2017 Politics open thread, February 26 — March 4

Open for discussion.

This happened yesterday.

Perez wins DNC chairmanship

The behind-the-scenes calls underscored why the race was broadly seen as a proxy battle between the Sanders-aligned progressive wing of the party, which supported Ellison, and those more closely connected with Hillary Clinton and Obama, who largely backed Perez.

By selecting Perez — and again spurning Sanders supporters — Democrats risk the backlash that could come with leaving the left wing of the party disappointed a second time in the past year.

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269 thoughts on “2017 Politics open thread, February 26 — March 4

  1. That is an interesting comment for John Boehner to have made. I wonder why he said it? With these congressional leaders, I often find it more interesting to ask *why* a particular person makes a particular comment rather than worrying about the actual content.

  2. Is there a place you can go to find out what Bannon’s logic is behind the need for higher defense spending considering we’re going to have Japan, South Korea, Germany, etc. pay for their own defense going forward?

  3. Gotta say I’ve developed a general feeling of political malaise over the past week or so, probably due to being tired of seeing/hearing the ongoing general handwringing against what has or may come out of the administration. There’s always going to be disagreement by some, and some portion of that is legit/needed if only to keep the loyal opposition relevant. And some feel we/they need to keep their guard up at all times.

    I guess where I’m going is that somehow I feel ok when there’s a specific target being mobilized against (e.g. the immigration XO) — I use that as an example only. There may be other things that have been specifically protested/lawsuits where I agree with the policy (change) but also agree with the protesters’/ACLU’s right to bring action. None come to mind as I write this.

    I’m feeling that to just be generally down on things, vs. taking a positive step (not just legislatively by Congress, but also grass roots) to enact something, is dragging me down. Thoughts anyone?

  4. I think there is a general over reaction on the media’s part. There is so much drama that it’s hard to tell what “crisis” is really important and what is not. i.e. Terrorist attacks in Denmark. I’d rather have the press focus on what’s important.

    I think Trump has the potential for being dangerous but he also has the potential of creating positive change.

  5. hard to tell what “crisis” is really important and what is not. i.e. Terrorist attacks in Denmark.

    What do you mean? That the attacks didn’t occur, or?

  6. The whole “resistance” narrative does not seem particularly productive. This isn’t Nazi Germany, and Trump isn’t Hitler, and to suggest otherwise on a tediously regular basis is only going to cause further polarization. Many on the left seem incapable of acknowledging that millions of decent people voted for Trump and are willing to give him a chance.

    Trump has been unfair to the media, but he and his administration do have some legitimate points on media bias, and with some polls* revealing that Trump is more trusted than the media, it would appear that everyone has some room for improvement.

    If all the furor over Muslim bans and Mexican walls inspires real, comprehensive reform of our immigration laws, it will be a furor well spent.

    *other polls say the opposite, of course

  7. “What do you mean? ”

    Focus on the important stuff–the stuff that’s potentially dangerous.

  8. I’m feeling that to just be generally down on things, vs. taking a positive step (not just legislatively by Congress, but also grass roots) to enact something, is dragging me down. Thoughts anyone?

    I agree. That’s why I didn’t participate in the Not My President protest. What good is that? I’m focusing on a few specific categories that I care about, e.g., education, and I’m trying to focus on specific bills before the feds and also the state of Colorado. There’s a bill in Colorado that will defund some educational stuff I believe in. So I’m calling my state rep about that today.

    Other than that, I’ve been listening to music in the car. Can’t take the news anymore. I check it in the morning and then try to stay away.

  9. I’ve been listening to podcasts, and avoiding NPR and all news. I recommend Story Corps as an antidote to the current news/politics ickiness.

  10. There seems to be so many things going on it is hard to figure out where one’s energy should be placed. I have concerns about the rollback of environmental regulations that don’t seem well thought through (such as our Texas proposal to posion ferral hogs), about public education (vouchers, reduction of free/reduced lunch, and education of students with disabilities), and health care (repeal with no replacement).

    My state is trying to enact a bathroom bill and we just made a student, who is transitioning to male and from photos has a male body type, participate in the girls wrestling state championships because it says female on the birth certificate. These appear to have more importance than actual education of students or repairing our infrastructure.

  11. Focus on the important and truly different from past presidents: massive financial conflicts of interest, potential colllaboration with the Russians, and attacks on the free press. Even George W Bush came out against that today.

  12. Seriously. I am appalled and disheartened by the policies, such as defunding the EPA and the NEH. But those are things any Repubican president would do. You elect a Republican, you are going to get Republican policies. But no president, no matter of what persuasion, should be allowed to not disclose conflicts of interest. And yes, I know he goes under a loophole, a loophole that most of us did not even realize existed. But a president with nothing to hide should be big enough to disclose.

  13. So, MM, playing a bit of devil’s advocate here, you’ve named 3 (defunding EPA, NEH, conflicts of interest). Since you have limited time and energy, which one do you pick?

    That does not really matter, though. My point is some/many people think there are indeed lots of things to battle against and, for me at least, it has recently become white noise. Whereas if the opposition could unite against e.g. conflict of interest maybe I’d stay tuned in. But the way it is, ennui sets in.

  14. OK, so say we agree*. Where’s the organized effort on this front? Who’s leading the charge? As I say to my kids when they have and issue with something “what are you going to do about it?”

    *btw, I don’t disagree. It’s your #1 and you’re entitled to it. My #1 is the faulty economics underlying policy decisions which will get us into (more) financial problems.

  15. Policy stuff : EPA, NEH, even healthcare, are standard Republican vs Democrat differences and will get sorted out in the usual way. If too many Republican things are voted in, there will be another shift in a few years and then everything will get put back again. This has been going since Reagan.

    What scares me. really and truly, are the things Trump is doing that break with longstanding traditions, traditions that were needed to keep our system working right. I was listening to a good analysis of this recently, in which the commentator was saying that the US’s system, far more than other democratic countries, relies on traditions and expectations of leaders instead of codifying things. That is dangerous, because if a leader breaks with those unwritten expectations, there is nothing to fall back on. My real fear is what comes next. Once the traditions are broken, future presidents will feel ever more emboldened to profit off the White House, to do things in secret, and to deny power to the press and to the courts. Keep in mind, the next demaogue could just as easily be a far leftist. How happy will today’s Republicans be when they are powerless against a Hugo Chavez or worse? What if the next President is collaborating with the Chinese?

  16. Fred, remind me what state you are in? Do you have Republican congresscritters? If so, get on the dang phone with them. Show up to town halls.

  17. And I joined a local organization of women who are Democrats and who are pushing back as hard as they can. I was supposed to have gone to the initial organizational meeting last Thursday but I was instead comforting my kids who had lost a good friend this week. I will get to the next one I hope and in the meantime, a lot of the events are being organized by mailing group.

  18. Oh, MM, driving I’m ~5 hours to the NW of you up along the lake. Our congresswoman is a democrat who has lots of rank in the chamber, so she’s actually doing what she can, along with Chuck and Kirsten. It’s just that their power is limited given our government structure.

  19. There are still things to be done. State government is a mess and part of the problem. For example, there are state senators who claim to be Democrats but who side with the Republicans in state government. I think a lot of their voters did not even realize this. Jeffrey Klein represents the Bronx and parts of lower Westchester (not my area though), and I guarantee you that Bronx voters, who are as liberal as it gets, did not realize this. One of the efforts now is to make everyone aware of how they actually vote. Remember how the Tea Party turned out its RINOs? Well we have DINOs and we need to get rid of them. A lot of the current problems in Congress go back to gerrymandering, and that happens at the state level

  20. Oh, totally agree with you re NYS gov’t! It’s a complete mess. One candidate for assembly this past November committed suicide before an impending indictment was made public; he won the primary vs 2 others anyway. Then the 3 (republican) county chairmen the district overlaps got together and chose a former (retired) assemblyman from the district to run in his place (vs. choosing the #2 finisher in the primary), running unopposed btw. The chosen candidate actually said Obama was encouraging blacks to kill whites. Elected anyway (see unopposed, above). I voted for myself as a write in.

  21. Forget pussy grabbing or anything else he’s said, somehow I find this to be one of Trump’s most offensive remarks.

    “I have to tell you, it’s an unbelievably complex subject. Nobody knew that health care could be so complicated.”

    In any case, Obamacare appears to be in a death spiral, perhaps intentional, so something has to be done. And the Republicans are not inspiring confidence with their dilly dallying.

  22. “I have to tell you, it’s an unbelievably complex subject. Nobody knew that health care could be so complicated.”

    I’m trying not to bang my head against the wall.

  23. WASHINGTON — President Trump, meeting with the nation’s governors, conceded Monday that he had not been aware of the complexities of health care policy-making: “I have to tell you, it’s an unbelievably complex subject. Nobody knew that health care could be so complicated.”

    Everyone knew it was and is complicated. What do folks on the other side think about comments like this?

  24. In any case, Obamacare appears to be in a death spiral, perhaps intentional, so something has to be done.

    It seems the only option is higher subsidies or harsher penalties. One of the republican proposals is to offer refundable tax credits for the entire cost of a bare bones policy* and to automatically sign everyone (regardless of income) up. It’s far more generous than what democrats thought they could offer but maybe republicans can pull it off.

    * Many republicans casually dismissed mental health and substance abuse coverage mandates. But, now that they are in power there is push back from republican governors in states with a heroin problem:

    http://www.concordmonitor.com/Sununu-to-Trump-Keep-substance-abuse-programs-in-health-law-8359386

    I have a hard time wraping my head around what those on the right actually think….

  25. perhaps intentional, so

    Or is it just a very complicated subject both economically and politically?

  26. Rhett,
    Are you asking whether the average person thinks that health care is complicated, or whether the average policy wonk (on either side) holds that view?

  27. Scarlett,

    I’m asking if you think republican politicians, including the president, were leading their voters on with promises of some magical free market solution that would provide everyone with not only cheaper coverage but also better coverage?

  28. “* Many republicans casually dismissed mental health and substance abuse coverage mandates. But, now that they are in power there is push back from republican governors in states with a heroin problem”

    Wondering how much a basic ACA-compliant plan offers in the way of mental health or substance abuse coverage. Would it be sufficient to fully treat a heroin or opioid addict? It’s my sense that repeated relapses are not uncommon, even when patients have access to appropriate treatment, meaning that even a generous policy would be exhausted before the person was considered to be clean and sober. And isn’t it likely that much of this population is covered by Medicaid rather than private insurance anyhow?

  29. Scarlett, there are many families with a loved one who has a drug addiction problem, or is suicidal, or a number of other issues, who do not qualify for Medicaid.

  30. And isn’t it likely that much of this population is covered by Medicaid rather than private insurance anyhow?

    In the HBO special most of those featured were late teens and 20 somethings who were presumably still on their parents insurance.

  31. You mean, “If you like your plan, you can keep your plan?”

    Exactly. Do you agree that Trump was being even more dishonest by saying he could offer a better and cheaper plan?

  32. Healthcare policy is really complex, but I wish normal people would spend a little more time thinking about it. It is like understanding the financial system – boring and complicated, but in the end you make better choices if you have some inkling of how it all works.

  33. It wasn’t just Trump. None of the Republicans had put much effort into actually understanding how healthcare and healthcare markets work, becaud they never thought they would be in the position of having to come up with something that works. I suspect a lot of them would just have rather gone back to the pre-ACA days

  34. And one of the reasons that insurance companies were having problems in the ACA market was that part of the plan was to subsidize insurance companies that ended up with more expensive customers. But the Republican Congress underfunded that program, which led to losses by the insurance companies. While I think the weak mandate (and that happened because conservative Democrats had to be appeased) was the biggest problem, the underfunding was also an issue.

