It's a great piece that I wish had been published 3 years ago. (Odd that he never mentions that the V.A. has purchasing power similar to Medicare's.)
Ack, oops. I almost double-checked to make sure I was using the right one, because I swap -care and -caid all the freaking time, but somehow worked through some mental logic that convinced me I had the right word in mind.
Fixed.
Sub-thread: come up with a mnemonic device to keep Medicare/Medicaid straight.
It really is an exhaustive documentation on how the billing system fucks over the working poor.
Will any of that be addressed by ACA? Or to what extent?
Yes, of course they will turn down expansion money. Being in charge of a system that dispenses deserved punishment is the only proper role of government, and poor people deserve their misery.
Apparently Scott in FL tried to turn the money down, but then reversed himself. A number of other Republican governors are also backtracking.
http://www.nytimes.com/2013/02/22/us/politics/gop-governors-providing-a-lift-for-health-law.html?pagewanted=all&_r=0
2. The ACA doesn't seriously address the charge issue, at least not in any wholesale way, but in section 9007 it does add to the requirements for nonprofit hospital status that the hospital not charge uninsured more than the insured - if they qualify for any financial assistance, if the care is emergency or otherwise medically necessary. (It then says the organization must "prohibit the use of gross charges", no qualifications, but I'm not sure what that means exactly.) Lots of cracks to fall through thereafter, I'd bet.
3. Amusing that Brill sort of realizes in the course of the article that Medicare-for-all would be more efficient, but then comes back to his mainstream senses and concludes recommending a bunch of anodyne shit.
4. The chargemaster system is indeed ridiculous and, when applied to the uninsured, unconscionable - the ultimate in asymmetric bargaining power - but I think it's pretty separable from the question of why what payers eventually pay grows so much. We could cap uninsured billing at costs tomorrow, and costs would just keep growing, because of utilization, because of prices, because of provider control over professional standards, etc. We care so deeply about our health (at least when we feel it's under direct threat, i.e., in the medical setting) that it will keep wringing the consumer surplus out of us under most presently existing economic arrangements, even single-payer (albeit more slowly).
7: That article still shows a lot of refusing red states.
4: Medicare (Medica-yer) is single payer.
Also, you 'care for your aging parents, and you give 'aid to the poor?
Pretty amazing that our asshole governor continues to prioritize increased poverty and unemployment above all else, including the revenues of the health care interests. Compared to the assholes in Ohio, Michigan and Florida I guess he has even less of a chance of ever being reelected, so he just wants to qualify himself for some jobs as a right-wing hack.
7: Also, it's worth noting that Scott in FL has agreed to expand Medicaid contingent on being able to entirely privatize it, so.
9: But if it was enough to get Rick Scott to turn, I suspect the same will happen with the current refusers, at least over the next five years or so (barring something big like reform-repeal). The hospital lobbies will keep hammering.
12: Which in itself is not that different from how it works in a lot of blue states - though I'm sure it'll be run worse.
Remember the original progress of Medicaid - 49 states took it up by 1972, although Arizona held out until 1982.
So essentially this chargemaster foe would be ideally eliminated when ACA is fully implemented because everyone would be insured, and thus everyone would have someone negotiating prices on their behalf?
14: I confess to having read only brief descriptions of his proposal, but it seemed somewhat more radical than what I think of as the standard Medicaid managed care approach.
It might still exist as a behind-the-scenes calculation mechanism (it's useful for a lot of regulatory and oversight purposes), but it wouldn't impact anyone, yes.
Hmm. I figured Mr. Roosevelt would be here by now.
17: In what way? I hadn't really seen detailed descriptions. From this it does seem to extend it to more populations than are common elsewhere.
I assume that the post title is supposed to be sung a la Destiny's Child, but unfortunately it has put the tune of Motley Crue's "Girls Girls Girls" in my head.
15: The more I learn about Arizona, the better I feel about living anywhere else, even if it is Texas.
Sorry, folks. Too much on my plate today. I hereby designate Minivet and emdash as my proxy commenters for this thread.
And somehow reading "Girls, Girls, Girls" got "Once Bitten, Twice Shy" stuck in my head.
Minivet, are there shadings you think he's missing on the big non-profit hospitals or do they pretty much suck that bad? He does mention exceptions like Seton, but overall?
On preview, I see that Kermie is deserting us, but I was going to ask Minivet anyway, so there.
