Actually it hasn't been a big boon for insurers. They hoped it would be but they bet wrong. The big winners from Obamacare are hospitals.

As for prices not dropping, if they don't then the death spiral will continue and eventually there won't be anyone with insurance. Which is certainly one solution to the problem. Given what I just read about Trump/Ryancare I'm betting the death spiral is the only solution.

I agree with Ben. A death spiral may be the only way to actually reform the healthcare system. Tort reform is the third rail that no one in the Uni party is willing to touch and it must be included in any legitimate and stable health care reform.

Right now the only people who have affordable major illness or surgical care are those on comprehensive government programs

The rest of us are subsidizing them and getting darn little care or security with our massive unaffordable deductibles and co pays.

"...prenatal dentistry..."

Is that a thing? I've never heard of it, which means nothing, but still.....

I think it is supposed to be prenatal care for an expectant mother.

And yes, women who can not bear children in a permanent sense - too old, hysterectomy, infertile, tubes tied, etc - are paying for pregnancy coverage on for themselves. Because it takes a village or some such nonsense.

Until such time as we can remove the major government influences that distort the market, any reform will be just a band aid on the skin cancer that's busily metastazing into our insurance.

Avik Roy: "House GOP's Obamacare Replacement Will Make Coverage Unaffordable For Millions -- Otherwise, It's Great"

https://www.forbes.com/sites/theapothecary/2017/03/07/house-gops-obamacare-replacement-will-make-coverage-unaffordable-for-millions-otherwise-its-great/#a1cf41737fdd

Prenatal dentistry -- hah...good point. You get it after your little snot (uh, little darling) is born:

https://www.thebump.com/a/affordable-care-act-pregnancy

As of January 1st, a new list of “ten essential benefits” will come as part of your insurance plan — regardless of which package you choose. The key parts of that essentials bundle you need to know about are maternity care, vision and dental care for children, emergency services, pediatric care and hospitalizations.

PS Changed that "prenatal dentistry" to "children's dentistry." Thanks, roadgeek!

Raddy is absolutely right. Current "health care" plans are a messy cross between truly insurance (the mitigating of financial risk to an individual by spreading the risk across a pool of people), and pre-paid treatment plans. (Ones with only a very loose correlation between what you pay in and what it pays out.)

And yeah, those Obamacare Lite programs that the GOP is kicking around in Congress won't make a damn bit of difference. What needs to be done seems to be incomprehensible to damn near everyone in Washington. I attribute this to the fact that the bulk of them are government employees, and therefore get health benefits far more generous than anything in the private sector. It isn't a problem for them, therefore it isn't a problem. QED.

As is the case with Social Security, it's going to be GenX that gets screwed on this one. (Millennials get screwed on a bunch of other stuff.) Those of us who paid in $$$ back when we were young and seldom had any claims are going to get our coverage sharply restricted, now that we're reaching the age where we need it. My family doc recommended that I see a cardiologist and get some tests done, not because I had any symptoms, but because of family history. So I did. I just got an $1100 bill from the cardiologist. The insurance refused to pay a dime because, in their esteemed opinion, there was no "medical necessity". As Raddy often says, the clerk is not sick. Fill out these forms and we'll consider your request. Eventually. Maybe. No promises.

My employer has a wellness program. If you participate, the company will reward you with a contribution to a health savings account. There are two tiers, according to what your salary is. The reward for the lower tier is generous (especially for people who have children), but in the higher-income tier it's a pittance. It's not worth the time you have to spend filling out all the forms and doing all of the activities. The company is puzzled as to why so few of the upper-tier employees are participating. They are thinking about making it mandatory for the upper tier, as a condition of being eligible for the company health insurance. Most of said employees won't care because they are military retirees or dependents. Those of us who graduated at the "peak" of the Carter presidency, when the military was turning down volunteers because it had no funds with which to put them through basic training, will be the ones who get screwed.

Groups. Divide people into groups. Shower favors upon one group and compel another group to pay for it. It's what government is about these days. It is the essence of Washington. It is why today's Washington exists. If people had freedom to choose things, it might tend to break up the designated groups. Can't have that. How would anyone know who belongs in which group if people were allowed to do that sort of thing?

Not only the hospitals were/are benefiting from Obamacare.