  35. You mean, “If you like your plan, you can keep your plan?”

    You seem to default into arguing with talking points. I’m far more interested to hear what you actual think about these issues.

  36. The Democrats famously told us that Congress would have to pass Obamacare to know what was in it. The rollout was a logistical disaster, as you may recall. So not sure that either party has covered themselves in glory on health care reform. Trump, however, is not a nuance guy, so his extravagant promises will sound worse than others. Whether anyone actually believes them is an interesting question.

    Politicians regularly tell voters what they want to hear, such as that the government can expand coverage without increasing taxes or premiums, or cut taxes without cutting services. Many “normal people,” at least those without employer-provided insurance, have a much better understanding of the complexities of this issue after going through several open enrollment seasons. But I agree that there is a lot of deliberate ignorance. Most people think that Someone Else should pay for even their routine and predictable health care needs, so it is very difficult to educate them on the realities of the health care and insurance markets.

  37. Most people think that Someone Else should pay for even their routine and predictable health care needs

    I hear tons of people saying that – where do you find that talking point?

    Personally, I don’t think people want someone else to pay so much as they want the comfort and predictability of a fixed expense. I think it all comes down to how the average person lives. The average totebagger has their cash emergency fund, taxable brokerage account, a bunch of 0 balance credit cards, six or seven figure retirement accounts etc. The average person doesn’t have two nickles to rub together. As such, they would much rather know they have to pay $x per month every month than pay $0.7X per month and then at some random interval have to come up with $5k.

  38. Rhett, it’s an observation, not a talking point, based on living in the world. Perhaps your experiences are different t?

  39. Perhaps your experiences are different t?

    I’d say it has far more to do with most people not having a lot of extra cognitive ability and executive function to spare. That being the case, they just don’t want more to deal with: more things to research, more things to compare, more things to budget for, more things to worry about, etc.

  40. Rhett my sense is that the average person sees no difference between health insurance and health care. So they regard health insurance plans as prepaid health care and don’t expect that they may have to budget for out of pocket costs. I have had conversations with extended family members with college degrees who have this mindset and aren’t willing to use their own funds to get a needed test or consult an out of network provider.

  41. So they regard health insurance plans as prepaid health care and don’t expect that they may have to budget for out of pocket costs

    That the reality of what people want. My theory is that preference results from a lack of excess cognitive ability and executive function. Why do you think they prefer it?

  42. “Personally, I don’t think people want someone else to pay so much as they want the comfort and predictability of a fixed expense. ”

    I agree. And they want it to be something that is at a certain price that seems reasonable – let’s say ~5% of gross income.

    Personally, for us, I would love HSA’s to be extended to everyone even without a high-deductible plan so that I can get more of my income into tax-sheltered savings. But I don’t think that is a great policy solution on its own if the goal is to keep the general population healthy at a reasonable cost to both the government (via taxpayers) and citizens. That’s just giving more tax breaks to PeopleLikeMe.

  43. “I have had conversations with extended family members with college degrees who have this mindset and aren’t willing to use their own funds to get a needed test or consult an out of network provider.”

    Me too, and it grates on me. Over time many people have come to believe that they should not have to pay very much for any health care out of pocket. At this point I think this presents something of a stumbling block in devising solutions to our health insurance issues.

    “Trump, however, is not a nuance guy, so his extravagant promises will sound worse than others.”

    Agreed, and I think looking at the “you can keep your doctor” and “who knew it was complicated” remarks side by side illustrates for me many why people can believe the dishonesty and/or stupidity of both presidents is similar.

  44. It’s not the preference for a single fixed expense that is a problem. It’s the attitude of I’m planning my $10k trip to Europe and I love my Lexus and no way will I wear Kohl’s fashions, but my insurance premium of $500/month is so unfair.

  45. You mean, “If you like your plan, you can keep your plan?”

    Classic Scarlett. Respond to a reasonable question about Trump by taking a shot at Obama.

  46. Even those on the cusp of retirement — the median couple in their late 50s or early 60s — has saved only $17,000 in a retirement savings account, such as a defined-contribution 401(k), individual retirement account, Keogh or similar savings account.

    That’s the reality. I can’t for the life of me figure out where CofC and Scarlett think all this extra bandwidth is going to come from. Do you think you’re the average person and you base your politics on that assumption?

  47. John Oliver had a great analysis of the ACA and healthcare in general this week. And he does give Obama his share of criticism. You can find it with a quick google search.

  48. “Do you think you’re the average person and you base your politics on that assumption?”

    No.

  49. Rhett, the wonky article I posted discusses cognitive ability (or lack thereof) quite a bit as it impacts healthcare decisions

  50. The continuous care requirement won’t work because people won’t do it. Then they’ll have no coverage, get some horrible illness, and we’ll find a way to cover it because, as a nation, we don’t want people dying in the gutters. It’s so unsanitary. And then we’ll wind up with some stupid system like we have now, where people go to the E.R. for every single thing.

  51. It’s ok to prefer a single fixed expense if you are willing to accept the tradeoffs and limitations that go with prepaid health care.
    The trend in medical care seems to be shifting decision making from providers to patients, which requires patients to take more rather than less control over them. Rhett, you are right that many people may lack the executive function to make such decisions, yet some of these same people spend hours on Pinterest evaluating shoes and sofas and hairstyles.

  52. CoC said “It’s not the preference for a single fixed expense that is a problem. It’s the attitude of I’m planning my $10k trip to Europe and I love my Lexus and no way will I wear Kohl’s fashions, but my insurance premium of $500/month is so unfair.”

    I agree with you, and a while back, I think I even posted something about that. Compared to Europeans, Americans value healthcare less in that they are less willing to pay for it. Europeans value healthcare quite a bit, and whether they are paying for it via taxes or monthly payments (and folks, European healthcare systems vary a LOT – it isn’t all taxpayer funded single payer over there), they are happy to do so. Europeans I speak with are baffled by the choice of young health Americans to forego insurance.

  53. I think most people would prefer socialized heatlhcare as long as it’s not called that. Just like all the people who hate Obamacare but like the insurance plan that they have thanks to the ACA.

  54. yet some of these same people spend hours on Pinterest evaluating shoes and sofas and hairstyles.

    Executive function includes the ability to do unpleasant things in the present to avoid unpleasantness in the medium to distant future*. For the majority of people shoes on Pintrest, video games, etc. are pleasant in the here and now. When I say lack of executive function what I mean is they don’t have the ability to pull themselves away from the pleasant in the here and now to focus on unpleasant tasks that will help them avoid unpleasantness in the future.

    * Something totebaggers are very good at.

  55. It’s the attitude of I’m planning my $10k trip to Europe and I love my Lexus and no way will I wear Kohl’s fashions, but my insurance premium of $500/month is so unfair.

    That’s just human nature.

  56. RMS, how DO you stop people from coming into the ER for primary medical care?

    You need to provide insurance that allows them to go to a PCP for the same cost to them as going to the ER. As long as it’s cheaper to go the ER, people will go to the ER.

  57. The trend in medical care seems to be shifting decision making from providers to patients

    I don’t see that at all. The insurers and the hospitals make the decisions. At least that’s what the doctors spend a lot of time bitching about over on ReachMD. (I really do recommend their podcasts. Very inside baseball.)

  58. “I wish normal people would spend a little more time thinking about it. It is like understanding the financial system…”

    MM – exactly! But no one wants to because it gets complicated quickly!

    On healthcare, most people just want to be able to pay some known low/reasonable co-pay to see their doc and get their prescriptions. Never mind that, truly, over time, most people/families will be financially better off with a (much) lower premium and higher out of pocket high-deductible + HSA plan. Really. But as Rhett will come back to “executive function”. It’s the same reason many/most people want to get a tax refund every year…it’s forced savings. With the higher premium / low(er) co-pay/deductible plans people who cannot manage to save in an HSA can get healthcare for what they perceive as a low(er) cost because they only pay $25-$50 per visit every time. It’s predictable, therefore better.

  59. DD, a friend who is an ER doc told me that they are still dealing with non-ER cases in part because of the convenience and also because this population doesn’t have a PCP even if Medicaid or their insurers cover those visits. Not sure how you create a system that works for those people.

  60. most people/families will be financially better off with a (much) lower premium and higher out of pocket high-deductible + HSA plan

    Doesn’t that require a minority of people/families being financially devastated by going with the HSA option?

  61. It’s not just executive function though. There is no transparency in health care. I can comparison shop for almost anything else like a vacation to Europe or a pair of shoes, but even as a reasonably smart totebag health care consumer, I have literally no clue how much any doctor visit is going to cost me when I go in. And if you are sick – forget it. And on top of that, there is no way to comparison shop or evaluate the cost/benefit of any particular lab test, treatment, etc. And evaluating the trade offs between different prescription drugs is even crazier. It’s near impossible.

  62. “my sense is that the average person sees no difference between health insurance and health care.”

    Scarlett – I agree completely with you.

    That’s why ACA/Obamacare is celebrated as a healthcare achievement vs a health insurance one. (also, since many who now have health insurance due to Medicaid expansion, it is pretty much 1-for-1 for them)

  63. The big healthcare costs are really unpredictable. That is partially because of the complexity of the way things are billed, but also in large part because serious illnesses and injuries are complex and unpredictable. You just can’t know in advance which tests you will need, which treatments, and so on. You can’t plan for the secondary infectioins, or the sutures that come loose.

    When we were forced to go out of network for DS when he had cancer, it was like jumping off a cliff. We had no way, no way at all, to predict what it might cost. And the costs were indeed heart stopping. One of the things people forget about the ACA is that it got rid of lifetime caps. It was common, back in our day, for kids to run through their lifetime caps in one year or less of treatment.

  64. “being financially devastated by going with the HSA option?”

    No…part of the HSA set up (law) is an out of pocket max that’s pretty low. Not necessarily “affordable” by all, but <$15,000/year per subscribing family IIRC.

  65. Rhett: What do you think about the European model for healthcare. Do you think it makes sense to try here?

  66. What do you think about the European model for healthcare.

    Germany or Switzerland? That’s basically what we have now. The only question would be how much downward pressure we want to put on costs. I assume Americans would prefer to spend significantly more than Germans.

  67. Yeah, and Rhett, if that average family has an ongoing medical need that’s eating up the out-of-pocket max every year ($13,100 for 2017 per the IRS), there probably is some way to get some additional assistance out of the system somewhere along the line. Not my area of expertise (but for the grace of God…)

  68. there probably is some way to get some additional assistance out of the system

    Probably? If that’s the case how does it end up saving significant money overall?

  69. Rhett, maybe because the system isn’t requiring claims to be submitted and paid or denied for every routine health care event?

  70. maybe because the system isn’t requiring claims to be submitted and paid or denied for every routine health care event?

    My understanding is with an HSA you don’t pay the $600 sticker price for a visit, you pay the $185 insurance negotiation discount price. So, it needs to be in the system to determine the discount to apply and (again as I understand it) the claim needs to be processed to apply the amount toward your deductible and out of pocket max.

  71. We don’t have an HSA so don’t know the particulars but presumably the processing is more or less automatic and does not require the vetting and initial denial pending further provider documentation that now seems routine in medical insurance claims?

  72. “there probably is some way to get some additional assistance out of the system somewhere along the line. ”
    Like begging for charity? That is what I saw families of kids with cancer doing in those pre-ACA days when they had a bare bones policy that wasn’t really covering things. There used to be threads on the mailing list discussing best strategies for pleading with the financial person at the various hospitals.
    It didn’t work very well. This is one of the reasons why even young healthy families should not be buying barebones insurance. ‘Coz you just don’t know when your kid is going to get lymphoma or something.

