Health Insurance Freedom

I posed a question up on Plum Line today and got some interesting responses. I think NoVA and jnc were active on the thread. We’ll make it a two parter. I thought Brent, Kevin or Mark might be interested.

1. Your employer pays for your family’s health insurance at a cost of $12,000 per year. Said employer offers to drop the coverage and increase your salary by the same amount. Under current law, you lose the tax benefit of deductibility, but gain the liberty to purchase whatever insurance you like. Is it worth the price?

2. Same as scenario #1, but assume that current law is changed to make health insurance deductible on Schedule A. That or make employer provided health insurance taxable.


I was effectively asked the first question when negotiating terms for a possible new position. I responded that I would have to purchase health insurance of some kind as my better half is a freelancer. The offer included health insurance. I’d take it that way as I don’t care for the tax hit.

I’d say yes to Question #2 as I dislike the link between health insurance and employment. It’s a relic of wage and price controls from the 40s. The U.S. spends as many public dollars as most developed countries do and then kicks in a few more precent of GDP.


Copied Without Permission from the WSJ


Every so often I have an extraordinary and surprising experience with a patient—the kind that makes us both say, “Wow, we’ve learned something from this.” One such moment occurred recently.

A gentleman in his early 60s came in with a rather routine hernia in his lower abdomen, one that is easily repaired with a simple outpatient surgical procedure. We scheduled the surgery at a nearby hospital.

My patient is self-employed and owns a low-cost “indemnity” type of health insurance policy. It has no provider-network requirements or preferred-hospital requirements. The patient can go anywhere. The policy pays up to a fixed amount for doctor and hospital bills based upon the diagnosis. This affordable health-insurance policy made a lot of sense to this man, based on his health and financial situation.

When the man arrived at the hospital for surgery, the admitting clerk reviewed the terms of his policy and estimated the amount of his bill that would be paid by insurance. She asked him to pay his estimated portion in advance. (More hospitals are doing that now because too often patients don’t pay their portions of the bills after insurance has paid.)

The insurance policy, the clerk said, would pay up to $2,500 for the surgeon—more than enough—and up to $2,500 for the hospital’s charges for the operating room, nursing, recovery room, etc. The estimated hospital charge was $23,000. She asked him to pay roughly $20,000 upfront to cover the estimated balance. (emphasis provided)

My patient was stunned. I received a call from the admitting clerk informing me that he wanted to cancel the surgery, and explaining why. After speaking to the man alone and learning the nature of his insurance policy, I realized I was not bound by any “preferred provider” contractual arrangements and knew we had a solution.

I explained that just because he had health insurance didn’t mean he had to use it in every situation. After all, when people have a minor fender-bender, they often settle it privately rather than file an insurance claim. Because of the nature of this man’s policy, he could do the same thing for his medical procedure. However, had I been bound by a preferred-provider contract or by Medicare, I wouldn’t have been able to enlighten him.

Hospitals and other providers make their “list” prices as high as possible when negotiating contracts with health plans and Medicare regulators. No one is ever expected to pay the list price. Anybody who has seen an “Explanation of Benefits” statement from a health plan will note a very high charge from the provider, and an “adjusted charge” based upon the contracted fee schedule, which usually leaves the patient with little or nothing in out-of-pocket expenses. The only people routinely faced with list prices are those few people who have insurance like my patient’s—that doesn’t include a pre-negotiated fee schedule with contracted providers—or those who have no insurance.

Most people are unaware that if they don’t use insurance, they can negotiate upfront cash prices with hospitals and providers substantially below the “list” price. Doctors are happy to do this. We get paid promptly, without paying office staff to wade through the insurance-payment morass.

