[mistermann]

Can someone knowledgeable on the subject comment on whether the "Obamacare movement" has been up front in acknowledging this aspect of the problem with health care in the US?

My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem. And if this is being conveniently ignored, it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans - they may wear a different mask, but their actions are only slightly different, in this case altering who is getting robbed.

[tptacek]

The fact that the problems addressed by the Democratic health care bill are orthogonal to some other problem you care deeply about is not, logically, evidence that the Republicans and Democrats are "indistinguishable" when it comes to health care. The status quo ante of the ACA was a system in which millions of people were locked out of insurance by fiat due to pre-existing condition bans. For those people, all providers were "out-of-network".

[CWuestefeld]

The kind of problem described in the OP doesn't seem orthogonal to ACA. It looks to me like the problem is part of the adjustments that the market has made in response to the regulation. One of the biggest tools used in differentiating between the various levels of ACA marketplace plans is the breadth of the network they allow access to: getting more providers to accept your plan will cost you additional money.

It only makes sense to at least postulate that the converse is true as well: if you find yourself stuck out-of-network, it's because these regulations created an environment where the insurance companies could do better by eliminating the providers it partners with. So it's reasonable, at a first approximation, to guess that this problem is the result of ACA.

[mistermann]

Right, which increases revenue for the medical establishment, while also helping some people (and harming others) in the process. For me to consider the Democrats as the true party of the people rather than a tool of corporations, I'd want to see the cost side of health care addressed as well. My question is: was it?

[tptacek]

I don't think you're going to get anywhere productive with analyses that connect all commercial health care spending with top-to-bottom regulatory capture by the health care industry. Essentially what you'd be saying is that any system short of federally-run single-payer was a sign of corruption.

Also: this idea that the "Democrats are the party of the people" and the "Republicans are the party of corporations" is pretty silly.

The Republicans are a conservative political party. The Democrats are a coalition of blacks (~25%), latinos (~10%), women (+10% share), labor unions, and urban (but not suburban) college-educated whites. Liberals are an important component of the Democratic party (and have no home whatsoever in the GOP), but they don't run the table.

[Spooky23]

Democrats are a big tent party and idealology doesn't rule as a result. When they get ideological they pay dearly, as gay marriage demonstrated. (Lots of older white and black voters stayed home or voted GOP)

Republicans can't win the numbers game so they hammer home on right wing populism. Unfortunately, the last 30-40 years hasn't been kind to the "Main Street" centrist republicans of the past.

[sanderjd]

My impression is that the tent-restricting social issue that has held the Democrats back in recent years is abortion, not gay rights. I'd be interested to hear if you have studies or polls showing otherwise.

[pstuart]

I'd say it is God, Guns, Gays, and Gynecological Gerrymandering.

[zanny]

On one hand, the Democrats did not have control of congress to pass whatever they wanted when the ACA was passed. On the other hand, the Democratic party of the US has never fought with any fervor against Republicans on pretty much anything. The closest I have seen in my lifetime to democratic resistance was to the most blatantly and obviously stupid and racist decisions Trump has made like travel bans and appointing fossil fuel and wall street banker execs and investors to every cabinet position. In the Bush years, there was practically no resistance at all. Bipartisan support for the evil Patriot Act and disastrous No Child Left Behind. No adherence to any ideology or conviction.

Probably the most important realization for the average American in the current political climate is how no party establishment represents you. Both have their sponsors, and none of them are the American people. Individual politicians might have more empathy than others and some might try to help the common man more than another, but they all still have their bosses and despite whatever rhetoric we throw around in almost every election (aside the scant few in contested states and counties) the people are not holding their leash, so they don't work for you.

It is like climate change. It doesn't matter how you want to argue about solving it, it is simply acknowledging the reality that has to happen first and moving on from there on a unified foundation of fact.

[tptacek]

Even if we just stay on the subject we're talking about here it's easy to rebut this notion that the Democrats don't fight the Republicans.

A lot of people forget that the GOP does not, as a political party, believe in universal coverage. Moving the country closer to universal coverage is not a GOP political objective. What is a GOP objective is minimizing federal interference and involvement with business. Health care is something like 15-20% of the entire economy, so the GOP's stated objectives run directly counter to universal coverage.