  73. vetting and initial denial pending further provider documentation that now seems routine in medical insurance claims?

    In terms of percent of GDP spent on healthcare how much do you figure that would save?

  74. Scarlett, those constant denials and requests for information were the bane of my existence when my kid was in treatment. I had sacks of those things. That was years before the ACA. WHen I worked at the healthcare IT place, I worked with a lot of people who came over from the payers and they explained to me that payers save money by delaying payment as long as possible. A lot of people just give up. Even hospitals just give up. And thus, the payer doesn’t have to fork over any money. And yes, this was pre-ACA too.

  75. If you are going to get the negotiated price for a treatment that you are paying for with your HSA, it has to be a treatment that is actually covered by your plan – otherwise there will be no negotiated price. So yes, there will have to be a claim generated and adjudicated.

  76. Fred,

    I assume your HSA plan if (God forbid) someone was diagnosed with MS or lupus that would have you hitting the out of pocket max every year was to switch insurance? I can see how this plan saves you money but I can’t see how it saves the system money.

  77. A friend of mine used to be CEO of a BCBS. When the ACA was being debated, he always said the Blues and other insurance companies were all good with it as long as truly everyone had to sign up, pay premiums, or be force-enrolled via the tax penalty (at a high enough level to make it more financially worthwhile to enroll than pay the penalty). A former classmate who now runs a large health insurer we’ve all heard of agreed with this.

    But such is not the case, so there are terrible gaps in the system, no competition in many places.

  78. Is there any thought to penalties for private insurance companies for improper denial of covered expenses, say, a fine of 10x the improperly denied expense for each improperly denied expense?

    That seems like a reasonable way to incentivize private insurance companies to improve their payment systems without the complexities of ensuring ongoing sufficient federal funding for a single payer option. (I am very skeptical that any federal option would be properly funded for decades.)

  79. The heavy (legitimate, i.e. non-fraudulent) users will cost any system money. A big issue is that the system is unbalanced because the young, healthy, invincibles are not in the system. Many of them, actuarially, will incur $0 or close in medical costs in any given year, or costs so low that they pay out of pocket for the services and save $ vs paying a full year’s insurance premium. We need them paying the premiums to offset the (relatively few) heavy users. As long as there is a choice to opt out with a fairly low penalty, and now apparently little risk of being caught, we’ll have this problem.

  80. “I can see how this plan saves you money but I can’t see how it saves the system money.”

    I was under the impression that it supposedly saves the insurer/benefit provider money because people won’t get “unnecessary” procedures if they see the real price & not the $20 copay. So health care consumers will be able to make efficient decisions about the cost/benefits of any treatment. (HA! Please.) That’s part of the reason why preventative care is covered 100%, right? Because the insurance companies didn’t want people skipping well visits, mammograms, or colonoscopies and then coming in with major health care problems because they hadn’t seen a doctor in years due to the price.

    This has nothing to do with ACA though – that was the explanation that I was given when these high-deductible plans with HSA’s started being a more popular option a decade ago. And IMHO it doesn’t work at all in practice because of the complete lack of transparency in pricing for heath care services coupled with the inability to evaluate treatment options effectively.

  81. When I think bare bones, I think of a policy that definitely includes catastrophic coverage but has limitations in other areas like choice of providers.

    “It’s not just executive function though. There is no transparency in health care.”

    I see how this can be a huge problem, and federal mandates on pricing would seem to help. I wish Republicans would jump on an idea like this.

    Healthcare reform is difficult because the industry spends more on lobbying than the defense, aerospace, and the oil and gas industries combined.

    To fix the system, providers must be required to bill all patients, insured and uninsured (other than where rates are fixed by law) the same amount for the same service.

    Hospitals, physicians and labs should have continued freedom to set their own prices, but predatory pricing — a different rate for each patient — must be prohibited.

    With real prices, patients would be empowered to shop for value and never face punitive out-of-network charges. Health providers would be forced to compete based on price, quality and service.

    Health insurance premiums, which are a direct function of charges, would plummet.

  82. (I am very skeptical that any federal option would be properly funded for decades.)

    I haven’t heard that many complaints about Medicare.

  83. Yes – COC – that’s exactly what I am talking about. Thanks for posting that article – very interesting.

    It’s impossible for the doctor to tell me in an office visit what something is going to cost me. When I went for a skin check, my OOP expense for having two moles removed and biopsied by the lab was a total mystery until I got the bill. (the other option being to delay treatment while going back & forth with the office and insurer about it) OTOH – when I wanted to get two moles removed for purely cosmetic reasons not covered by insurance, the derm office had a printed price list to offer me on the spot.

    Also, dentists and vision care providers seem to be much easier to compare to each other. I wonder why that is – vision and dental coverage seem to be less universally covered by insurance, but yet they seem to go after uninsured consumers effectively.

    This was interesting too, and something that I did not know:

    “Perversely, the Affordable Care Act’s requirement that insurers spend roughly 80 percent of premiums on patient care, has legally enshrined higher medical costs as the only means for the insurance industry to keep growing profits. The higher medical bills climb, the higher premiums rise and the higher the insurance industry’s 20-percent share goes. Insurers, on whom the system relies to negotiate deals with providers, actually benefit from higher costs, while consumers can’t protect themselves because of the lack of real prices. Nobody is watching the store.”

  84. Health providers would be forced to compete based on price, quality and service.

    Health insurance premiums, which are a direct function of charges, would plummet.

    I don’t know how much that will be true. If doctors make X, nurses make Y, a new knee joint costs Z, where do you expect the savings to come? I’d think it would primarily come down to having something like a nurse orthopedist* who would be trained to only do a certain kind of left knee replacement rather than a more generalist orthopedic surgeon.

    * Sort of like a nurse anesthetist vs an anesthesiologist

    If the current legal restrictions remain in place, I don’t know how much you can end up saving.

  85. Ivy,

    But then you fall back into the idea that there is some great untapped font of cognitive ability and executive function and voters are just going to love having to price out everything rather than paying X per month and not having to worry.

  86. CoC said “When I think bare bones, I think of a policy that definitely includes catastrophic coverage but has limitations in other areas like choice of providers.”

    What people don’t understand is that a barebones policy can provide supposed catastrophic coverage that ends up not covering a lot of things. Before the ACA, there were a million ways to do it. There were of course high deductible policies, but there were also policies that only covered, say, 60%, or had very low yearly caps, or didn’t cover entire classes of medications. There was an entire class of plans called mini-meds, which paid far less for hospital visits than the actual costs. Those were popular with employers who wanted to offer some kind of health plan to hourly workers. The problem was, if something really serious happened to one of these workers, they would be on the hook for lots of uncovered expenses.

  87. Rhett, do you think the cuts to Medicare that are part of the Affordable Care Act will go into effect? Part of running any large system over time is having the control to raise prices or cut services so the system remains financially stable. I don’t know how if healthcare costs would increase or decrease if the system converted to Medicare rates for all. Medicaid rates would go up, private insurance rates would go down, I assume, leaving a net increase in government funding required.

    I think healthcare should be like utilities and railroads- private, but heavily regulated to have a ~5% profit over the long term, with businessmen like Warren Buffett providing capital and smoothing the need for capital over time. And Rhett and others have largely convinced me that an ACA-like option, probably heavily subsidized by federal tax dollars, is probably best for the population at large.

  88. “Also, dentists and vision care providers seem to be much easier to compare to each other. I wonder why that is – vision and dental coverage seem to be less universally covered by insurance, but yet they seem to go after uninsured consumers effectively.”

    Because dental procedures are a like a million times less complex than cancer treatment or a heart bypass operation or Parkinson’s disease?

  89. Rhett, do you think the cuts to Medicare that are part of the Affordable Care Act will go into effect?

    They already did.

  90. @Rhett- I agree with you that most people would rather pay 1.0X monthly & have minimal OOP rather than 0.7X plus paying more when they actually need treatment. And that might actually work better if we are looking for plans that work best for the majority.

    But for me, where I can see the value of a high-deductible plan w/ HSA to PeopleLikeMe, I still don’t see it working as well in practice as promised because the pricing is so obtuse and because there generally aren’t good ways for regular heath care consumers to do cost/benefit analysis. It is not at all like buying other goods/services.

  91. “When I went for a skin check, my OOP expense for having two moles removed and biopsied by the lab was a total mystery until I got the bill. (the other option being to delay treatment while going back & forth with the office and insurer about it) OTOH – when I wanted to get two moles removed for purely cosmetic reasons not covered by insurance, the derm office had a printed price list to offer me on the spot.”

    OK, in this example, the big difference is the biopsies, which probably went to a different lab, and were billed separately. My guess is that the lab procedures may have cost more than the office procedure. Also, I am betting that a mole removal for biopsy has to be done more carefully in case the moles were cancerous. In any case, the doctor would have no way of knowing the lab charges – might not even know which lab would be doing the work. In many cases, your insurance determines which lab they send the moles to.

  92. Rhett, they’ve started, but do you think the full ~10 year phase-in will occur?

    Just so we are on the same page what cuts are you talking about? I’m talking about the ending of the subsidies that were funneled through Medicare to hospitals that had a lot of patients that were uninsured.

  93. “Because dental procedures are a like a million times less complex than cancer treatment or a heart bypass operation or Parkinson’s disease?”

    But they aren’t less complex than the types of care that people routinely need, and that is no less of a maze.

  94. where I can see the value of a high-deductible plan w/ HSA to PeopleLikeMe

    I assume your plan was always to switch plans if it looked likely you’d hit your max for years going forward?

  95. OK, this is a case study of a pre-ACA barebones plan. It had a yearly cap of $25,000 and severely resrticted what was covered
    “For cancer patients, CoverTN’s limit of five or six chemotherapy or radiation therapy visits
    per year could present a huge barrier to recovery. For example, patients with breast cancer
    or prostate cancer who receive radiation therapy typically require five visits per week for
    at least six or seven weeks, respectively.27 CoverTN would pay a mere fraction of the costs
    of this critical treatment. ”

    “One accident or illness could easily rack up bills that exceed CoverTN’s annual hospital
    coverage limits of $10,000 or $15,000.”

    http://familiesusa.org/sites/default/files/product_documents/covertn-a-closer-look.pdf

    And when Republicans talk about removing the requirements for comprehensive coverage that were part of ACA, they are thinking of pepole going back to faux-plans like this one

  96. “OK, in this example, the big difference is the biopsies, which probably went to a different lab, and were billed separately. My guess is that the lab procedures may have cost more than the office procedure. Also, I am betting that a mole removal for biopsy has to be done more carefully in case the moles were cancerous. In any case, the doctor would have no way of knowing the lab charges – might not even know which lab would be doing the work. In many cases, your insurance determines which lab they send the moles to.”

    Right – that’s the why. But does it have to be that way? And how is anyone supposed to navigate that to make “rational decisions” about their health care options and spending?

  97. And how is anyone supposed to navigate that to make “rational decisions” about their health care options and spending?

    Most don’t have the extra bandwidth to do it even if the numbers were easily available.

  98. Ivy,

    Keep in mind that your insurance company is currently the one negotiating the rates with Quest of whatever vendor they want you to go for a given test.

  99. “If the current legal restrictions remain in place, I don’t know how much you can end up saving.”

    I’m not sure which legal restrictions exist, but I’m sure there are some that probably should be removed. Also, some of the cost savings should come from simplifying the pricing procedures and bureaucracy. Certainly from the doctors’ perspective where so many resources are devoted to handling this and also from the insurers’ perspective.

