**Like**

(And no “Second Amendment” financial protection for consumers, unfortunately.)

We have been disarmed by the medical/industrial/political complex.

For example, Medicare in 2000 paid for 13 million hospital admissions and the cost to Part A was just under $100 billion.

In 2010, Medicare Part A paid for 13 million hospital admissions and the cost was over $180 billion.

Hospitals learned to admit more patients into intensive care, and to maximize reimbursements based on the diagnostic code (DRG’s).

Countries have binding national fee schedules have learned to fight this battle. As you point out, American payors have given themselves no weapons.

Just one point in addition — we could wipe out medical school debts for less than $30 billion a yearin federal spending ongoing. We could forgive a large chunk of existing debt also.

This would be money well spent, as opposed to overpaying doctors for the rest of their professional life,

Insurance premiums go up simply because the bills go up. And those bills originate with providers. All the “downward pressure” in the world isn’t going to get results as long as premiums are tax-advantaged and employer contributions are deductible business expenses. Tax policy and GAAP have the effect of sheltering medical bills from close scrutiny. And in most settings there is no real competition. I don’t know about other places but where I live competing systems cannot be built without prior approval requiring a CON (certificate of need), a politically generated official document with a totally misleading name. Certificates of need are never or rarely issued for places where there is an actual need such as a poor part of town or in a rural community. The reason is simple — there is no competition for those places where real needs are not matched by money.

During the Bush administration a proposal which originated with AEI (hardly a Liberal bastion) which proposed what strikes me as an excellent suggestion — uncouple employment from insurance altogether, not all at once, but pushing the current system in that direction by crafting tax policy to move insurance in that direction.

http://qote.me/VqogU5

Take a look at that document and see what I mean. In a global economy employers already have competition enough without having to include the cost of health care in every product they are trying to sell when similar products are coming from other countries in which basic health care is a universal, tax supported, typically with cost controls.

These are treasonous ideas I am advancing. Just ask any medical professional making payments on a second home or salting assets away in a sheltered trust for his heirs. Or ask any newly-minted medical student, matriculating up the ladder, facing student debt in the mid to high six figures and see how they like the idea of being compensated less. (Which brings up another problem — the outrageous costs of training and development of medical professionals. There are timid advances buried in the bowels of ACA — like loan forgiveness in return for time in an “under-served” area or working for a non-profit — but the incentives are not stellar enough to attract any serious numbers of people when the lights are so bright in the big time.)

No other industrial nation would consider asking its population to refuse care and, effectively, suffer and die, so as to challenge high medical bills.

This is just cowardice, as opposed to doctors and hospitals which post unconscionable bills.

Bob Hertz The Health Care Crusade

John, the maddening thing to me about group insurance to me is that the carriers do exert price restraint. And yet premiums go up every year.

This is mainly due to an actuarial death spiral. The medium sized employers who cover their workers are shrinking. The large employers with healthy workforces are mainly self funded.

What is to be done?Let’s keep talking.

Bpb Hertz, The Health Care Crusade

For some of us spending money on a dog’s health is in the same category as spending money on one’s own health or the health of one’s other family members. I don’t know if these are investments or expenses, since, as Peter writes, not all health spending has tangible returns to the one that spends the money. Children’s future earnings are rarely a consideration for a parent spending that million dollars on a sick kid.

Point is that in health care for human or non-human family members, pricing cannot be driven by the consumer.

Pets can be an investment in personal well being. Some will argue that people who keep and love their pets experience better health.

Would putting granny on DNR be a way to cut expenses while spending a million dollars on a child’s health care be an investment?

Margalit, for my answer to your question about pet care I refer you to my comment above pointing to the difference between investments and expenditures. There is a qualitative difference. that makes them different from person to person depending on their social and wealth status. One person’s investment is another person’s expenditure. In short, pets and pet care are expenses, not investments. Take horses, for example. I’m not in that league, but if I were I would regard my horse as an expense, not an investment. But for some people with far more wealth than I (Would it be tacky to mention Mrs. Romney here?) horses are more than an expenditure.. They can be an investment. Show horses, race horses, they have value in many cases for stud fees alone, years after their glory days are behind them. And that revenue stream pays for their upkeep many times over.

Short answer: pets and pet care are expenses. Personal and family medical care are investments in future earnings and minimizing future expenses.

bob, my understanding of the system was informed by Paul Starr’s Social Transformation of American Medicine, somewhat dry and academic, but the gold standard for anyone wanting to know about the subject, and Maggie Mahar’s Money Driven Medicine.

If I recall correctly, right after the war the first of the group insurance products came along in the form of the original Blue Cross. It was for hospital care only and was an attractive company benefit aimed at attracting good people from other companies that may not have had it. The doctors, aka AMA, were absolutely opposed to the idea, suspicious of anything big and afraid that hospitals would be competing for patients. But they realized that the practice of medicine was impossible without hospitals, and when their fears didn’t come to pass, the insurance people advanced the Blue Shield model to form groups to pay for professional services in addition to hospital charges. Again the doctors were opposed, fearing price controls which during the war made their fears more than imaginary. The only way that AMA went along with both insurance models was that all hospitals would be non-profit and there was a tacit agreement that there would never be any interference from government messing with physician charges (price controls).

This was my impression of the background, the health care industry being wed to the insurance industry. Until the Sixties all hospitals in the country were non-profit until the profitability possibilities were exploited in the name of “size, efficiency and the economy of scale” by entrepreneurs with profit motives. It may have been HCA or some other outfit that aimed to do with hospitals what McDonald’s was doing with hamburgers. I don’t know. Again, I’m just reeling out my understanding and I’m certainly open for correction. But I think this is more or less accurate.

I have been arguing the case against the fallout of this incestuous relationship between insurance and medical care for a long time, most recently in another comments thread.
http://qote.me/tU9k08

And here as well
http://qote.me/wt8CFa

But the problem in America, unlike the other countries you mentioned, is precisely the prohibition of price controls — for either medicine or services — that other countries have no compunction about making in the interest of public health. The early fears of doctors (and now even so-called not-for-profit hospital systems with “competitive” executive compensation packages) were long ago made real in other countries. But in America, where ain’t nobody gonna tell the private sector how to run their business, where any kind of regulation or control is seen as just another step toward socialism, the best the government can do to “bend the curve” is negotiate with the private sector, hoping for the best against a large and growing army of lobbyists who have more elected representatives in their pockets than any crime boss.

It is no accident that Medicare Part A is modeled after the original Blue Cross (hospital) coverage and Part B (professional services) is an echo of Blue Shield. It took a few years more, but the pharmaceutical-industrial complex finally got into the comfort zone with the hugely wasteful Medicare Part D which was not even funded — coming from general revenue!! And now we wonder why the budget is out of balance. Don’t get me started….

Any way, Medicare, even now, doesn’t actually tell anyone what to charge. All the government can do is publish a schedule of reimbursements which is waaay different from what doctor, clinics, hospitals and others actually put on their bills. The difference, of course, is picked up by “supplemental insurance” which in turn is tax-advantaged thanks to the sweet political arrangements that industry has crafted with politicians of both parties over the several decades.

I could rant on for pages like this, but I think anyone can see the points I’m making.