Blue states with Republican governors are turning down Medicaid too. Maine is cutting the MaineCare rolls, the only New England state to do so, and it really pains me.
I thought of it as Hamlet.
Same here.
Not my field, but I think yes, of the big chains. Major principal-agent and oligopoly problems; their desert of nonprofit status is dubious. I imagine it varies for the smaller, independent hospitals, but they're dwindling. Still, hospitals are just one subgroup of the various rent-extractors (doctors are another).
Wonkblog explains it all.
Steven Brill started his cover story in this week's Time magazine with a simple health-policy question: "Why exactly are the bills so high?"
His article is essentially a 26,000-word answer, the longest story that the magazine has ever run by a single author. It's worth reading in full, but if you're looking for a quick summary, the article seemed to me to boil down to one sentence: The American health-care system does not use rate-setting.
I don't see why lazy people who don't work deserve free healthcare.
--Kermit (by proxy)
How did assholes convince people that government expenditures that benefit most people interfere with the market, whereas government expenditures that make assholes rich are normal things the government does?
Oh hey also my novella is free today here.
34: Double yep.
21: I may have been misled by sloppy summarizing of the approach. It looks like a generally crappy for-profit version of MMC, but not anything revolutionary.
I thought Yggles really hit the nail on the head here: http://www.slate.com/articles/business/moneybox/2013/02/american_doctors_are_overpaid_medicare_is_cheaper_than_private_insurance.html
32: I was horrified by the discussion of the chargemaster--which it doesn't seem will be terribly affected by the ACA--but actually surprised by the rent-seeking of "not-profit" hospitals. I guess I still had some naivete left after all.
Are there consumer protection laws that people can use against Dr. Chargemaster? I.e., you won't tell me in advance how much that acetaminophen cost so I'm not paying $50 for it? If we're going to play Free Market Rocks, then we should play it on both sides.
Perhaps this is answered in the story, tl;dr.
I was interested recently to see my dental insurer exploiting the chargemaster system to exaggerate how much they were helping me.
My claim is summarized as follows:
Bill received by __: $1,403.00
Your __ member rate: $818.00
Your plan pays: $495.30
Your responsibility: $322.70
I doubt I would have paid anything like $1400 without insurance.
16: Well, not everyone will be covered, even under the ACA. My recollection is that illegal immigrants, for example, were explicitly left out as part of the political negotiations necessary to get the thing passed at all. So if you are a Dreamer whose parents brought you to this country at age 2, and you happen to have some sort of health crisis in your twenties, you're probably still screwed big time. But there's no question that lots of people will be better off under the ACA than not.
Maybe it's different in, say, an ER situation, but normally there are all these "I agree to pay you whatever" forms to sign each time I show up at a doctor's office, so I've probably waived that option already. I assume if I asked for prices before signing that, I would get a blank look, and then refused service until I did sign.
Yeah, I had a post about that when I had a bit of cancer taken off my neck. They handed me a form saying "I agree to pay whatever you charge regardless of what my insurance has to say about it", and in a moment of caution I tried asking how much the surgery would be, just in case my insurance did one of those things they do sometimes. No idea. No idea of how they could find out. I don't think there was any way I could have gotten a price quote in time to go ahead with the surgery that day.
42: Good point, I should have said the problem will be eliminated only once absolutely everyone has some kind of insurance, and the ACA doesn't come close to that - not only undocumented immigrants, but many people will stay out of the Exchange due to the cost, despite the mandate, especially at lower income ranges.
How topical! I went in for my first mole check this afternoon, and during the short interval between the injection of the anesthetic and the application of the scalpel, the doctor's assistant presented me with yet another authorization form to sign. I kept asking the doctor whether this was going to be covered, whether it would be billed as an "office visit" or a "facility visit" (this distinction was meaningful to the insurance rep I talked to on the phone), whether I needed to get the pre-clearance thingie from my insurance, and she just didn't know but thought it would be okay.
Afterward, still high on adrenaline, I asked to speak to somebody about billing. She was very nice. The answer was "it'll depend on how the doctor codes it, which she doesn't usually do until the end of the day." We'll see! I tried!
If I hadn't waited to talk to the billing person, the whole thing would have taken about 15 minutes. Surely an expensive visit would take much longer?
The whole thing is so outrageously exploitative that it's hard to discuss it without getting enraged.
Like, I'm debating (re-)sharing my two most outlandish billing experiences, and part of me just doesn't want to get so worked up. One involving the death of the wife of my widowed colleague.