    MM — Those are certainly not the type of catastrophic plans I have in mind and I was unaware that Republicans were pushing for annual coverage limits, and certainly not any as low as $15,000. I don’t support that!

  100. “I assume your plan was always to switch plans if it looked likely you’d hit your max for years going forward?”

    The OOP max? Yeah, probably, but it depends. Lots of things to consider – HSA vs use-it-or-lose-it FSA, level of employer matches/contributions to the HSA, and monthly premium difference. At my old company, the HSA funding by the company was very generous, but at my current one it is next to nothing.

    But in practice, I’ve never actually had one of those plans because DH’s employer doesn’t offer it, and his premiums are so heavily subsidized that it didn’t make sense for us to even consider my insurance options. We had a fantastic HMO for many years, and when that option became undesirable because our preferred providers dropped out, we switched to a traditional PPO plan.

  101. It is that way because
    1. the dematologist practice probably does not have its own lab. In fact, insurance companies often will not pay for lab procedures done by a lab owned by the practice.
    2. because different policies cover different labs, most practices send to a variety of labs.
    3. The policies all negotiate different prices with the labs, which the practice has no way of knowing – in fact, payers won’t disclose their negotiated rates because that is “business intelligence”
    4. A mole removal for suspicion of cancer (however remote) is a different animal from a cosmetic procedure because there is always the possiblity that the whole thing is going to become much more complex. The dermatologist does have to be more careful and standard of treatment, and things happen – the mole is much deeper or more invasive than thought. That unfortunately does happen with moles that turn out to be melanoma. So even though in your case, the chance of this may have been remote, the practicioner still has to be careful

  102. “Most don’t have the extra bandwidth to do it even if the numbers were easily available.”

    Agreed. But it’s next to impossible to begin with, so I am suspect of any plan that has “rational decision making” by heath care consumers as an assumption.

  103. @MM – I get that & I appreciate the additional perspective. But that’s more why. The question is – does it have to be that way? That’s the million dollar question, right? It seems hopelessly inefficient.

    And is it reasonable to assume that consumers can make informed decisions in this system? I say no.

  104. “most people would rather pay 1.0X monthly & have minimal OOP rather than 0.7X plus paying more when they actually need treatment”

    For me, my high-deductible plan premium is more like 0.1x (yes, 10%) of the PPO plan premium; the difference I dump into the HSA. That second step is the hard part for many people, back to Rhett’s two-nickels comment earlier.

    There’s a woman who works on our floor; she probably makes $50-$60k/yr. Single, no kids. But the rest of life: mortgage, car payment, maybe some credit card debt. She’s on the high deductible plan, so pays $10/month (really) in premiums vs $130 for the PPO plan. But she does not fund her HSA. Presumably she could afford to do so, but I don’t know and really don’t want to know that much about her financial situation.

  105. CoC, that was what was meant by barebones plans back pre-ACA. We knew some families on those plans, which were often offered by state governments as a way to get some kind of coverage to low income people, and believe me, they were in the financial office on their knees begging for charity.

    What you guys don’t understand is that the costs are in the catastrophic coverage, not the routine stuff. It doesn’t cost that much for insurers to pay for vaccines or strep throat or well baby visits. So they are happy to throw those things in. But if they are going to make money, they have either strictly limit catastrophic coverage, using means like caps and high copays, or they have to set their rates higher and get more healthy people in. Worrying about whether plans should offer birth control or well visits or vision care is not important because even if you stripped all that stuff out, the costs will still be high.

  106. Ivy, as long as we have a myriad of private insurers, the system will be like that because it is largely driven by what the insurers want.

  107. “For me, my high-deductible plan premium is more like 0.1x (yes, 10%) of the PPO plan premium; the difference I dump into the HSA.”

    They must really want you in the high-deductible plan! I wonder how that works from a financial analysis standpoint for the company. My company premium difference is actually 0,7X for the High-deductible vs. PPO. And then they fund $250 of the HSA. I don’t have much insight into why they priced it that way as our Shared Services group handles all of that & dictates the employer and employee cost to us.

  108. Rhett, I think I’m talking about the combination of changes to Medicare Advantage that reduce its costs, a temporary increase in Medicaid reimbursement rates to equal Medicare rates that has already ended and changes to long-term reimbursements that affect the Medicare Trust fund but the fact that I don’t understand it means I’m not equipped to debate it.

    “For reference, Medicare, the federal health coverage provided for seniors, offers physicians a reimbursement rate of approximately 80% of what private health insurance pays. Medicaid, which provides coverage for low-socioeconomic individuals who qualify, reimburses physicians a much lower rate of about 56% [3]. The Affordable Care Act focused on providing greater availability to primary care. Physicians who supported the ACA saw a large increase in their reimbursement rates, leading to an overall higher revenue.
    However, this “two-year bribe” to enlist the support of physicians for the new Medicaid insurance plans had expired on January 1, 2015 [3]. As a result, the Medicaid reimbursement rates for physicians have decreased in 2015. An Urban Institute report has estimated a 42.8% reduction in Medicaid reimbursement rates for physicians as a result of the readjustments to pre-2013. The magnitude of the reduction depends on whether or not states have decided to extend the Medicaid primary fee bump using their own state funds. Due to ongoing budgetary concerns, many states were unable to use their own funds to extend the fee increase policy “

  109. @MM

    ” It doesn’t cost that much for insurers to pay for vaccines or strep throat or well baby visits. So they are happy to throw those things in.”

    Why do doctors offices charge uninsured people so much for those types of services then? Is it the risk of non-payment (like charging an exorbitant interest rate to people with poor credit)? Or is it a profit center because the insurance reimbursements are low? Something else?

    I do see that this is where the Minute Clinics are making inroads though. I was surprised when I had to take my kid to the CVS Minute Clinic for a strep test & there was a price list on the wall that listed a strep test for $60 or something. (it was covered by our PPO, although CVS couldn’t tell me what the ultimate bill would be and mailed it to me later after someone in a backoffice somewhere ran my insurance through)

  110. Certainly from the doctors’ perspective where so many resources are devoted to handling this and also from the insurers’ perspective.

    Most of that bureaucracy is to combat fraud. However, you’re right that there could be some savings by moving toward a Kaiser like model where the doctor, hospital and insurer are all one entity. I think that would be a fantastic idea. It would be monumentally difficult to legislate I’d imagine.

  111. Fred,

    Would you have opted for the high deductible plan if it locked you in with no option to switch?

    But she does not fund her HSA.

    Presumably her plan is to set up a payment plan for the out of pocket max and switch to gold plated coverage at open enrollment. I see how that saves you and her money but it doesn’t change how much you’re going to cost the system.

  112. Ivy, I am talking about costs to insurers, not profits to doctors. Insurers don’t pay that much for those procedures. I think doctors charged uninsured people high prices because most people did have coverage and weren’t paying those prices. The doctors offices never thought about things like Minute Clinics grabbing that market because Minute Clinics didn’t exist for a long time. The Minute Clinics fit well into a CVS, low margin retail model, and honestly, the doctors offices probably don’t care because they weren’t seeing many of those people anyway.

  113. Rhett,
    I only have the option to switch at open enrollment or if one of the ~10 life situation events occurs mid-cycle. I’m in it for a full calendar year.

    Each year I do the math of (PPO premium+co-pay+lower deductible+X=OOP max) vs (Hi deductible premium+required deductible+x=OOP max) and IN EVERY CASE if I reach the plans’ OOP max, I am better off with the High Deductible plan. So I don’t know why I’d switch. Ever. Unless the amount of gray matter required to use the plan got to be too much for DW and me.

  114. Jeez, DH’s firm only offers one plan to the partners. It’s a high-deductible with HSA, and we pay the entire amount (about $1,200 a month for two of us). No subsidies for the premium. No firm contribution to the HSA.

  115. Fred,

    For the sake of round numbers you’re paying $100/month and the OOP max is 15k and if you signed up for PPO it would be $1350/month?

  116. “The trend in medical care seems to be shifting decision making from providers to patients”

    Lots to talk about in the above, but I will start here. I’m not exactly sure what the above is referring to, but perhaps it is the trend in medicine for “shared decision making”? This is becoming more common, especially with chest pain evaluation in the Emergency Department.

    This is the paper that lots of people are using and talking about:

    What you don’t see is the comparison of costs in that picture. On step 3, what should we do at this point, there is no disclosure that various options may cost 10x the other options. I engage in shared decision making all the time, but I am not competent to add cost into the equation. Should your child with a possible transient loss of consciousness after head injury have a CT? – let’s talk risks and benefits and I’ll let you make the final call. However, I am unable to compare the costs of CT vs 12 hours observation in the ED vs repeat visit in 12 hours vs discharge home now. (For many patients, the costs are equal – medicaid, hmo, etc.).

  117. This is an interesting, lower-cost twist on concierge medicine:

    “There’s no waiting room at Linnea Meyer’s tiny primary-care practice in downtown Boston. That’s because there’s rarely a wait to see her. She has only 50 patients to date and often interacts with them by text, phone or email. There’s no office staff because Dr. Meyer doesn’t charge for visits or file insurance claims. Patients pay her a monthly fee—$25 to $125, depending on age—which covers all the primary care they need.

    “Getting that third-party payer out of the room frees me up to focus on patient care,” says Dr. Meyer, who hopes to expand her year-old practice to 200 patients and is relying on savings until then. “This kind of practice is why I went into medicine, and that feels so good.”

    Dr. Meyer is part of a small but growing cadre of doctors practicing “direct primary care,” which bypasses insurance and charges patients a monthly membership fee that covers everything from office visits to basic lab tests.

    It’s similar to “concierge medicine” but less costly: The average monthly fee for direct primary care is $25 to $85, according to the Direct Primary Care Journal, a trade publication. That compares with $100 or more a month for concierge practices—which often charge patients, or their insurers, for individual visits as well. Concierge practices, which can run as high as $25,000 a year, often target affluent baby boomers in high-cost urban areas and may include services such as personalized wellness plans and advanced testing.”https://www.wsj.com/articles/with-direct-primary-care-its-just-doctor-and-patient-1488164702

  118. Rhett, here is an answer from another direct primary care doc:

    “People ask me how I can do this for $60 a month,” says David Cunningham, who left a large medical group to open a two-doctor direct-care practice in Mansfield, Mass., last year. They think it should cost more, he adds, but “that’s only because we have this bloated way of paying for it.” In his old practice, he says, more than 60 cents of every dollar went to administrative costs.

    Patients in direct-primary-care practices still need insurance to cover hospitalizations and other costly services (as well as meet the Affordable Care Act’s requirement). But with their primary-care needs covered, they can choose high-deductible plans with lower premiums. “You’re essentially buying insurance against using your insurance,” says Jay Keese, executive director of the Direct Primary Care Coalition, a trade group.

    While some people balk at paying for both a membership and insurance, others say it is still a good deal. Josh Maibor of North Attleborough, Mass., says the $60 a month that he and his wife each pay Dr. Cunningham for unlimited care “is less than we’d pay in copays for a single visit.” Plus, Mr. Maibor says, “it’s like having a doctor in the family. I texted him on Christmas Eve, and he got back to me in 10 minutes.”

  119. Yeah, what does primary care mean here? I am betting it doesn’t cover tests and certainly doesn’t cover specialists

  120. Scarlett,

    That’s sort of the Kaiser model, which can work very well. Although, since not everyone has Kaiser where Kaiser is offered, I don’t know that the savings are all that great.

