because all that information is basically public record as part of the Medicare set up.

And those insurers KNOW they are being charged about 125% of what they "should be" without all the other factors in play.

[pilferk]

I'm gonna try some numbers, here. Keep in mind, these are general approximations.

Say your bi-weekly premium for insurance is $100

About 25% of that covers uncompensated care and covering the gap in UNDER compensated care (medicaid).  Illegals are not on Medicaid, so that piece (about 18% of that 25%, given the national payor mix for FY 2015) gets pulled out.

So, now you're down to about 7% of your premium going toward uncompensated care.  That has ranged as high as 12%, in previous years...but, believe it or not, Obamacare has brought that number DOWN, so there are more patients with some compensation.  Also interestingly enough, the illegal %, amongst that same segment, while it's risen SLIGHTLY (over that time), it hasn't changed more than it has during other cycles you look at (a couple percent, year to year).

FY 2015, nationally, 8% of self pay/uncompensated care were illegal aliens.

So of that $7, exactly .56 cents went toward the care of an illegal, or roughly 1.12 per month. 

Again, interestingly enough, in previous years, that would have been .96 bi-weekly, or 1.92 per month.  So, in actuality, you can say Obamacare has SAVED you about .80 cents a month. 

But..yeah..the immigrants are the problem we should focus on in health care.

[GeorgeSteele]

Yeah, device failure does not USUALLY come back and bite the provider in malpractice.  Especially if there was no way the doc could have known it would fail.  If it's FDA approved, and you use it in the manner prescribed, and implant it correctly..that lawsuit goes right to the manufacturer.  I didn't mean to imply otherwise. I'm just saying...that's a little convenient, no? They get a much more structured damages table in that section of jurisprudence.

And that last bit....well, that's pretty much how it's done.  Just not via actual price fixing, but by negotiated reimbursement rates with the commercial providers, and the fixed rates of reimbursement from the govt.

You're sort of set at a fixed level of revenue over costs (direct and indirect), because the commercial folks (aka blue cross, aetna, etc) get that information shared with them as part of the negotiations.  They know what charges vs costs are literally per case.  There's complete transparency, by design, because all that information is basically public record as part of the Medicare set up.

And those insurers KNOW they are being charged about 125% of what they "should be" without all the other factors in play.

OK, so it's not so much that the providers are overcharging, it's that their costs are too high.  Especially malpractice insurance, which gets us right back to where we started, lol.   I think there's much that can be done to reduce the cost of medicine/drugs, as I mentioned with patent grants and as you rightfully noted with dumping abroad.  

As a personal example, my mother broke her hip while in Europe a few years ago.  She had the hip-replacement operation at the foreign country's hospital because she could have died if she had waited to get back to the U.S.  Thing was, neither Medicare nor her supplemental insurance would cover the cost of the operation because she had been abroad more than 90 days (the accident happened on the 94th day she was away).  So, she had to pay for the operation out of pocket.  Cost her about $5,000.  The same procedure here in the U.S. would have been $100K minimum.  Granted, the U.S. facilities would have been far superior, but... 20 times the cost?  Has to be a way to bridge that gap, even if only a little.  

[pilferk]

OK, so it's not so much that the providers are overcharging, it's that their costs are too high.  Especially malpractice insurance, which gets us right back to where we started, lol.   I think there's much that can be done to reduce the cost of medicine/drugs, as I mentioned with patent grants and as you rightfully noted with dumping abroad.

Pretty much.  Some of that "cost" is offsetting uncompensated and undercompensated care (thanks, Medicaid!).  So they raise their charges to take that into account, because, as we've covered, nothing is really "free".  Someone has to pick up the tab.

And the kicker is: Insurers not only know this, they actively participate in the process to do it.  They know that, to make money, there have to be providers. To have providers, providers have to make money (at least enough to cover costs). 

To be sure, providers aren't blameless.  But, in the grand scheme of things, their ability to control prices is limited by the costs they incur, their expenses (like malpractice insurance and, for the mds, student loans incurred) and the desire to actually make a decent living on top of that.  And non-profits invest EVERY dollar above costs back into their facilities, so.....

The insurers aren't blameless either.  They all have HEALTHY profit margins, on the backs of your (our) premiums.  And those have grown, not shrunk, so at least some of the growth people are seeing is that (though some of it is on volume, as the roles increase under Obamacare, too).

As a personal example, my mother broke her hip while in Europe a few years ago.  She had the hip-replacement operation at the foreign country's hospital because she could have died if she had waited to get back to the U.S.  Thing was, neither Medicare nor her supplemental insurance would cover the cost of the operation because she had been abroad more than 90 days (the accident happened on the 94th day she was away).  So, she had to pay for the operation out of pocket.  Cost her about $5,000.  The same procedure here in the U.S. would have been $100K minimum.  Granted, the U.S. facilities would have been far superior, but... 20 times the cost?  Has to be a way to bridge that gap, even if only a little.  

Yup, and you know why they can do that in the EU? Single payor.  If you are a provider, your costs are fixed. You have low or no student loan debt.  The "malpractice insurance" is provided by the government...so when someone "sues" for malpractice, they're suing the govt (and guess how much torte structure there is, given that?). Supply costs are low, because it's a more centralized system, with one point of negotiation (the govt) for the manufacturer. You are, if you are working in the industry, essentially, a govt worker with govt pension, benefits, etc.   And most facilities are basically "not for profit".  Add to that the fact that 95% of your patients are compensated care (via taxes), and you have the ultimate cost control mechanisms.

Those same conditions just don't exist over here.

That's not to say there aren't private facilities over there that provide a "premium" healthcare experience.  There is.  They take your insurance and then bill you for the extras which you pay out of pocket.  But that's OPTIONAL.  And the clinical care isn't always necessarily better (well, it is for optional/elective surgical procedures, like plastics, etc), in many cases....you just get better digs while you're in.

[GeorgeSteele]

Yeah, but with single payor being politically impossible, how about the "public option" which was the original selling point of Obamacare (and the first thing to be scrapped in the negotiations with Congress).  Wouldn't that go a long way towards keeping private insurance companies competitive with their premium rates and help incentivize overall cost reduction?