So we canceled the surgery and started the scheduling process all over again, this time classifying my patient as a “self-pay” (or uninsured) patient. I quoted him a reasonable upfront cash price, as did the anesthesiologist. We contacted a different hospital and they quoted him a reasonable upfront cash price for the outpatient surgical/nursing services. He underwent his operation the very next day, with a total bill of just a little over $3,000, including doctor and hospital fees. He ended up saving $17,000 by not using insurance. (emphasis provided)

This process taught us a few things. First, most people these days don’t have health “insurance.” They have prepaid health plans. They pay premiums to take advantage of a pre-negotiated fee schedule arranged for and administered by a third party. My patient, on the other hand, had insurance.

Second, even with the markdown for upfront “cash-pay” patients, none of the providers was losing money on my patient. Otherwise they wouldn’t have agreed to the prices. With the third-party payer taken out of the picture, we got a better idea of the market prices for the services. It is the third-party payment system that interferes with true price competition, so “market clearing prices” can’t develop.

Take the examples of Lasik eye surgery or cosmetic surgery. These services are not covered by insurance. Providers compete on the basis of quality, outcomes and price. And prices have continually dropped as quality and services have improved—unlike the rest of health care.

When my patient returned for his post-op visit we discussed the experience. It was clear to both of us that the only way to make health care more affordable is to diminish the role of third-party payers. Let consumers and providers interact through market forces to drive down prices and drive up quality, like we do when we buy groceries, clothing, cars, computers, etc. Drop the focus on prepaid health plans and return to the days of real health insurance—that covers major, unforeseen events, leaving the everyday expenses to the consumer—just like auto and homeowners’ insurance.

Sadly, we are heading in the exact opposite direction. ObamaCare expands the role of the third party and practically eliminates the role—and the say—of the patient in the delivery of health care. Will they ever learn?

Dr. Singer practices general surgery in Phoenix, Ariz., and is an adjunct scholar at the Cato Institute.

A version of this article appeared August 22, 2013, on page A15 in the U.S. edition of The Wall Street Journal, with the headline: The Man Who Was Treated for $17,000 Less.

Flip Flopper in Chief?

I just don’t see how someone with so many different opinions or statements on one subject can realistically believe he can or even should be President.

A quote from Romney’s book “No Apology”;

After about a year of looking at data — and not making much progress — we had a collective epiphany of sorts, an obvious one, as important observations often are: the people in Massachusetts who didn’t have health insurance were, in fact, already receiving health care. Under federal law, hospitals had to stabilize and treat people who arrived at their emergency rooms with acute conditions. And our state’s hospitals were offering even more assistance than the federal government required. That meant that someone was already paying for the cost of treating people who didn’t have health insurance. If we could get our hands on that money, and therefore redirect it to help the uninsured buy insurance instead and obtain treatment in the way that the vast majority of individuals did — before acute conditions developed — the cost of insuring everyone in the state might not be as expensive as I had feared.

It’s not as if this interview with Glenn Beck was while he was in college, it was in 2007.

When they show up at the hospital, they get care. They get free care paid for by you and me. If that’s not a form of socialism, I don’t know what is,” he said at the time. “So my plan did something quite different. It said, you know what? If people can afford to buy insurance … or if they can pay their own way, then they either buy that insurance or pay their own way, but they no longer look to government to hand out free care. And that, in my opinion, is ultimate conservativism.

And in a 2010 interview on Morning Joe he was asked if he believed in universal health coverage and said;

Oh sure. Look, it doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way.

And then surprise of surprises last night on 60 Minutes he reversed course.

“Well, we do provide care for people who don’t have insurance,” he said in an interview with Scott Pelley of CBS’s “60 Minutes” that aired Sunday night. “If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.”

h/t Sam Stein & Amanda Terkel

My oldest daughter finally convinced one of her friends to apply for the CA PCIP enacted as part of the ACA. Her friend Sara completely lost the ability to speak and also lost control of many motor skills while in graduate school about three years ago. Her medical insurance expired as she was forced to quit school and was also unemployable. Luckily, her partner was able to support the two of them, but just barely. Sara was unable to purchase health insurance and had no medical diagnosis so was also denied disability.