  121. When I think of my own medical care, I realize that the primary care doctor is really the minimal part. I see him once a year, he takes my blood pressure and reups my prescription for blood pressure pills.
    He refers me to radiology to get the normal annual tests done, like a mammogram. I also had a bone density scan done last year. I guarantee you that this would not be covered under the model above.
    Other than that, I have seen a dermatologist for a rash/chapping on my face that wouldn’t heal. And I saw the sports medicine doctor in November, which meant Xrays. The year before last, I had my routine colonoscopy, which had to be set up through a gastoenterologist.
    So, you can see, the primary care part of my care is a small part.

  122. t he and his wife each pay Dr. Cunningham for unlimited care

    If they aren’t paying for tests, drugs, scans or specialists, the care is far from unlimited.

  123. No, the Kaiser model is quite different. In Kaiser, you go to a large group practice, housed all together with radiology, labs, and specialists all working together. At least that was what it was like when I was on it.

    And I have to tell you, you do not want to get a rare disease or a kid with cancer if you are covered by Kaiser. They won’t let you go outside, and they don’t have the expertise to deal with really hard, unusual care.

  124. They won’t let you go outside, and they don’t have the expertise to deal with really hard, unusual care.

    Presumably that would be less of an issue if legislation pushed everyone into a Kaiser like plan. In the mean time, in exchange for cheaper premiums, you’d tend to receive less than idea care in rare circumstances.

  125. Well, I think that is the big reason Kaiser, which has been around forever, never took off as a solution. It was an experiment which actually dates from the 90’s (yes, people thought healthcare was in an affordability crisis then too). A number of plans used that model – Harvard Community Health in Boston, for example. These were your classic HMOs. People didn’t like being limited to Kaiser providers, though, so gradually the industry moved to the current model which is the networks of providers who are all scattered around lots of practices and facilities, with the ability to go out of network while paying more.

  126. MM, this practice is not aimed at people like you:

    “Proponents say the direct-primary-care model may work particularly well for patients with complex medical conditions who need careful monitoring and help coordinating multiple specialists.

    Judy Cozine of North Attleborough, Mass., age 68, says she and her husband, who both have Type II diabetes, visit Dr. Cunningham’s partner, Wendy Cohen, every few months to have their blood sugar and blood pressure checked. Their two daughters, a son-in-law and all four grandchildren are patients of Dr. Cohen’s, as well. “I can talk to her about anything and know that there’s no clock ticking,” says Mrs. Cozine. “None of us would go back to another model of practice again.”

    If you know that you rarely need to see a PCP, you’re not going to sign up for this kind of practice.

    If a family member is dealing with any kind of rare disease, there are few insurance plans that will work well without a ton of patient advocacy. Every person I know in that situation has the reams of the paperwork that you have described compiling for your son, and these are all post-Obamacare. You usually have to go out of network, or get insurance approval for a treatment regimen that hasn’t yet been approved for that condition, or both.

    Of course, you also have to have the bandwith and connections even to know how to find the one doc that specializes in your condition, and to get past the gatekeepers to see her.

  127. I think people expect it to be low cost or almost free because it used to be that way. Earlier in my career, I paid nothing toward my monthly premium and routinely had HMO co-pays of $5. From the day I found out I was pregnant until I left the hospital with my son, after a C-section, I paid $5. I don’t think that drives the right decisions, but that is how a lot of people were used to healthcare working

    Now, my DH has an HSA and the rest of us have a PPO. Both companies have an app that lets us estimate costs. DH was at the orthopedist on Monday and texted that he was going downstairs to the hospital for an MRI (where Dr referred him). I pulled up his app and found that place, and the others on the list from Dr, were not in-network. I gave him the 4 places where the negotiated rate was $375 and told him to pick one. Others on the app had higher negotiated rates, but were at least still in-network. So I have seen some improvement in transparency, but it still requires a lot of executive function. For that reason, I am foisting myself upon my 79 year old parents as they navigate my Dad’s complex issues with Medicare. It is overwhelming to deal with the medical issue and have to have bandwidth left over for the financial part.

    For us, the current medical plans have triggered me to become a better consumer. I challenge orders for tests that I have had done recently, and ask for free samples of medicine or look for coupons online. I also ask if there is a cheaper drug with similar effectiveness that I could try first. I never used to do that.

  128. Still not getting it… I would assume the daughters need to be seeing a gynecologist, and the kids should really be going to pediatricians. Not sure about the person with diabetes – don’t they usually see endocrinologists? It sounds to me like they are paying extra so they can gab with a sympathetic sounding doctor.

    I guess I have never met a primary care doc who could do much more than treat for strep throat and test your blood pressure, and know when you are supposed to schedule your routine tests like mammograms and colonoscopies. Does anyone here see a primary care doc for much else?

  129. These were your classic HMOs

    The key part of Kaiser is they own the physician practices with all the providers on salary and they also own the specialty practices and the hospitals and they are the insurance company.

  130. Rhett – (was in a meeting, real work)

    Actual numbers

    My high deductible plan: $28/mo premium; Given my age I can contribute $7750/yr to my HSA. Employer puts in a small amount of that. So my part is $8100. My out of pocket max is $6,000 if I can do 100% in network, up to $9500 if I were 100% out of network.
    If I were on the PPO plan, monthly premiums $384/mo = $4600/yr with an OOP max of $5k in-network and $8k out of network.

    So let’s say I consume $12,500 of billable (negotiated rates) in a year and it’s all out of network.
    – high deductible + HSA premiums $336 + OOP max $9500 = $10k
    – PPO premiums $4600 + OOP $8k = $12.6k

    If in network, the costs with OOP maxes would be (HSA) $6300 and (PPO) $9600

    Why would I ever change?

  131. Fred,

    The OOP max is doing a lot of the work in that calculation. What’s the deductible and co-pay for the PPO? You seem to assuming a high cost event is going to have you hitting the OOP max in both the PPO and the high deductible plan. That is unlikely to be true in many cases.

  132. “Does anyone here see a primary care doc for much else?”

    I don’t, but the parents do. My dad’s PCP has a big senior patient load, and his waiting room is filled with folks who seem to be on a first-name basis with the staff. My dad sees the PCP at least once a month to monitor several conditions and to adjust meds and refer for tests as needed. MIL’s PCP does the same. For both of them, managing and adjusting meds seems to be a big part of why they need to be making regular visits.

    “It sounds to me like they are paying extra so they can gab with a sympathetic sounding doctor.”

    They say they are paying less, and, if they value having the opportunity to gab with a sympathetic doc, shouldn’t they be permitted to do so? This sort of practice will appeal to people who need regular care for common health issues.

    “The American Academy of Family Physicians supports direct-pay primary care, too. With the new practice model, “you’re not on the hamster wheel of getting paid based on the volume you do,” says John Meigs, the group’s president. “Patient satisfaction goes up. Physician satisfaction goes up. Quality goes up and costs go down because you don’t have to prove it to Uncle Sam or an insurance company.”

    Doctors in such practices say the steady income from membership fees frees them from having to pack patients into 10-minute visits to make ends meet. They can take more time with those who need it and handle many issues via text or email, which are rarely reimbursed in traditional fee-for-service medicine.

    “I’ve cared for eight patients today and it’s only 11 a.m.,” says Terry Ann Scriven, a direct-primary-care doctor in Cape Elizabeth, Maine. “But I haven’t seen any of them in the office because they didn’t need to be seen.”

    Dropping out of insurance networks and opting out of Medicare also frees doctors from haggling with claims adjusters, filing quality reports and meeting standards for electronic medical records, which helps keep overhead low.”

    Being able to reach your doctor via text or email can be a real godsend. It is, as one of the patients in the article noted, very much like having a doctor in the family.

  133. Why would I ever change?

    Psoriatic arthritis has you on Embrel for $1600 a month.

    With the PPO you pay $40/month plus $358 for a total cost per year of $4392.

    With the high deductible plan you need to hit $6k before they start to pay so you’re at $6650.

  134. Exactly. I’m not assuming I get hit with a big event, but I know for sure that if I do the high-deductible plan is less costly.

    The co-pay in PPO PLan is generally $15-30; the deductible is $1000-$2000.

    The other view…buy health insurance and never go to the doc in a year:
    Premiums only: HSA plan $336; PPO $4600.
    If I want to “break even” I put the $4200 difference in my HSA and call it a day.

    At 1159pm on 12/31 my balance sheet looks like:
    HSA $4200 positive
    PPO $0

    High Deductible plan wins.

  135. Where Scarlett and MM might agree is on ending the fee for service model for primary care – which various reform proposals are trying to do.

  136. Exactly. I’m not assuming I get hit with a big event, but I know for sure that if I do the high-deductible plan is less costly.

    I assume you mean one big event vs. a long term chronic condition (psoriatic arthritis etc.) with the PPO being cheaper for long term chronic conditions.

  137. The co-pay in PPO PLan is generally $15-30; the deductible is $1000-$2000.

    My plan has a zero deductible for drugs, what’s the medication deductible on the PPO plan on offer?

  138. Actually, I am arguing that we need to spend less time worrying about payment models for primary care, because that isn’t where the costs are. It is lovely that these little concierge practices let lonely elders spend a little more time chatting with a PCP (who I hope is trained in gerontology) in exchange for an extra fee. But that isn’t going to have much impact on the overal cost of healthcare in this country.

  139. It’s not where the costs are, but it’s where most voters experience the health care system.

  140. I’m sorry I missed this discussion today, since this is my baliwick.

    MM, I think you are underestimating the effect an internal medicine physician can have on complex, chronic medical conditions. If you have someone truly managing the patient – let’s say the diabetes patient – and coordinating their care when needed with the endocrinologist, the cardiologist, etc. – then you keep that person out of the hospital. Which, as you correctly note, are where the costs are. And that’s part of why the Kaiser model can be so successful in both health outcomes and cost management. Of course it takes patient compliance, but patient compliance is higher where a primary care physician or physician extender is managing the patient.

  141. Lark,

    MM might be also unaware of how much direct patient care a PCP can provide. IIRC the line between arthritis that can be managed by a PCP and that requiring a rheumatologist isn’t all that clear. Just like some depression can be managed by a PCP and more severe depression requires a psychiatrist.

  142. Fred – that makes perfect sense. The difference in premiums is crazy! I’ve never seen a difference like that. Plus, you add on the fact that the HSA money is tax-efficient and not wasted since you can roll it over and eventually use it for non-medical expenses. If you had the PPO, you’d only have an FSA as an option which is not as flexible and involves a gamble on your OOP expenses for the year. Is there a big difference in the size of the networks or the available providers?

  143. @ Rhett – agree.

    Personally, I’m 100% in favor of a single payer, government plan, with the option to separately buy Cadillac insurance privately. UK system.

  144. “I’m 100% in favor of a single payer, government plan, with the option to separately buy Cadillac insurance privately. UK system.”

    +1

  145. Sorry, but I don’t think someone with depression should be treated by a PCP, not at least until they have been accurately diagnosed and good levels of medication established
    http://www.pbs.org/newshour/rundown/for-depression-primary-care-doctors-could-be-a-barrier-to-treatment/

    Same thing with ADHD – PCPs tend to throw medication at ADHD kids without also recommending behavioral therapy or tweaking the medications carefully over time.

    I do think there is a role for someone coordinating care, but I almost think that could be done more effectively by a nurse who acts as a case manager.

  146. Lark,

    Why is the UK system better than the heavily regulated system of non-profit health insurers like they have in Germany? More or less the public utility model that WCE mentioned.