I'll tell the one that makes a more ridiculous story:
I had some tests done in Summer 2010. They were covered by insurance.
In Summer 2011, Heebie U switches insurance companies.
In January 2012, I get a bill for the tests, from 18 months earlier. I call the lab. They say, "The insurance company asked for their money back. So we refunded their money. So you have to cover the payment now."
I call the insurance company. "Since we're not your current company, we don't have your file on our computers anymore. Legally. Legally, we can't look up or answer any questions, because we're not your company."
Me: But you clearly had access to my file within the last month or so, because you asked for your money back.
Them: Isn't it funny how our hands are tied!
I took the documents to HR, and let them go in circles, and then finally paid up when it got too stressful not to.
48.1 agreed. It's crazy that healthcare depends on getting through dysfunctional bureaucracy, crazy that knowing in advance about billing codes and service classifications for a diagnosis and being pushy about those while being sick or caring for someone you love who is sick is the way through.
finally paid up when it got too stressful not to
That's pretty much what they count on- you'll pay up if the money is worth less to you than the relief of stress related to it. Which basically means the incentive for them is to make it as complicated and stressful as possible because then they can raise the charges and still have payment
We had a similar ridiculous thing- when SPouse started working at a charter school that was still relatively new they didn't have their own HR and were administered by a consortium of charter schools run from Michigan. So her health care was BCBS Michigan. She had a test, gave them her health insurance info, and got a bill saying that BCBS didn't have her in their files. Called hospital, they had been calling BCBS MA because, you know, the names are almost the same! Tried to explain this several times to no avail, tried to contact BCBS Michigan and they said the hospital had to contact them directly. Eventually we got collection notices and decided paying the ~$65 was better than having credit score ruined or wasting more time speaking to stupid people.
I wonder how much effect a law requiring medical providers to give price quotes before providing services would have.
Would the subsequent heart attacks be considered felony murder charges?
And if they were, would you execute the hospital executives who set the prices?
SYNERGY!
When I used to work for a BCBS affiliate, there was some big important thing that I didn't understand having to do with the fact that were were a Not-for-profit, not a NonProfit. And that is an important distinction, for some reason. No idea what that reason is.
49
I took the documents to HR, and let them go in circles, and then finally paid up when it got too stressful not to.
What's stressful about not paying?
57: That my belief was that I'd never be able to get the charges covered by anyone else. So if I weren't going to pay it, I'd talk myself blue in the face, on the phone, but still owe the money. Eventually the charges would get turned over to a collection agency. At that point you're getting harassed by the collection agency, it's wrecking your credit score, and the only way out is to...pay the money.
58
57: That my belief was that I'd never be able to get the charges covered by anyone else. So if I weren't going to pay it, I'd talk myself blue in the face, on the phone, but still owe the money. Eventually the charges would get turned over to a collection agency. At that point you're getting harassed by the collection agency, it's wrecking your credit score, and the only way out is to...pay the money.
I have refused to pay medical bills and as far as I know they were never turned over to a collection agency.
Really? I assumed that's the way it went, unless you negotiated and worked out some sort of payment plan.
The little dental bill snafu I went on about in a prior thread was making me reflect on this a bit. And the next very predictable shoe dropped when they turned down the claim for "deep cleaning" with (what appeared to this observer as) extremeprejudice. I now have the 2nd half of that cleaning coming up Thursday and have not had time (well ok, or inclination*) to have the big discussion with the dentist. So I will probably cancel for now. Because wimp--and also actually inconvenient**.
For dental I am beginning to believe that I would sign up for something where they covered nothing, if I got the insured rates (but of course, the games they all play mean there really is no such thing in isolation). I'm actually willing to do basic dental like with the cat and the vet--but that is probably not actually in the interest of my dental health nor that of the public.
*Part of my general retail/price/shopping incompetence and avoidance of confrontation. My wife can give plenty of details. For instance, if the thing you bought goes on sale the next day, you do what?
**With almost no notice I have been presented with an "opportunity" for a trip to a distant event which includes a "black tie optional" affair. In Arizona.
For instance, if the thing you bought goes on sale the next day, you do what?
Shrug and do absolutely nothing.
And you may ask yourself: "my god! what have I done?"
I can't operate on stormcrow's kid! He's my son!
That's absurd, I'm not that kind of doctor!
It's a watched wheel that turns no one good.
I'm a girl watcher! I'm a girl watcher.