She has spent the last three years in emergency rooms and trying to get care and a diagnosis through the health department but most tests were denied and no one seemed able to make a diagnosis even though she has gone down hill dramatically in the past three years. At one point the state sent her to a mental health expert as they thought she was making herself sick or something. She now walks with the help of a walker, can no longer drive and barely leaves the house as it’s too much effort.

About a month ago she received her insurance through PCIP and was finally able to see both a GP and the neurologist he sent her to and now has a likely diagnosis and even medication to improve her condition. Her tests were ordered on an emergency status and she was diagnosed with PLS a very rare (only 500 cases in the US) and degenerative form of ALS (Lou Gehrig’s) that is not as deadly or rapidly progressive. There are treatments and while it is debilitating it isn’t a death sentence and can be mitigated while improving her quality of life.

We had a similar experience with our niece who died in 2008. We waited a very long time for her insurance company to approve the tests she needed but the approval never came. Instead she received a notice that her insurance had been terminated. We couldn’t get in to see a neurologist until we could prove we had the money to pay for whatever tests and treatment she might need. We converted our IRA’s to cash and put our rental house on the market but we were too late. While I was on the way to bring her home from Albuquerque to see the neurologist I’d found to treat her she had a seizure and died.

Mitt Romney can’t even seem to figure out if we have an obligation to help people in these circumstances or not.

Health Care Link Dump

Just wanted to post some of the recent health care news.  There’s also been an uptick in the number of SCOTUS ruling previews, but none of them are really all that insightful.  Just parlor game speculation.

Also, the White House has issued a veto threat on the medical device tax repeal bill.  [Edit:  Link to Statement of Administration Policy]

AHIP released a survey that found the number of people enrolled in health savings accounts and high deductible health plans has tripled over the last five years.  Survey is available here.  The Washington Post and Kaiser Health News recently profiled employers’ increasing use of high deductible health plans.  Most of these plans already covered a lot of the essential benefits stuff for free, even before the ACA, which I probably should have known.  The article is available here.

Medical costs are expected to rise by 7.5 percent in 2013, the fourth consecutive year of modest increases, according to a study released by PricewaterhouseCoopers LLP’s Health Research Institute.   Four factors that will continue to slow the rise in medical costs in 2013: medical supply and equipment costs are moderating under market pressure; growth in physician services is expected to be one of the slowest areas of cost growth as consumers choose alternatives to traditional office visits; accessibility to information on prices is exerting downward pressure as consumers in high-deductible plans seek cost information and pricing information becomes more readily available; and pharmaceutical patents are expiring.  The study is available here.

The Washington Post and GAO on a ACA tax credit in that small businesses aren’t using due to the complexity of taking it.  article is available here.  The GAO report, “Small Employer Health Tax Credit – Factors Contributing to Low Use and Complexity” (GAO-12-549) is available here.

Video:  Former CMS Administrator says that premium support (aka vouchers) is going to happen.

Health Care Costs Flattening. Why?

The New York Times has an article on the the slowdown and leveling off of health care cost, as a percentage of GDP. The economy is undoubtedly a factor, as people simply delay care. But consumer-directed plans might also be a factor.

Many experts — and the Medicare and Medicaid center itself — point to the explosion of high-deductible plans, in which consumers have lower premiums but pay more out of pocket, as one main factor. The share of employees enrolled in high-deductible plans surged to 13 percent in 2011 from 3 percent in 2006, according to Mercer Consulting.

That means thousands of consumers with an incentive to think twice about heading to the doctor. One study by the RAND Corporation found that health spending among people who shifted into a high-deductible plan dropped 14 percent — though the study also found that enrollees cut back on some care that tended to save money in the long run, like vaccinations.

The article notes that there also haven’t been any big “blockbuster” drugs released in the past few years.

I think that makes the case for high-deductible and/or consumer-directed care. Patients that are insulated from the true cost of care will consume more. Shift costs their way and they consumer less.

Across the silos of care the only constant is the patient. Policymakers are being on “patient-centeredness,” but that typically means some way of monitoring and tracking patients. I think these can be a useful tool to complement, but not replace, what ultimately has to be the patient’s responsibility.