And yet, repeated efforts to eliminate the ACA have all retained policies built around universal coverage, including a massive federal expenditure in Medicaid (block granted or otherwise) and an extremely intrusive regulatory requirement for guaranteed issue insurance, something that only Ted Cruz has tried to push back on.

If that's not a win for the Democrats it's hard to imagine what plausible outcome would be. Nothing that involves 15-20% of the American economy will be simple, or will happen in one legislative session.

[zanny]

Is that the Democratic party fighting the GOP, or just the GOP realizing that if they start throwing people off healthcare, especially those that both need it most and represent their most substantial voting block (middle aged, white, poor midwesterners and southerners) no amount of campaign dollars will keep them in office. They would probably never turn blue, but the GOP establishment would primary them out of their own reelections for how unpopular they would be.

[ComradeTaco]

Obamacare only reduced the growth of healthcare costs, it did not stop the growth. The approach that most democrats believe would reduce cost is single payer or Medicaid for all.

[0xbear]

As far as I can tell by looking at my premiums, it actually significantly sped up the growth of costs. I don't know how anyone could argue otherwise with a straight face.

[tptacek]

That's not the cost we're measuring! We're measuring cost on the macro scale, in terms of the percentage of the economy spent on health care and, in particular, the percentage of the federal budget spent on health care entitlements. That's the cost curve we're talking about bending, because the pre-ACA projections were literally prima facie untenable.

Any number of effective cost-saving measures could be passed that would have the effect of increasing your premiums.

[0xbear]

You can measure whatever you like, but my costs have gone up nearly threefold and my plan is worse now than it used to be. I'm not interested in solving world peace here. I just want to understand why insuring a relatively healthy family of three under a very high deductible plan costs $1700/mo, and why is it now illegal to not go along with this ridiculous rip off.

[KekDemaga]

Unfortunately for the DNC, the costs many voters were measuring last November wasn't healthcare spending compared to GDP it was actual out of pocket costs that have risen dramatically for many working class Americans.

[dankohn1]

Because premium growth actually has slowed since Obamacare was passed: http://www.factcheck.org/2015/02/slower-premium-growth-under...

[tptacek]

... and this underplays the effect, because the plans being sold under the ACA have a higher cost basis for insurers than pre-ACA plans do. You can easily observe this for yourself if you're in a major insurance market by calling up an insurer and asking for prices on non-ACA-compliant plans, which are still sold.

[rdtsc]

> If the RNC wanted to show what has happened to employer-sponsored premiums under the Affordable Care Act, it should have started the clock in 2010, the year the law was passed. But that makes Obama look better. The rate of growth in average premiums from 2010 to 2014 is 22 percent.

That's why factcheck should not be used to check... facts. Just as they claim the RNC have twisted this and that to make themselves looks better factcheck is twisting things here as well, to make someone else look better. Health insurance providers had raised premiums in anticipation of the vote and the legislation passing. So it's specifically important to look not at 2010 when it was signed into law but a few years below when there was this uncertainty about it. One way market deal with uncertainty is to hedge their bets. "Not sure what will happen, but this might pass, and why don't we just raise the rate now" kind of idea.

I've heard this directly from the health insurance representative who came and told us told us, "sorry but rates are going up sharply because we anticipate this new legislation".

[0xbear]

Of course they do. Raise the deductible 5-10x and you can claim some pretty interesting "premium reduction" numbers.

[dboreham]

There are a couple of forces at work: 1. Medical folks charge more over time, for...reasons. 2. Previously insurance could be sold tailored to the customer's ability to pay; but that insurance didn't actually cover many useful things and had a low cap (hence was almost worthless). ACA disallowed that and made insurance industry offer policies that cover the stuff a regular person needs covered.

So you could have the impression that you had "cheap insurance" as long as you never need to have significant healthcare paid for.

[kobeya]

I made significant use of my healthcare pre-ACA ($30k-$50k charges before insurance). All of it was in-network, covered, and a small annual premium.