  147. My problem is that I just don’t think one person can possibly know all the nuances and up to date treatment protocols in areas ranging from developmental pediatrics to sports injuries to infectious diseases. So to me, the role of a PCP is to make referrals, which then means that a lot of people don’t spend much time with their PCP. It also means that a nurse practitioner may be just as good of a choice

  148. Ivy – the networks are essentially the same for both PPO and high-deductible plans.

    p.s. I really do love your handle, even though I root differently.

  149. MM,
    I think that you greatly underestimate the extent to which most people consider that a PCP is “good enough” to treat their depression, asthma, diabetes, high blood pressure, etc.
    ITA with you on the inability of a PCP to stay abreast of everything. My personal experience has led me to bypass the PCP entirely and self-refer to specialists as I see fit, but most people I know are not that demanding. In many cases, the standard treatments probably work perfectly well.

  150. I don’t know much about the German system so I can’t advocate one way or the other.

    MM, your understanding of the role of the primary care physician – and I’m referring to a board certified internist, not the old fashioned general practioner – isn’t accurate. Might have been in the past, but the level of complexity an internist is trained to deal with is much higher than what you’re describing.

    Does that mean he or she is in a system that properly exploits those skills? No, of course not. But I think your fundamental assessment of that level of provider is wrong.

  151. My personal experience has led me to bypass the PCP entirely and self-refer to specialists as I see fit, but most people I know are not that demanding. In many cases, the standard treatments probably work perfectly well.

    I do that too. Or, if I can’t figure what specialist I need to see, I check with the kids pediatrician, who is personable, wicked smart, and entirely comfortable admitting when she doesn’t know something. She would be perfect, if I could get her to treat adults.

  152. “I think that is the big reason Kaiser, which has been around forever, never took off as a solution. It was an experiment which actually dates from the 90’s ”

    It goes back to well before the 90s. I know for sure it was around back in the 70s.

    Locally, it was a pretty easy transition for a lot of plantation workers; as the plantations closed down their hospitals and clinics, they moved many (if not all) of their workers to Kaiser, which from a patient perspective wasn’t that much different than the plantation care.

    For people who don’t have the executive function to deal with anything beyond a regular monthly costs, the HMO model makes sense.

  153. Anybody read the Consumer Reports article about high deductible plans? I think it was titled something like, “How to Survive a High Deductible Plan.”

    I didn’t read it myself. DW tends to grab CR issues when they come in, and I often don’t see them until much later, and in this case I read the letters about that article in a subsequent issue.

    From the letters I read, it sounded like CR agreed with Rhett, that despite the financial benefits pointed out by readers, they didn’t think their readership had the executive function necessary to set up automatic funding of their HSAs through payroll deductions at the same time as switching to a high deductible policy.

    That surprised me, as I would guess that the average CR reader has a higher executive function than the average adult.

  154. NY times is reporting that Trump made some statement today about being open to legalizing most undocumented immigrants? Evidently he said this at a meeting of TV news anchors? But no one else is reporting it, and Trump often says things that he doesn’t really understand anyway

  155. “It’s not the preference for a single fixed expense that is a problem. It’s the attitude of I’m planning my $10k trip to Europe and I love my Lexus and no way will I wear Kohl’s fashions, but my insurance premium of $500/month is so unfair.”

    ITA, and have no sympathy for someone willing to pay more on a car payment than on health insurance.

  156. I wonder how much executive function is used up by societal efforts to make life more difficult? For example, preventing stores from giving grocery bags to shoppers, so that shoppers need to remember bags when they shop, or buy new ones each time. Or the fetish about separating garbage for recycling?

  157. “You need to provide insurance that allows them to go to a PCP for the same cost to them as going to the ER. As long as it’s cheaper to go the ER, people will go to the ER.”

    How about urgent care clinics, or other walk-in clinics like the CVS clinics?

    Our plan covers them the same as regular office visits, and I’m 99% sure our co-pay for an urgent care visit would be no more than the co-pay for an ER visit.

    My experiences in ERs and urgent care clinics also suggest that for non-emergency care, wait times will be much shorter at the urgent care clinics.

    I’ve long wondered why nobody seems to set up urgent care clinics right next to ERs.

  158. “I wonder how much executive function is used up by societal efforts to make life more difficult? For example, preventing stores from giving grocery bags to shoppers, so that shoppers need to remember bags when they shop, or buy new ones each time?”

    I think such efforts to make life more difficult were efforts initiated because many people chose to not use their executive function to properly dispose of grocery bags. IOW, such efforts likely were to relieve people of the need to use executive function to decide what to do with their grocery bags after unloading them, given an obvious lack of such use on the part of a significant part of the population.

  159. There seems to be an inconsistency between these:

    “To fix the system, providers must be required to bill all patients, insured and uninsured (other than where rates are fixed by law) the same amount for the same service.

    Hospitals, physicians and labs should have continued freedom to set their own prices, but predatory pricing — a different rate for each patient — must be prohibited.”

    “For reference, Medicare, the federal health coverage provided for seniors, offers physicians a reimbursement rate of approximately 80% of what private health insurance pays. Medicaid, which provides coverage for low-socioeconomic individuals who qualify, reimburses physicians a much lower rate of about 56% [3].”

    OK, so Medicare and Medicaid rates may be set by law, which makes it seem like the government is leading the way in predatory pricing, as described here.

  160. I use urgent care! My PCP is part of a huge group practice that maintains its own network of urgent cares. So I can go get checked out for, say, strep, and the wait will be really short, and my electronic record will go right to my PCP the next day.

  161. I guess I have never met a primary care doc who could do much more than treat for strep throat and test your blood pressure, and know when you are supposed to schedule your routine tests like mammograms and colonoscopies. Does anyone here see a primary care doc for much else?

    I’m sure you didn’t mean this to be as insulting as it sounds. As a primary care provider, here are some of the conditions I treat and manage on a daily basis:

    Parkinson’s, epilepsy/seizure disorders, COPD, asthma, CHF, a-fib, warfarin management, hypertension, diabetes, osteoarthritis, rheumatoid arthritis, headaches/migraines, vertigo, fibromyalgia, chronic pain, urinary incontinence, overactive bladder, BPH, reflux, constipation/diarrhea, hemorrhoids, orthopedic issues, depression, anxiety, dementia. Plus acute illnesses, infections, all kinds of skin conditions, wounds, etc.

  162. I’m with Fred on the high deductible plan. We assume we’re going to hit the out of pocket max every year, and the cost of premiums plus OOP is always cheapest on the HD plan. Add in the tax savings from running the OOP money through an HSA and it’s a no-brainer. Last year was the first time in at least 7-8 years we didn’t hit the OOP max.

  163. I guess I have never met a primary care doc who could do much more than treat for strep throat and test your blood pressure, and know when you are supposed to schedule your routine tests like mammograms and colonoscopies.

    Not to pile on, I think you are confusing your lack of knowledge with your internist’s lack of knowledge. Just because you are unaware of his/her capabilities in treating and managing chronic health conditions doesn’t mean they don’t exist. The problem is that our health care system isn’t set up to take advantage of the internist serving as the “medical home” (to use old consultant-speak).

  164. I have so much work to do right now AND so much wrong to correct on the internet.

    Let’s start with two bits of information: 3000 endocrinologists in the US, 30 million people with diabetes. Each endocrinologist could manage 30,000 patients (perhaps with 240 per day for their one time per year appointment), or we could develop a different system.

    Next: Kaiser is not some failed expeirment. It is the largest insurer in California, the third largest in the country and is growing at a rate of approximately 500k members per year.

  165. “I wonder how much executive function is used up by societal efforts to make life more difficult?”

    I think about this every time we need light bulbs.

  166. @Ada, Kaiser is exceptional from an operational and access standpoint. I cannot speak to the quality of their outcomes. I’ve been out of the biz for a long time.

  167. “I think about this every time we need light bulbs.”

    Switch to LEDs, and you won’t think about this much.

  168. I was with Kaiser for a number of years and was very pleased with the plan I had there, as well as the providers I had. I switched when I changed jobs and no longer had that option.

    They did some things I really liked that also probably saved them money. One was a 24 hour line staffed by nurses (I’m not sure if RNs or NPs) who we’d call whenever we weren’t sure whether to see our PCP, often saving us (and them) an office visit.

  169. See, i n my practice, the PCP just wouldn’t do most of these
    “Parkinson’s, epilepsy/seizure disorders, COPD, asthma, CHF, a-fib, warfarin management, hypertension, diabetes, osteoarthritis, rheumatoid arthritis, headaches/migraines, vertigo, fibromyalgia, chronic pain, urinary incontinence, overactive bladder, BPH, reflux, constipation/diarrhea, hemorrhoids, orthopedic issues, depression, anxiety, dementia. Plus acute illnesses, infections, all kinds of skin conditions, wounds, etc.”

    Well, he would do the constipation, and the migraines, and possibly reflux. He already does my high blood pressure. But for most of those conditions you list, he refers. The practice has all those specialists, mainly in the same building.

    Two weeks ago, I had an irritated rash on my face. I called to get an appt with a dermatologist, but they were having trouble finding a timely appointment that fit my ridiculous schedule. So at some point, I said “why can’t I just see my primary care doctor? I am sure this rash is nothing serious, it is just annoying”. The receptionist replied ” Because your primary doctor will just refer you to the dermatologist anyway so there is no point”. And, I am sure he would. Maybe it is an East Coast thing, because when I take my kids to their well child visits at the pediatrician, I always walk out with a fistful of referrals.
    My pimary doctor is board certified, and the pediatrician is the head of the pediatric service at the biggest hospital in the county. So it isn’t their qualifications. It just seems to be the mindset here.

  170. the pediatrician is the head of the pediatric service at the biggest hospital in the county

    This person has very limited time for clinical activities. I bet 10-30% of their time (4-12 hours per week) is spent on seeing primary care patients. The rest is on administration, hospital rounds, resident teaching/supervision, etc. In my experience, this type of physician refers everything because s/he does not have the daily fluency or availability to deal with anything other than preventative care questions.

    There is an east coast element to this kind of behavior. There is an embarassment of riches in NYC specialty arena. The pay sucks, the housing is hard to find, but everybody wants to live there. I’ll bet that Manhattan has more psychiatrists than the Mountain Time Zone.

  171. “This person has very limited time for clinical activities. ”
    That is true – she only sees patients on Mondays. But she is my favorite PCP because she spends a lot of time with us. We chose her after DS2 was moving off the worst of his treatrment, and starting needing a normal ped again, because she was experienced with pediatric cancer survivors and had the ability to communicate well with the oncologists. But after spending lots of time discussing the kids various issues, she still ends up giving us tons of referrals.

    I should note that we are not in NYC, and do not have access to the many psychiatrists in Manhattan. It was a battle finding someone to see my DD recently when the ped decided she was suffering from anxiety (and that was quite a story in itself). We were given a list of 10 child psychiatrists, none of whom was taking new patients. The PCP was NOT going to treat for anxiety herself, and frankly, I appreciate that since my daughter is very complicated and it turned out she doesn’t have anxiety in any case.

  172. Ada – I like what you said so I took it one step further:

    The info is a little dated, but Mountain Time Zone has 18.7M people http://answers.google.com/answers/threadview?id=714986

    and NYC metro area 23.7M.

    So on a per capita basis the coverage is roughly equivalent, which actually surprises me. I would have figured the # of patients per doc would have been higher in MST.

  173. I think for most people the Kaiser model would work fine. We so far have routine visits to the pediatrician, obgyn and off and on visits to the PCP for the seniors but no on going issues.
    We have used minute clinics on weekends and the urgent care on occasion.
    The referrals our seniors got to have certain issues checked out worked well. We saw “a” specialist not a specific specialist. We got in very quickly, required tests were done and went on.
    My observation is that certain doctors are perhaps popular and closed to patients but others are available without a wait.