WHEN CORRECTLY VIEWED EVERYTHING IS LEWD
58, 59: I am not going to advise anyone not to pay their bills - but if you don't pay, call up the credit reporting agencies and dispute, dispute, dispute. If they close the dispute out, dispute it again. Takes less time than arguing with someone, and sometimes some lenders will ignore disputed tradelines when determining creditworthiness.
We've had a medical bill go to collection. (Mixup over whether a doctor was in-network caused by a practice where some doctors are in-network and some aren't, compounded by them having an old address so we never got the bill).
For instance, if the thing you bought goes on sale the next day, you do what?
Shoplift it to teach the store the lesson. Right? Is this a trick question?
No, you burn the store to the ground to protest its capricious pricing policies.
I think that in France doctors are required to post the prices of the 5 most common services.
The nice thing about MA is that if you're below a certain income threshold, they can't send you a bill. Now that everyone has insurance they can go after people with insurance for their co-pays.
At Nordstrom I saw that a sweater I had bought went on sale. I went back to buy one in another color and returned the one I had bought. I then bought one of the original color at the same price.
77: In France it's normally a standard fee schedule like Medicare due to (what amounts to) single-payer; this makes it look like doctors can choose to charge extra, even within the system, but only if they forgo certain other benefits.
78: Good shopping! It's hard to do that with a kidney though.
|| Today's Clapper decision vindicates all those who've argued that standing is bullshit. And all those who said doing anything that increased the possibility of a Republican in the White House was madness. |>
80: When I was on the Board of an adoption agency, someone raised this issue in connection with a proposed new income-based discount plan.
81:And which side of that case was Obama on?
A while ago Lemieux topped this by saying the drones weren't at all Obama's fault, because Congress hadn't exercised it's power to stop him. It was beautiful
For anyone else not up on legal news:
In a 5-4 decision that split along ideological lines, the court ruled that activists, journalists and lawyers represented by the American Civil Liberties Union (ACLU) could not prove that they were harmed by the wiretapping program. "Simply put, respondents can only speculate as to how the attorney general and the director of national intelligence will exercise their discretion in determining which communications to target," Justice Samuel Alito wrote for the majority, agreeing with the Obama administration's position that the challengers lacked the legal standing to sue.
Read more: http://thehill.com/blogs/hillicon-valley/technology/284949-supreme-court-blocks-challenge-to-surveillance-law#ixzz2M27uLS1t
83.1 -- I don't excuse his conduct wrt the national security establishment, and while it is right that Congress is to blame for a whole bunch of things, this certainly doesn't remove blame from the Executive where they are in agreement.
(They didn't bother to take Wilner, in which the Second Circuit held that the feds don't have to tell you if they've been monitoring your communications.)
Obama is about to take the National Surveillance State up a whole new level with this Chinese hacker excuse. Then he can hand off his authoritarianism to a designated Republican successor in 2016. Fuck SCOTUS. They won't save us.
But you know who is fun and hints at hope?
Ian Welsh gives some options
I didn't see either hope or options in either of those posts. Yes, a well enough funded insurgency can find ways to protect its privacy. That doesn't have anything to do with anything that's going to go on in the US.
Huh. That's really shitty. Any response more sensible than renewing ACLU membership?
Weren't there two senior military careers just ended because of essentially surveillance leaks? And widespread Chinese military co-opting of security firms' computers? Why do the supremes hate America?
Why do the supremes hate America?
That's no longer a rhetorical question, we could come up with a fairly long list of reasons why.
No, seriously, a loosely-controlled, powerful surveillance bureaucracy is a serious political weapon just waiting for someone to pick it up. This isn't a subtle point that requires fine print, and there was a scandal with leaked surveillance affecting the US military just this year.
And yet, pointing all of this out publicly is a fringe opinion, ostensibly because of America's enemies armed with technology suitable to high school kids. I really don't get it-- this is self-defeating behavior.
||
Mortgage insurance premiums are tax deductible, but big fat capital losses on the sale of your house get you nothing. WTF???
||>
92: the classic Anglo-American tax set-up AFAIK is that income expenses are deductible from income tax and capital losses or expenditure are deductible from capital gains and never the twain shall meet. (Mortgage interest relief has been done away with on my own teddy-bear-shaped island.)
94
Mortgage insurance premiums are tax deductible, but big fat capital losses on the sale of your house get you nothing. WTF???