Unfortunately, the ACA makes the high-deductible plans more expensive and subjects them to the same requirements to offer “free” preventive care and the like, thus defeating the purpose.

Bartlett on Health Care in the Financial Times

Lapsed R Bruce Bartlett says government can do it better.  Hmmm.


The folly at the heart of the US healthcare debate

America is the only developed country that does not offer some form of national health insurance to all its citizens.

Those over the age of 65 have coverage through Medicare and the poor are covered through Medicaid, both established in 1965. Those who are neither poor nor old are expected to obtain their own health insurance or get a job that provides coverage. The federal government does subsidise private insurance through the tax code by allowing its cost to be excluded or deducted from taxable income. This reduces federal revenues by some $180bn per year.

In 2009, the Obama administration put forward a plan for extending health insurance to those who did not have it through an employer, those who could not afford it and those who could not obtain coverage due to a pre-existing medical condition. A complex system of subsidies was established to make coverage affordable to everyone and a mandate was put into place requiring people to get coverage or else pay a fine.

The mandate is by far the most controversial element of the Affordable Care Act. Its rationale is that insurance companies cannot be forced to cover those with pre-existing conditions without it, or else people will simply wait until they are sick before buying health insurance. Nevertheless, many Republicans view the mandate as an unconstitutional intrusion into the economy and they have brought a case before the Supreme Court to declare the legislation null and void for that reason. Court watchers believe the case could go either way, with a final decision expected just before the election in November.

Exactly what would replace the Affordable Care Act if it is found unconstitutional is a mystery. The Obama administration appears to have no back-up plan and Republicans have steadfastly refused to offer any proposal for expanding health coverage. One problem is that before Barack Obama became president, Republicans were the primary supporters of an individual mandate, viewing it is as a more market-oriented way of expanding health coverage without a completely government-run health system. Indeed, Mitt Romney, the likely Republican presidential nominee, established a healthcare system in Massachusetts, where he was governor, that is virtually identical to the national system created by Mr Obama.

Simultaneously, Republicans are keen to cut spending for Medicare and Medicaid, because they are among the most rapidly expanding government spending programmes. A plan supported by Republicans in the House of Representatives would effectively privatise Medicare, giving the elderly a government voucher to buy insurance or health services, in lieu of the pay-for-service system that exists now. Medicaid would be devolved to the states.

What neither party has made any effort to grapple with is the extraordinarily high cost of health, public and private. According to the Organisation for Economic Cooperation and Development, the US spends more of its gross domestic product on health than any other country by a large margin. Americans spent 17.4 per cent of gross domestic product on health in 2009 – almost half of it came from government – versus 12 per cent of GDP or less in other major economies. Britain spends 9.8 per cent of GDP on health, almost all of it through the public sector. The total government outlay is almost exactly the same in the US and the UK at 8.2 per cent of GDP. This suggests that for no more than the US government spends on health now, Americans could have universal coverage and a healthcare system no worse than the British.

However, the option of a completely government-run health system was never seriously considered in the US when the Affordable Care Act was debated in 2009. Americans are too convinced that everything government does is less efficient and costs more than if the private sector does it. The fact that this is obviously wrong in the case of healthcare has never penetrated the public consciousness.

At the moment, everyone is waiting for the Supreme Court to speak before moving forward on any serious new health reform plan. Whichever way the court rules, it is likely to give some push to further action next year regardless of the election outcome. Moreover, the growing governmental cost of Medicare and Medicaid is something that has to be addressed if there is any hope of stabilising the national finances. That alone would be an impetus for action even if the Affordable Care Act had never been enacted.

The writer is a former senior economist at the White House, US Congress and Treasury. He is author of ‘The Benefit and the Burden: Tax Reform – Why We Need It and What It Will Take’

Drive by Post: Combining Free Market Insurance with Universal Catastrophic

I’m passing this along because I thought it was an interesting model. Unfortunately, I don’t have the time right now to do a full post on it.