Pharmaceutical companies are profiting from it via price-gouging (The Epi-Pen price hike for example) measures, and they are spinning it by saying that it's still cheap because the insured will not pay full price for it thanks to discounts.

But who's footing the bill for the discounts? The devil is in the details of course.

Sixclaws, The Epi-Pen thing is not Obamacare. That is due to standard FDA practices that goes back decades. Obamacare caused many people to have high deductible policies. At that point people saw all the billing stupidity that had been going on for decades.

On medical billing in general, there are different prices for different situations and little of it is transparent or simple. If it is an option paying cash at time of service almost always is the cheapest option. When you bill through an insurer what typically happens is the service provider figures out how much the service costs. Then they add how much it costs to fill out the insurance paperwork. Then they multiple by some number (1.7, 2, 3 are all common). That way that insurer can negotiate a 'discount' from that inflated price and the provider still gets their money. Everyone knows the system is a joke and the discounts aren't real. But they aren't the ones paying. It is the patient who gets stuck with the bill in the form of higher premiums who really pays. And often they don't know how much they are paying because their employer takes those bills out of their paycheck before the employee even sees it.

That Forbes article is very interesting Amy. And a perfect example of a deceptive headline. The ACA already makes insurance unaffordable for millions of Americans. So of course a few small tweaks don't change that.

The more I've looked at the Ryan plan the more I suspect that death spiral is his objective. Essentially there is little that the Republicans can do. They don't have the votes in the senate to pass a plan without Democrat support. But they aren't going to get any support from the Democrats. So without changing senate rules (which I think they should do) all they can implement are budget and not regulatory fixes. That is why the Ryan plan essentially comes down to repealing the individual mandate or obamacare tax. An extremely mild change, which is why that Forbes article is so pathetically deceptive. All that this will do is increase the rate at which people abandon obamacare plans, essentially speeding up the death spiral.

The Republicans refuse to change senate rules so they can't repeal Obamacare. Instead they are making it irrelevant.

How does the Republican plan deal with people who lose their jobs and so lose their health insurance plans? COBRA plans have always been hideously expensive, so losing a job often means defacto, having to switch to an individual plan that provides less and cost much more.

Health insurance must be removed from employers.

If you want to argue that current regulations offer perverse incentives, that's fine. We should definitely try to align the regulations and the incentives. The problem is always with priorities. At the same time the priority for savings is increased, the priority for ignorant laymen to see a doctor is decreased.

Is this just my standard headache that I can get through the day, or am I about to stroke out?

Is this nagging persistent cough part of the season, or do I have pneumonia that is contagious, and will take me out of the job when it gets so bad I am hospitalized as a much larger cost to everyone?

etc.

Basically, it's Type I and Type II error all over again. Push down on one and the other pops up. You need to attack both at the same time.

Another way to look at that is that Raddy is both right and wrong. If the people want a pre-paid medical plan, that's what legislators should trying to create, and fuck the current insurance model and fuck current insurance companies. They can adapt or die. They are not protected by the constitution.

As of January 1st, a new list of “ten essential benefits” will come as part of your insurance plan — regardless of which package you choose. The key parts of that essentials bundle you need to know about are maternity care, vision and dental care for children, emergency services, pediatric care and hospitalizations.

Christ Almighty. If there are such things as "essential benefits," one would assume they would be vision care, basic dental maintenance and preventative checkups for the policyholder, not someone else's children.

I'm pretty sure ObamaCare was designed to crash & burn, in the hope that "the people" would clamor for single payer.

Christ Almighty. If there are such things as "essential benefits," one would assume they would be vision care, basic dental maintenance and preventative checkups for the policyholder, not someone else's children.

That's to win the votes of the "Free Shit Army". Paying for things from Obama's stash of money.

"Christ Almighty. If there are such things as "essential benefits," one would assume they would be vision care, basic dental maintenance and preventative checkups for the policyholder, not someone else's children."

Shhh...you'll ruin the illusion. Of course any health care policy only covers the policy holder. Children are, in the end policy holders too. So saying that you provide pediatric care for the parent really makes no sense.

They do this, because it makes it more difficult to object. If something is "for the children", you have to be a hard-hearted bastard to object to it...