I don't know anything about mortgage insurance premiums but you can't claim capital losses when selling your house for the same reason you can't claim losses if you sell your car or your tv. A house (which you are living in) is a consumption good not an investment.
Obama is about to take the National Surveillance State up a whole new level with this Chinese hacker excuse. Then he can hand off his authoritarianism to a designated Republican successor in 2016.
"Designated Republican successor" is funny, bob, because it's not that long since you were telling us all that Obama was going to engineer another recession in order to allow him to run in 2012 as a Republican.
But you pay capital gains tax on a profitable sale (in certain circumstances, above a threshold) of your home. Cunningly, my parents are going to have to pay US capital gains tax on the sale of their UK home even though it's not taxable in the UK.
I don't have mortgage insurance myself, I'm mainly bitching that the effect of that particular tax policy is to jack up housing prices and subsidizing the financial services industry, and encourage people to buy more house than they can afford. Meanwhile, the little guy who go screwed after prices collapsed - thanks to the financial services industry - gets nothing.
Also, Shearer, you are being quite dense not to acknowledge that there is a difference between real-estate and consumption goods. Last I checked, land does not get consumed, and houses only very slowly (the house was 150 years old).
I think the real reason that you can't deduct losses is because there is another fool policy out there that says you don't get taxed on the first $250,000 in capital gains on the sale of a house. Which, again, is a policy set up to help the winners that, alas, screws the losers.
97
Also, Shearer, you are being quite dense not to acknowledge that there is a difference between real-estate and consumption goods. Last I checked, land does not get consumed, and houses only very slowly (the house was 150 years old).
Perhaps I should have said is treated by the tax code as a consumption good.
99
I think the real reason that you can't deduct losses is because there is another fool policy out there that says you don't get taxed on the first $250,000 in capital gains on the sale of a house. Which, again, is a policy set up to help the winners that, alas, screws the losers.
I think this is a sensible policy. I am currently selling a townhouse I lived in for 20 years. I have a nominal gain but adjusted for inflation I am actually losing money. So I don't think it is unreasonable not to be taxed on it. Not to mention it saves a lot of record keeping hassle.
income expenses are deductible from income tax and capital losses or expenditure are deductible from capital gains and never the twain shall meet except for $3000 per year used to offset regular income with the rest carried over until it is used up.
It makes sense a priori for house sale losses to be not considered income, since there is no income after you subtract your basis, but Spike is right that it's a ridiculous policy mismatch that we have lots of tax breaks designed to help people buy homes, but much less (nothing?) to help people underwater.
Another example of the one-sidedness is that if you sell your (main, personal-use) home at a profit, you get $250K of that profit tax-free. Double that for married couples.
At the very least, I'd like to be able to carry forward my $60K loss on the off-hand chance I ever need to offset a corresponding capital gain. Not that I'll be buying and selling a house again anytime soon.
101.2: Until recently wasn't that a one-time per lifetime exemption (not sure if it was capped)? I thought pretty much designed to not whack people who were selling in retirement to downsize or move into some other living arrangement. But unsurprisingly it's all perks for the affluent winners
97: and houses only very slowly (the house was 150 years old).
But what was the upkeep cost as a share of the value? If you did nothing to maintain a house for 150 years there would not be a livable house by the end.
I have a nominal gain but adjusted for inflation I am actually losing money.
While I'm generally in favor of high capital gains taxes, I do think paying capital gains on inflation kind of sucks. When I am in charge of the world, there will be a high capital-gains tax rate, but you will also be able to adjust the cost-basis based changes in the Consumer Price Index.
adjust the cost-basis based on changes
Until recently wasn't that a one-time per lifetime exemption (not sure if it was capped)? I thought pretty much designed to not whack people who were selling in retirement to downsize or move into some other living arrangement.
This is a new subject to me, but I think yes, if by "recently" you mean 1997. Now you can do it with any number of homes as long as you've lived in them for 2 years (nonconsecutive) of the 5 preceding sale.
Interesting how often huge across-the-board tax breaks are justified as helping seniors. That's the lens Prop 13 is often viewed through here.
I remember "live in it for two years" was a pretty prominent element of the various "you too can get rich in real estate" house-flipping strategies that were floating around in the early 2000s.
107.1: but I think yes, if by "recently" you mean 1997.
Probably, my previous data point was from 1986 when I did pay capital gains on a house sale profit of far less than $250K. Did not have reason to check again until a couple of years ago.