  174. I’m sure a lot of it is skewed by the nature of my practice. I see patients in nursing homes and assisted livings, and for most of them, getting to a specialist can be very difficult, so I can’t refer them for everything. Additionally, I have more time to spend with them than a typical PCP – I average about 12 patients a day, I don’t need to cram everything into 15 minutes.

    Let’s start with two bits of information: 3000 endocrinologists in the US, 30 million people with diabetes. Each endocrinologist could manage 30,000 patients (perhaps with 240 per day for their one time per year appointment), or we could develop a different system.

    Most diabetics don’t need to be managed by an endocrinologist, they are pretty stable. For them, a PCP can handle monitor an A1C regularly and make adjustments to oral meds and insulin as needed. Some diabetics are not stable and require more attention and expertise than a PCP can provide.

  175. DD – that was my unspoken point. It’s ridiculous to suggest “diabetes needs to be managed by an endocrinologist” and reflects a real rarified view of how medicine is practiced.

  176. Oh! And my math was bad. Each endocrinologist is only responsible for 10,000 diabetics. And since some portion of those aren’t diagnosed, they probably don’t need to see more than 100 patients per day (on top of all the other endocrine disorder patients they are managing).

  177. In MM’s defense she does have extenuating circumstances that understandably weakened her faith in primary care.

  178. I would add that I think we had a very productive discussion today and I don’t think anyone went away angry.

  179. Rhett, I definitely understand that, especially in regards to her kids. At the same time, it blows my mind that her PCP won’t even attempt to treat a rash. That’s part of basic primary care. Maybe it ends up being something more difficult that does require a referral to dermatologist, but refusing to even look at it seems totally absurd.

  180. My husband, a power user of health care, does not see a specialist for mild Type 2 diabetes, warfarin management, gout, ataxia, and routine senior degenerative ailments. That is part of his primary care. His cardiac care is coordinated between PCP (annual physical) and cardiologist (twice a year). He sees several specialists within the large Kaiser style group, for things that have to be prescribed or administered under their policies by a specialist, or gets a quick look-see from the first available specialist (as Louise described it) if the PCP or urgent care doc has questions (it always comes back to non intervention and monitoring by the PCP). I see a PCP in a family practice group that serves our town with its large senior population, and so far she can handle everything. They even do gyn exams for those who need them as part of the annual physical. I am not sure if they still deliver babies. The founding docs, now retired, did 35 years ago – three of mine.

  181. Consensus?

  182. “Free nations are the best vehicle for expressing the will of the people, and America respects the right of all nations to chart their own path,” POTUS stated.

    “My job is not to represent the world,” he added. “My job is to represent the United States of America.”

    While Trump’s statement drew a round of applause from the Republican side of the room, no more than a handful of Democrats rose to their feet to cheer.

    Offensive?

    //players.brightcove.net/5107476400001/B1xUkhW8i_default/index.html?videoId=5342335930001

  183. I’m angry, but I haven’t gone away yet.

    I’m sorry you’re angry, but I’m glad you haven’t gone away.

    My nurse-practitioner handles my depression meds, high blood pressure meds, and cholesterol meds.

  184. Yes, I’m glad you’re still here! Ada, what are you angry about? The misinformation?

  185. Offensive?

    It represents an abondonment of America’s post WWII role in the world*. I can’t say that I oppose abandoning that role. As for standing, I bet many republicans stood that wildly oppose such abondonment and many democrats sat that wildly support such abandonment.

    *. You’ll recall “Mr Gorbachev, tear down this wall!” Regan embraced his role as the leader of the free world, not just the leader of the US.

  186. The practice has all those specialists, mainly in the same building.

    Thinking about this more, I think it’s a function of your practice more than anything. From a business standpoint, they likely want the PCP to refer as much as possible to keep the specialists busy, since they can usually bill higher. Since they are all part of the same practice, they are retaining the revenue regardless of who you see.

    I’ve never dealt with a PCP in a situation like that – every one I’ve ever had was part of a practice that was solely primary care. So if they refused an appointment and referred the patient out, they would lose money. My PCP will do the initial rash evaluation and try to treat it, and then if she is unable to, she’ll refer me to derm.

  187. While Trump’s statement drew a round of applause from the Republican side of the room, no more than a handful of Democrats rose to their feet to cheer.

    That’s just all posturing. The members of the president’s party will always applaud everything he says, and the members of the opposing part won’t applaud anything. Who cares.

  188. Robert Reich suggested that Breitbart operatives were behind the riots at Berkeley, and that Trump was responsible for the recent riots in Sweden. He has absolutely zero credibility.

  189. The one specialist I see regularly is the derm, because of the Botox. Occasionally I ask her to do a mole check.

  190. “Reagan embraced his role as the leader of the free world, not just the leader of the US.”

    But note that Trump kind of hedged his comments. We respect the rights of all nations to chart their own path, but free nations best express the will of the people. Those comments, taken together, would be consistent with demanding that Gorbachev tear down the wall, but also letting Britain exit the UK and each European nation determine how many Syrian refugees they are prepared to welcome.

  191. Did you see what Trump recently said about the attacks on Jewish people? He has no credibility, yet here we are.

  192. Oh! I was more flip than angry. And now I am just very very tired. I have lots of health care commentary. However, I can’t address that because I have a (virtual) stack of health care paperwork to do. Which is its own kind of commentary.

    But now we’re back to Trumpservations and I think that’s mostly entertaining.

  193. kind of hedged

    Right. Hedged against what he was very clearly saying. It’s what Bannon’s been hammering at for years so it’s not a surprise. And for me, not an unwelcome surprise.

  194. Oh! I was more flip than angry.

    Just know we take what you and DD say with the utmost seriousness. There is just a lot of things we don’t know.

  195. We have a similar high deductible plan like Fred’s. We had an unique situation a few years ago where DH’s company would reimburse him for having to switch over to my regular insurance plan. DS, who has asthma, was in the hospital for a week with RSV and was discharged on 1/1. We had switched back to the HSA on 1/1 and both plans were with BCBS. It was a mess trying to figure out what all the costs were and crossing years caused payments to get routed wrong or hung up. It took hours to figure out all the costs, but in the end we would have been $3,500 better if we had been on the HSA the whole time.

    Every year after I had to figure out what projected costs would be on DH’s HSA plan vs. mine. After running through multiple scenarios, they are close to a wash. But we choose the HSA plan to build up the tax-free savings and to limit our known risk. Our yearly max deductible is $6,000 and $3,000/person. It is nice to not have to figure out co-insurance and all of that.

    It takes a lot of executive function to figure out the costs and psychologically it hurts less to have the premiums taken out of the paycheck vs paying the equivalent out-of-pocket. Asthma medication on the regular plan was $7/month but my premiums were ~$400/month. Our premiums on the HSA were about $35/month and the asthma medication was $400/month. The HSA plan really helps people like us Totebaggers get further and further ahead. We now have about $12K built up in the HSA, so I don’t worry about how much healthcare costs right now as I have money saved up for it. What I really should be doing is not use my HSA account at all to reimburse expenses and pay for them out-of-pocket in order to maximize the tax-free benefits in the HSA for when I’m older.

  196. Asthma medication on the regular plan was $7/month but my premiums were ~$400/month. Our premiums on the HSA were about $35/month and the asthma medication was $400/month.

    How is that cheaper?

  197. It really does depend on the practice. At our previous practice (large, in Boston), many things were in-house – first visits for mental health and Rx for those, following for my clotting stuff and thyroid, initial visits for DH’s foot, etc. Not the dermatology, but our derm was right down the street there (closer than the PCP) so it didn’t matter. Plus it was a huge system and we had a lot of specialists to choose from if we needed one.

    Our new doc doesn’t follow or handle any of those, except the thyroid meds. EVERYTHING else is referred out. DH hates going to multiple doctors so he hasn’t enjoyed the switch.

  198. We rarely see specialists, but we have never had any major health issues. (knock on wood)

    “That’s just all posturing. The members of the president’s party will always applaud everything he says, and the members of the opposing part won’t applaud anything. Who cares.”

    I agree. Nothing new to see here, business as usual.

    Given the craziness of the past 6 weeks, the speech was relatively normal and calm. It was good to see that DJT can reel it in a little, but I don’t know that it means much of anything on its own. The line about the SEAL looking down from heaven and being proud of the applause was slightly tasteless, but it was obviously ad-libbed too.

    I also agree with Scarlett about the light bulbs. Shopping for light bulbs is one of those times when you see the beauty in lack of choice. Last time, I left Home Depot with nothing and just bought a big pack at Costco (which has far less options to chose from), and I kind of hate them. But I just can’t bring myself to waste more mental energy on light bulbs. This was awhile ago, so they are CFL. I feel like I shouldn’t have to google & research options while standing in the light bulb aisle. There are some things that I just don’t want to put effort into thinking about.

    Thanks Fred! 41 days till the home opener! I’m hoping it’s above 40 at least.

  199. I am also a big advocate of the HSA, and have run the numbers many years. Like others have commented, I have also come out ahead in high use years with the HSA. The challenge is that people must be responsible enough to defer the “premium savings” into the HSA account. I don’t worry about healthcare costs because our HSA balance is extremely healthy. I would much prefer to have a health insurance policy that did not cover preventive care (or birth control) but did have lower premiums. I want to know what my healthcare costs are and I don’t want it to be disguised by a co-pay or insurer-negotiated discount, and I certainly don’t want it to be a disguised tax. The healthcare savings problem, of course, extends far beyond healthcare and also permeates the retirement savings crisis. In our home, savings (healthcare, retirement, ER funds, college, life insurance, disability insurance) gets funded off the top before we make big decisions about cars (no Lexus) or mortgages (a higher mortgage would mean a lower savings rate) and even small decisions like cell phone plans, where to dine out and that expensive cable subscription (long gone). This self-imposed discipline means that we suddenly have more freedom to spend in our 40s, even though we may not have all the toys or outside indicators of success. Now, I will admit, this self-imposed disciplined was learned by watching my parents behave in a less responsible fashion; I can remember the struggle for the unexpected field trip fee or the very expected college tuition payment…the same month the interior designer was re-doing a room or two in the house or a new car was purchased, and I remember how that made me feel as a child, and I knew that was something I would do differently for my children. And this discipline is aided by my spouse being on the same page financially, even though he refuses to look at my complicated spreadsheet detailing our financial life.

  200. Asthma medication on the regular plan was $7/month but my premiums were ~$400/month. Our premiums on the HSA were about $35/month and the asthma medication was $400/month.

    How is that cheaper?

    I’m assuming at some point they reached their OOP max because of other expenses and the asthma meds became free.

  201. Late the HSA decision, but I’m one of the few where my total out of pocket is higher on HSA than a PPO, and it is all due to the prescription medicine ($3500/month) that I have to pay full price for before I hit the annual deductible. Pharmaceutical company that manufactures the drug covers the full price of the PPO pharmacy cost, but with HSA they only cover the price based on financial need. I work in insurance and I’ve run the numbers.

    For most of the population the HSA will work, but the bandwidth of needing to understand how the plan works is missing. Too many people are just taking the low monthly premiums and not funding their HSA enough.

  202. The asthma medication did hit the out-of-pocket max for my son, but my thought was that the $28/month difference was negible and once you factor in the tax-free savings of contributing the $400 into the HSA probably slightly favorable to the HSA. I also wasn’t sure if we would need the medicine monthly. The $400/month premium payment is money out the door no matter what, whereas if I put the money in my HSA and then end up not needing to use the money, I get to keep the HSA money.