Liberals Are Wrong: Free Market Health Care Is Possible

Statistical retrospective on Massachusetts health care revision just published

Health Affairs published a retrospective on Massachusetts Health care.

Some highlights: Coverage is broader than it was in 2006, outcomes are better, costs are still increasing.  However, what I found most encouraging yet most problematical for ACA was that the use of ERs for non-emergency treatment has been reduced, but only in the last couple of years.

If ACA is to obtain a savings for the taxpayer, IMHO its best opportunity will be to remove non-emergency treatment from the ER.  I will be the among first to suggest that could have been done, years ago, without federal intervention, and there are examples of this around the nation.  For example, the @45 neighborhood clinics in SF, funded cooperatively by major employers,  the City, UCSF, and the two large insurers in the state, have been successful at this.  Now Massachusetts has proven successful at the state level.

However, the fact that there was no relief for the ERs for 3 years in Massachusetts indicates to me the lag time to spread the knowledge of “where to go” to those who need treatment.  That lag time would seemingly be, under ACA, a dependent variable upon other functions.  Is the state, responsible for the make-up of the “essential” package, disseminating information or remaining silent?  Does the locality actually offer alternate choices? [There are huge areas of the Big Empty in TX that don’t offer any choice but a 90+ mi drive to an ER, or to an unknown alternate facility].

NoVAH, could you please address this aspect of ACA – how it is to be implemented re: moving non-emergency patient care out of the ERs?

Thanks, in advance,


State “Flexibility” and the ACA’s Essential Health Benefits

HHS has been making a big deal about how “flexible” the essential health benefits requires are for states.   Sure, it’s very flexible.  They can choose from column A or column A1.

States would have the flexibility to select an existing health plan to set the “benchmark” for the items and services included in the essential health benefits package.  States would choose one of the following health insurance plans as a benchmark:

  •  One of the three largest small group plans in the state;
  • One of the three largest state employee health plans;
  • One of the three largest federal employee health plan options;
  • The largest HMO plan offered in the state’s commercial market

States can modify coverage within a benefit category, but they have to cover items and services for the following 10 categories of care: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.

So, states have the “flexibility” to craft a benefit package that is based on the existing plans in their state and must include a statutorily mandated list [Section 1302(b)(1) of the ACA] of benefits.   States can tweak the specific benefits in each category but can not reduce the value of coverage.   And God help you if you try, for example, to change a formulary to cover a generic vs. a brand name, or institute step-therapy in that prescription drug category.

As far as the ability to craft a unique policy, that ability just isn’t there.  HHS admits as much in its recently released guidance.

Generally, according to this analysis, products in the small group market, State employee plans, and the Federal Employees Health Benefits Program (FEHBP) Blue Cross Blue Shield (BCBS) Standard Option and Government Employees Health Association (GEHA) plans do not differ significantly in the range of services they cover. They differ mainly in cost-sharing provisions, but cost-sharing is not taken into account in determining EHB. Similarly, these plans and products and the small group issuers surveyed by the IOM appear to generally cover health care services in virtually all of the 10 statutory categories.

The HHS analysis found that the differences among plans are minor.  Some plans cover or don’t cover acupuncture, bariatric surgery, hearing aids, and smoking cessation programs and medications.   So Mississippi can strike a blow for federalism by telling HHS, no, we’re not covering acupuncture.

Where there might be some differences now will be eliminated.  Not every state mandates coverage for behaviorial health treatment.  Now it is number 5 on the “must cover”  list.

Basically, the differences will be on the edges, minor and will address how something will be provided.  For example, pediatric dental plans may be wrapped into a medical benefit.  Or they can be sold as stand-alone plans.   That’s an issue that will be worked out on state-by-state basis.   But I don’t think that makes it more or less “flexible” for states.

States also have varying definitions of the various mandated benefit categories.  What “habilitative services and devices” isn’t necessarily consistent across state lines.  But, in general, it’s for physical therapy (PT), occupational therapy (OT), and speech therapy (ST).  Differences might be who qualifies (meaning what medical condition) and at what level of cost sharing for such benefits.   I don’t consider that flexibility.