I have asked doctors many times how much a procedure/lab costs that they are recommending for me. They never know. How can one shop for price when no one can tell you the price? Imagine a restaurant that you only find out the price after you eat!

I have asked doctors many times how much a procedure/lab costs that they are recommending for me. They never know. How can one shop for price when no one can tell you the price? Imagine a restaurant that you only find out the price after you eat!

cc at March 7, 2017 11:58 AM

Of course they dont know, because there are many different labs, and the prices your deductible is probably different at each one of them.

Your doctors staff can barely figure out what they have to charge to stay above water, let alone what an independent lab is going to charge you,

Stop asking doctors, and start calling medical labs. I have used a cut rate one for many years now. Their tests are processed by the same labs as the expesnive places, and they have more tests every year.

My state has this service. Your state may have something similar.

https://wyominghealthfairs.com/

Thanks for the credit, guys. As mad as I am about this, I'm sure you get sick of hearing about this issue.

Let me link one more time and ask you a favor: Please modify this as you see fit and send it to your representatives!

With all the turmoil, maybe somebody's looking to stand out from the herd...

"Stop asking doctors, and start calling medical labs."

Bullseye!

I have asked doctors many times how much a procedure/lab costs that they are recommending for me. They never know.

Try a group that practices concierge medicine. They'll be able to tell you how much a given procedure will cost. This is my idea of single payer: the patient.

I found a link and posted it on this blog, likely in one of the daily linkies, about a concierge practice in Oklahoma where they had set prices, even if there were complications. Probably sometime after the election.

Here's another article, and it maybe about the same folks:

http://watchdog.org/166973/oklahoma-obamacare/

Sarah King is a 27-year-old dental assistant from South Dakota. When she was 11-weeks pregnant with her first child, she had a gallbladder attack that landed her in the emergency room. After her daughter’s birth, she said she realized the gallbladder needed to be removed. Instead of going to the local hospital, she began researching alternatives. The price she ended up paying at the Surgery Center of Oklahoma was more than 50 percent less than the amount she said she would have paid for the same procedure at her local hospital.

And...emphasis mine...

But King said there was another reason she chose the Surgery Center, and it has nothing to do with price. Her local hospital’s infection rate was significantly higher than the Surgery Center’s, which posts its infection rate along with its prices.

If something is "for the children", you have to be a hard-hearted bastard to object to it...

You can call me H.H.B. for short.

"Christ Almighty. If there are such things as "essential benefits," one would assume they would be vision care, basic dental maintenance and preventative checkups for the policyholder, not someone else's children."

And those are the worst things to place under 'insurance'. Every vision and dental plan I've used cost more than just paying cash. There was zero benefit. Yes they claim you got a discounted rate. But that discounted rate is still higher than just paying cash.

"How does the Republican plan deal with people who lose their jobs and so lose their health insurance plans?"

No different from Obamacare. Like I said above all they are doing is removing the Obamacare tax for not having insurance and fiddling with how medicare is paid for. That's it. The whole enchilada. Which is why the claims that it will take insurance away from millions and cause death and destruction are all lies. This is just a very minor change to the current status quo.

And as for COBRA plans, you always paid that before. You just didn't know how much they were taking out of your paycheck. All COBRA does is make you pay the full amount.

And as for COBRA plans, you always paid that before. You just didn't know how much they were taking out of your paycheck. All COBRA does is make you pay the full amount. ~ Ben at March 7, 2017 3:39 PM

Actually, your employer was paying a fair amount of the premiums while you were employed. With COBRA, you pay the entire premium.

The costs of employing someone in the US includes payments for benefits (beyond the employee contribution), vacation and sick day costs, unemployment, workers comp, etc. I always used a 35% multiplier applied to salaries when estimating labor costs in my analyses and staffing models.

My point was that it is part of your compensation. Most people don't know how much of their 'wages' are spent on health care.

When converting from employee to contractor I use x1.25 for unskilled labor, x1.5 for semi-skilled labor (assembler/electronic lab tech, i.e. some college but no degree), and x2 for skilled labor (engineer, i.e. degreed). Employers only care how much a resource costs. They don't really care how you get paid. For most electrical engineers even without providing your own lab space and tools you are still cheaper than a full time employee after you double that employee's wages.