    What I like best about our plan is I know exactly how much I will owe. I have an HSA at my work that doesn’t make sense financially because the premiums are too high and then there is a labyrinth of payments with co-insurance etc.

  203. IME it’s almost impossible to truly understand and make the best decisions about your personal healthcare costs because of the lack transparency. We also have an expensive medication along with accompanying treatment needed six times a year. We (the employer) changed carriers this year, and it wasn’t until AFTER we made our choices did we find out that this new carrier has some Rx program that cuts the cost of the medication to $5/treatment! Who knew? Maybe it was buried somewhere in the literature, but now I know for next year that maybe the HSA option may be better for us.

  204. Advocate Mom shows the perfect example of how people with high executive function benefit from HSAs. I bet there is high correlation with having an HSA balance and 401k balance >100k (or some arbitrary top quintile number).

    I think I’ve shared this before, but maybe with different details. About 5 years ago, we had a killer deal on an HSA. The premiums were far cheaper, and DH’s company was putting a generous amount each month automatically into the HSA. However, this was before the ACA required vaccines and routine care to be covered. So, as the plan year came to a close, I tried to figure out how to schedule two well-child visits, a non-urgent radiology visit and some routine adult health care, and how to fill a very expensive one-off prescription (as much as a few thousand dollar in total). First, much of the information wasn’t immediately available to me – it was all in the company intranet. DH has impeccable security morals, so he would retrieve information as I asked for it, but I could not find out myself what our balance was, how much had been deposited by the company, could we use the money retroactively, had we reached our out of pocket maximum on certain family members? Second, I had to work around doctor and procedure availability over the holiday. I’m likely at the skinny end of the bell curve (just like the rest of you) for ability to manage this crap, but it was just too much to wade through. Open enrollment came around and I chose the HMO option, even though premiums were much higher.

    Well, 2 weeks after we got new coverage, lightning struck. One child had a sudden, severe illness that landed us in the ICU, on a ventilator at times, on dialysis. We were recommended to have a 5 dose course of the most expensive medication in the US at that time (of course it was being used off-label, explicitly not covered by our HMO). We called it the Jetta Med, because the first dose cost about as much as our new Jetta.

    The HMO had a pediatrician following us at the regional children’s hospital. He filed the paperwork to ask for an exception for the medication the day we decided to go ahead with it. Our PCP (who we had never met) made sure to make all of the referrals in a timely fashion so that we could have prompt follow up when we left, without any prompting from us. He called us at home the day after we left the hospital to ensure we had everything we needed. From an insurance standpoint it all went incredibly smooth.

    We got the bill 6 months later – roughly 500k, insurance wrote down 150k, we were responsible for about $500.

    Not all HMOs are shining white knights. However, my experience has been uniformly positive, and I think it is the right choice for almost everyone (Fred and Advocate notwithstanding).

  205. Lemon – I feel for you in your situation; you are one of the exceptions included in my original “for most people the HSA is better…” and completely agree that most people are incapable of figuring out which choice is better financially for them.

  206. “For most of the population the HSA will work, but the bandwidth of needing to understand how the plan works is missing. Too many people are just taking the low monthly premiums and not funding their HSA enough.”

    I agree. It’s not just bandwidth though, it’s also impulse-control or whatever it is that gets people to prioritize the future over the present. I think that there are plenty of people who have the ability both financially and mentally to work out the options and know that they should save in their HSA, but just don’t because they’d rather spend the money NOW. And I’m specifically talking about UMC and up with that example because that is where I just don’t have ANY sympathy when I am subjected to those tales of woe (like a previous poster described above with the Lexus example).

    I don’t know what the answer is, but I don’t think that policy should be built around the ideal “responsible” person even if that benefits me personally – it should be built around how people actually work/think when it comes to things in the basic safety net.

  207. Ivy,

    All very good points. We also have to keep in mind the paradox of thrift i.e. if everyone suddenly became prudent the economy would collapse and we’d all be out on our ass. I would also add demographics. I’ve mentioned my friends who had a second kid with the knowledge that they’d have to put daycare on a credit card. If everyone waited until they owned a home with a 12 month emergency fund yadda yadda to have kids, not only would the economy collapse, so would the population.

  208. “know that they should save in their HSA, but just don’t because they’d rather spend the money NOW. ”

    Willingness and ability to delay gratification is often underrated. In my case, it has been s a key factor in getting to our current financial situation of not qualifying for any need-based financial aid.

    “if everyone suddenly became prudent the economy would collapse and we’d all be out on our ass”

    Perhaps the justification for punishing the prudent?

  209. “What I really should be doing is not use my HSA account at all to reimburse expenses and pay for them out-of-pocket in order to maximize the tax-free benefits in the HSA for when I’m older.”

    You can also then deduct the medical expenses you pay for out of pocket.

  210. “But I just can’t bring myself to waste more mental energy on light bulbs. This was awhile ago, so they are CFL”

    IME, CFLs last a long time, so why not just leave well enough alone, and wait until one of them actually fails to spend any mental energy on light bulbs? By then, bulb technology is likely to have advanced quite a bit from what it is now, so you’d have saved a lot of mental energy.

  211. “Pharmaceutical company that manufactures the drug covers the full price of the PPO pharmacy cost, but with HSA they only cover the price based on financial need. I work in insurance and I’ve run the numbers.”

    Is this sort of thing typical for HSA/high deductible plans? I don’t have any such options offered by my employer, and neither does DW, so I’ve never looked into those plans in detail.

    But from some other postings here, I had the impression that they offered plan-negotiated rates to their policy holders even when they were below the deductible threshold.

  212. I don’t know the details behind “why”, but my Nasonex prescription for allergies was around $10-$20,while the same prescription on DH’s HSA prescription plan was $90. So my experience is that PPO plans have better prescription coverage. Although I will say that his new blood pressure medicine had $0 cost. I don’t know if that is standard or something specific to his plan.

  213. MBT – did you factor in hitting the deductible? For us, on a HD HSA plan, prescriptions are a lot in January and then drop in price later if we’ve met the deductible.

    We keep trying to save funds in the HSA, but with various therapist costs not covered by insurance and the braces years approaching, I fear we’ll continue to use most of it up year to year.

    We fully fund it yearly, just like our 401K. Comes straight out of the paycheck so we don’t have to think about it.

  214. You can also then deduct the medical expenses you pay for out of pocket.

    And the rich get richer. A strong argument can be made that a lot of this is just a way of screwing Joe and Jane Sixpack.

  215. I’ve read in many places recently that shopping around for prescriptions can really pay off, because there can be large differences in price between pharmacies, and that often uncovered prices are better than covered prices. Costco, Target, Sam’s Club, and Walmart are often mentioned as places that often have good prices on prescriptions.

  216. “A strong argument can be made that a lot of this is just a way of screwing Joe and Jane Sixpack.”

    Even though I take advantage of things like this when I can, I’d prefer that the tax code be simplified in a revenue-neutral way. That would reduce the cost of administering it, leaving more $ available for other fed priorities.

    As I’ve mentioned before, the rising floor for certain deduction categories, e.g., medical and business, is a step in that direction, as would be a raising of the standard deduction.

  217. BTW, one way around the medical expense floor is to deduct your kids’ medical expenses (paid out of pocket) on their returns.

  218. Finn, in my situation the PPO co-pay rate was $150 for a monthly prescription. The manufacturer offers a co-pay assistance (not based on financial need), so I would actually pay $0. I assume because it is for a child they offer it. But with the move to HSA, the manufacturer will only cover the prescription cost on a financial need basis. The HSA requires that we pay the negotiated rate in full (their negotiated rate is $3500/month). Based on my deductible I have to pay for Jan & Feb medicine, and then everything is $0 after that (but only for that one child). The rest of the members of the family still has to meet their own deductible.

    For non-specialty meds, Costco seems to be the best price. Target is now CVS and appears to be highest among the pharmacy around me. My parents were just given a hard time at the US/Canada border for bring back OTC cough medicine, so the border portal appears to be cracking down on buying meds of any kind in Canada.

  219. “You can also then deduct the medical expenses you pay for out of pocket.”

    Isn’t that only if medical expenses exceed some percentage (10%?) of your income?

  220. “Isn’t that only if medical expenses exceed some percentage (10%?) of your income?”

    Yes, I’m not sure what the current floor is, but that’s correct.

    However, if the expenses are for one of your kids (as was TCmama’s case), my understanding is that you can deduct those out of pocket expenses on that kid’s schedule A. I’m also assuming that kid has enough income to have a tax liability, or at least a tax liability without the medical deductions, but not enough income that the medical expense floor isn’t exceeded, and that the amount of deductible medical expenses (along with any other deductions) exceeded the standard deduction.

    We’ve had some years when DS had a lot of medical expenses, so our total out of pocket for those years was well above what he had in our flexible spending accounts. I used the flex accounts to pay for my, DW’s, and DD’s expenses, paid DS’ out of pocket, and deducted them on DS’ returns.

    BTW, similarly if one spouse has a lot of out of pocket medical or business expenses in a year, it may make sense to file separately that year.

  221. But from some other postings here, I had the impression that they offered plan-negotiated rates to their policy holders even when they were below the deductible threshold.

    Yes they do, as long as the provider is in-network.

  222. Now Sessions. Seriously- I have a day job I need to focus on, but there is so much to keep up with. Statistically, what are the odds that every single person in the president’s inner circle would have murky financial ties to the same country? And why don’t Republicans care, given their history as being strong against Russia?

  223. MBT – Apparently Sen. Marco Rubio cares, based on his interview on NPR this morning.

  224. Oh, and a rare I toldya so moment for me. I kicked off one of the political threads recently saying I’m worried about Sessions as AG.

  225. @MBT – McCain and Graham are saying it too. Maybe it will gain traction with the Senate.

  226. They don’t care because power is the most important thing to them. And apparently their voters don’t care either.

  227. If you want to see the family that can’t possibly make adequate decisions about their own health insurance, or finances, or really anything at all, watch last night’s My 600 Lb Life. Dear sweet mother of Jesus. When the four members of the family were sitting together, I told DH, “The collective IQ in that room is somewhere around 160.”

  228. President Trump said Thursday that he had “total” confidence in Attorney General Jeff Sessions

    And he’s out in 3,2…

  229. Is this what it was like to live through Watergate?

    Do we think that Sessions will resign? Trumps ranting last night on Twitter could go either way, given the short history with Flynn.

  230. With Sessions, I am having trouble discerning whether these meetings were incidental (he was a sitting senator, after all, such meetings would not be entirely out of the norm) or fit more broadly the narrative of ties to Russia intended to overtly influence the election.

    Flynn’s case – much more clear. But Sessions, I am not entirely sure this isn’t nitpicking.

  231. With Session’s Russia meetings, he could easily have said they were incidental to his Senate role. That’s why I don’t understand why he denied ever having met with anyone. For people in those positions to constantly claim they forgot is getting annoying. If everything is above board, acknowledge you met, give a vague non-committal answer as to the topic, and move on. It’s the lying and denials followed by acknowledgment that there were meetings that makes it all appear so shady.

  232. “For people in those positions to constantly claim they forgot is getting annoying. If everything is above board, acknowledge you met, give a vague non-committal answer as to the topic, and move on. It’s the lying and denials followed by acknowledgment that there were meetings that makes it all appear so shady.”

    Yes. Exactly.

  233. The issue for Sessions is not the meetings per se, but lying about them at his confirmation hearing. Even so, he probably won’t get prosecuted, from what I have read. I don’t understand why he didn’t just come clean. By the time of his confirmation hearings, everyone knew that Russian contacts were a big issue for Trump people

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