Not all states current mandate coverage for the 10 categories (mostly  habilitative services, pediatric oral services, and pediatric vision services) .   While HHS is considering how to best rectify this, the law and HHS are very clear on this point: they will be covered.   How is TBD, but the guidance (linked below) lays out some options and basically tells state to pick an existing plan coverage, for example, the Federal Employees Dental and Vision Insurance Program, and graft it onto their “flexible” state plan.

States do have some flexibility within a benefit category, but only to a point.  States can adjust benefits within a category subject to a baseline set as reflected in the benchmark plan.

Here’s the kicker: Section 1302(b)(4)(G) and (H) direct the Secretary to periodically review and update EHB.  Translation.  Those 10 mandated benefit categories can become 20 if we want them to be.   Also, look for those categories to be more clearly defined through regulatory capture guidance.   Want to make sure a plan covers a specific treatment?   Gather data, hire a good lobbyist and you too can have your benefit become essential.

Full HHS guidance here. [Note:  opens PDF]

And if you missed it, Sebelius was on the Daily Show to talk about the ACA.   Bonus points for work-related Daily Show viewing.   Link at KHN.

[Apologies to Mark for taking so long with this. ]

Health Care Headlines

I wanted to put this post up last week, but got distracted by work and my one month old son (he’s great by the way). So some of this is a week or two old and I don’t have much time to add a bunch of analysis, but I thought some of these may provoke some discussion or just be informative to those who are interested.

The American College of Physicians encourages physicians to take into account the cost-effectiveness of their treatment decisions. In their ethics manual (which you can access for free), the ACP does more than just argue that physicians should take into cost effectiveness with regard to exposing patients to excessive, unnecessary or potentially harmful treatments. The manual encourages physicians to think about how cost effective care can increase the availability of health care to more people. Now I’m all for more cost-effective health care, but I’m not sure I want my physicians worrying about how a treatment they are ordering for me may somehow reduce health care resources available to the community as a whole.

USA Today recaps some of the provisions of the ACA that have already had an impact. It’s not exactly a critical look at the law (OK, it’s pretty much a puff piece), but the government’s success in fighting fraud has gotten more attention lately and the article leads with that aspect of the ACA. While the Obama Administration deserves some credit for the crackdown on fraud, I would also point to the increased use of electronic medical records as a reason for the increase in fraud prosecutions.

The Washington Post has a depressingly humorous article about doctors complaining that the Medicare “doc fix” was closer to becoming a reality than ever. So they’re complaining that the perpetually scheduled reimbursement cut that they know Congress will never pass was closer to passing this time than in the past. Boo-freaking-hoo. The refusal of Congress to pass the cut in physician reimbursement under Medicare is of great amusement to me and NoVa, but it’s emblematic of why we need to fundamentally change our health care system.

The Detroit Free Pressdiscusses all the merger activity between solo hospitals and larger health systems. One of the criticisms of the ACA and programs like ACOs was that they would lead to mergers which would lead to less competition and higher prices. To a large extent mergers were occurring before the ACA so it’s a bit difficult to determine to what extent the ACA increased that activity. It’s also difficult to determine whether or not the mergers will lead to higher prices. The argument that they won’t is that consolidation will lead to increased efficiency which will lower health care spending. It remains to be seen whether or not one or both of those theories will be true.

Lastly, here’s a link to the government’s anti-trust complaint against Blue Cross Blue Shield of Michigan (BCBS). It provides an interesting (albeit one-sided) read. As a brief summary, BCBS entered into most favored nation (MFN) agreements with hospitals throughout Michigan that required the hospitals to charge other insurers as much or more than they charged BCBS. Since BCBS has such a large share of the insurance market here in Michigan that made it hard, if not impossible, for some insurers to compete. And obviously it drove prices up for everyone, including BCBS. Both Michigan and the Feds are in on the suit and several private insurers have filed similar suits.

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