I have gone with out dental insurance and paid cash. Paying cash was definitely more... even with the dentist further discounting it because I "was in a tough spot" and he wanted me to have care. If you were not paying up front then it was really expensive.

Paying cash was definitely more... even with the dentist further discounting it"

More over what time period? I've had some serious work done in the last five years but none of it was even close to five years of premiums for dental insurance. Especially when you consider the insurance would only give me a discount and not pay the whole bill.

Dental insurance is like Obamacare. If you are seriously sick and had poor dental care as a child, you might want it and come up slightly ahead with it. Especially if it is provided by your employer.

If you are a generally healthy individual who only needs an occasional crown, filling or cleaning, it is a terrible waste of money.

Speaking of insurance, I have an uninsured friend who is kind of a miser. He went up to Yellowstone over Labor day weekend a couple of years ago, and ended up with an emergency appendectomy at the Jackson Hole hospital on a Saturday morning. The bill was 17k. For the math imparied with an unsubsidized Obamacare policy you would pay a 10 or 12k deductible before your insurance kicked in. So his emergency appendectomy cost him five thousand less than one year of Obama care premiums plus the co pay. That is pretty cost effective for emergency surgery.

It was several years ago now and was about a 2 year period.
On a Cobra type plan it was $150/year
which I didn't take. (I did take the Cobra health insurance)
Actually I think it was 1.5 years.
what I paid
2 basic checkups 2x$50
chip fix and filling $325
$425 total but he gave like $25 off so $400
If I didn't pay up front it would have been about $600

with insurance
1.5yrsx$150
2 basic check up copays 2x$10
chip fix and filling - my portion $150
$395 total

In 2016, I paid ~$75 for dental with my employer picking up the rest (I don't know how much). I had a really bad year - 2 crowns, another chip, some old filling replaced - I got my max annual benefit of $2500 in coverage.

Former Banker. That's pretty cheap insurance. Most of what I have seen is quite a bit more thab that.
And the 2500 dollar limitation wont even cover the cost of one good implant.

That is way better insurance than I've ever had. I went through three different plans and they all were worthless. It was ~$1k for a crown both with and without the plan. I don't remember what premiums were. And it was over five years ago anyways.

The prices are negotiable if you're paying cash price. My insurance doesn't cover the radiology read for imaging. Don't get me started on how absurd that is. But when the bills came in, $367 each, I called and told them I needed some help and was gonna pay cash since insurance wasn't covering. She didn't miss a beat and said, "I can offer you 50% off, but you have to pay within 30 days."

Didn't know that medical bills were a negotiation, but I'm glad to be in on the racket now.

All hail Raddy.

I have also made the same argument.

Brilliantly, I might add, without a hint of blushing.

E.g.:

Already, the first conceptual hurdle is staring us in the face: anyone using the words "health" and "insurance" next to each other is to demonstrate for all to see a comprehensive inability to grasp what insurance is about. To wit, insurance pools risk. A great many homeowners buy fire insurance, very few of them have their homes go up in smoke. But if all houses were built knowing in advance that they would eventually burn down, there would be nobody around to take the other side of that bet. As David Cohen ... memorably put it, the fire insurance market consists of bets by homeowners that their houses will burn down, and counter bets by insurance companies that they won't.

Damn, forgot the tag line:

Clearly, when it comes to healthcare costs, that doesn't apply, because all the houses, or near enough as makes no difference, burn down. So what healthcare "coverage" really amounts to is cost shifting.

Damn, forgot the tag line:

Clearly, when it comes to healthcare costs, that doesn't apply, because all the houses, or near enough as makes no difference, burn down. So what healthcare "coverage" really amounts to is cost shifting.

I wrote that post four years ago.

And nailed it.

Just sayin.

(And, perhaps, channeling crid just that little bit.)

Health insurance: my proposal:

1. Make all medical expenses and insurance tax deductible. Kill some other deductions to compensate. I suggest putting caps on the mortgage tax deduction, so it is no longer an incentive for the very rich to buy ridiculously bloated mansions, nor for the upper middle class to buy more house than they can afford and call it an investment. That is, I would limit this deduction both in absolute amount and as a percentage of income.

2. As the main means of deducting medical expenses, make _everyone_ eligible for HSAs, whether or not they have insurance or an employer. Just like now, what you put into the HSA is non-taxable, as is any interest it earns. You can pay for your insurance through an HSA, as well as for all medical and dental treatments, devices, and drugs. Change the annual limit on contributions per individual to $5,000 plus all expenses paid through it - that is, encourage people to build up tax free savings in their HSA while they can afford more than they are spending.

3. Insurance should be separate from employment.

4. Insurance should actually be _insurance_. That is, it should pay off only on large expenses due to unexpected events. You use the HSA for routine stuff. You should never lose coverage because of illness, even when the expenses go on for years. (Unlike the current so-called insurance plans, which are sometimes comparable to a fire insurance policy that only pays for rebuilding your house if you can get it done before they can cancel it at contract renewal time.) Get a serious condition that is only treatable, not curable, and your insurance company can neither get you off the books nor raise your rates.

5. Insurance must be portable between states. You change jobs and move to another state, and you have the option of taking your insurance with you. If they don't have "in network" providers in your new area, including any specialists you need, they'll have to treat all the providers as "in network". Insurance companies will have one out - they can negotiate with other insurers to transfer your policy to one with a better local presence, but coverage must be as good or better, and the premiums can go up only to the extent that the federal plan ("CrappyCare", see below) rates the new location as a higher cost area.

6. Finally, what happens when the uninsured get sick (and don't have enough in their HSA and bank accounts), and what happens to people that never make enough to cover their medical expenses? We'll provide for them, but not generously:

7. Emergency rooms are still required to provide care for anyone brought in with a medical emergency. Hey, if someone conks you over the head and steals your wallet, you want to be cared for until you wake up and can tell them how you're going to pay. But they are no longer providing free care for the indigent and irresponsible, and no longer allowed to inflate the paying customers' bills to make up for the deadbeats. Instead, unpaid charges can be sold to the IRS for collection, at a 10% discount. (Preferably this is tied to a tax code simplification, so the IRS can transfer staff rather than expand.) There are limits on the amount, and an appropriation to cover those debts that cannot be collected, but lets make it quite clear that misusing an emergency room for a "free" visit to the doctor's office is going to cost you.

8. The ultimate fallback: CrappyCare (the federal healthplan, like an expanded Medicaid). Politicians will make a nicer name for it, but let's be honest in these pages: government insurance either busts the budget by allowing providers to raise their rates and "do everything possible", or it is crappy. Everyone is eligible, but there is a means-tested premium; it's only free for the very poor. You can pay from an HSA or with a checkoff on your income tax return. Pre-existing conditions are covered, and you can even sign up in the emergency room and have that and other recent expenses covered, but if you were uninsured before, you owe premiums for the last three years. Once again, if you need treatment now, you get it (whatever CrappyCare will pay for), and can pay later, but you do have to pay it and the IRS is the debt collector.

I've got a better solution - remove all government interfecence.

Government wage caps led to heath benefits as compensation

Government interference in that led to more regulations

Government attempts to "fix" that lead to HMOs

Which led to more regulations to fix that and finally the ACA

So how about the government does nothing but make sure there is an even playing field* and then buts the fuck out

employer contributions to any perks must be delineated with their cash value and it gets taxed at the same rate as the rest of an employees salary

then there will be no need to force employers to stop providing health insurance as people will know what they are really paying and can go looking for a better plan

lujlp: I agree in principle, but we're now several cycles into increasing government interference to "fix" the ill effects of previous government interference. It's politically impossible to unwind all that at once.

I did not suggest forcing employers to stop providing health insurance, but rather ending the tax advantage of employer insurance by making both paying for health care directly and privately-purchased insurance equally deductible. That's leveling the playing field among the non-governmental options.

I don't take away the tax deduction because many will think that taxing sick people is wrong - instead I change the laws that tax _some_ sick people. I provide a tax-subsidized fall-back because it clearly isn't politically possible to leave the poor with nothing, and because we need to stop them using emergency rooms for none-emergency treatment, but it is impractical for emergency rooms to require payment arrangements up-front.

markam, picking and choosing subset of people for extra governemnt help ALWAYS leads to abuse and ALWAYS leads to more legislation to fix the problem

The only way to truly fix is it to end government interference entierly