The very year ACA took effect my health plan was canceled, my doctor went off-network, my new plan had 3x the annual premium and has grown 30% year over year, as have deductibles, and I fight tooth and nail every single charge to make sure it is in network and covered.

Yes, one anecdote is not data. But there is no more validity to the politician's lie that I can "keep my health plan, keep my doctor, and health care costs will go down."

[neuronexmachina]

If you're curious, the non-partisan KFF has pretty comprehensive data on how average premiums for single and family coveraged have changed from 1999-2016. The increase is pretty darn linear: http://www.kff.org/report-section/ehbs-2016-section-one-cost...

[mcv]

I recently read that while 80% of Democratic voters support single payer, their members of Congress prefer something that keeps insurance companies in the loop snd profits high for the medical industry. Presumably because of donations.

If that's the case, then the difference between Democrats and Republicans is that the Dems want to insure the poor while still ensuring high profits for the industry, while the Republicans want to screw the poor while ensuring high profits for the industry. They differ on one very important issue, but are still mostly the same.

Actually reducing medical costs requires a far more thorough overhaul of the system.

[dgfgfdagasdfgfa]

> For me to consider the Democrats as the true party of the people rather than a tool of corporations

It hasn't been like this since LBJ. Both parties are completely driven by corporate lobbies. All that differ are the excuses why.

[hnbroseph]

there is no 'party of the people' in the US. or if there is, their political clout is at best described as 'trivial to nonexistent'.

[Mz]

The problem isn't abuse on the billing side per se. The problem is that insurance is about risk management. In laymen's terms, it amounts to taking a bet. When you insist that private insurers cover people with pre-existing, incurable, chronic conditions, there is no "bet" to take there. It is all downside for the insurer. It amounts to charity. This fact then seriously distorts the business model, driving up costs for everyone in a big way. It has to be covered somehow.

We need a single payer system because, at the societal level, it makes sense for government to make sure people get their healthcare needs met for the same reason it makes sense for government to provide police and fire protection. But forcing all Americans to get private health insurance makes no sense and indicates a fundamental misunderstanding of what the insurance industry does.

Direct Primary Care, single payer and wellness programs all have a good track record of genuinely getting people healthier while bringing down costs. Obamacare cannot do any of those things and just runs expenses up.

Source/qualifications: Among other things, I worked in insurance for over five years. I have a certificate from a technical college in life and health insurance, paid for by my former employer.

[cookiecaper]

The insurance model is at the heart of the medical system's issues; it distorts the market by disconnecting prices from providers and consumers and severely disaligns their interests.

The provider must set a high sticker price so that they can give the insurer the expected 60-80% discount to get in-network (and still tolerate underpayment and other shenanigans). The consumer is either intentionally misled or confused (usually both) about basically everything cost-related, and often won't learn the true out-of-pocket cost of a service until ~1 year after receiving it, when the billing process has (mostly) finished.

Example: just yesterday I got a new bill for a routine lab test I received in December. It says that the insurance discount applied, but they never sent a payment, and thus I owe a balance of over $200 to the lab company. Now I have to call the insurer to figure out why they denied payment, which is sometimes due to an administrative error, sometimes a paperwork thing like signing a document that verifies there is no other possible insurance carrier whom may have been responsible for the bill, etc.

Obamacare is thus anything but up front, because honestly working to fix the American medical system would involve excising market-breaking, paper-pushing leeches from the marketplace, but Obamacare props up this destructive apparatus by forcing every American to pay in or get fined.

[dv_dt]

Not only the insurance model, but the encouragement of health insurance as an employer benefit. It adds one more aspect of indirection to an already complex health system.

[thephyber]

Almost any politician will tell you that taxing employer-sponsored health insurance is a "3rd rail".

Almost any economist will say this is one of the largest problems with US health care costs and employment mobility.

[dv_dt]

> Almost any politician will tell you that taxing employer-sponsored health insurance is a "3rd rail".

Every employer outside of the health insurance and drug industries should be furious at the price they pay to pay their employees health benefits. Besides having a distraction that operating businesses in other nations don't have, they're likely paying more than double than what they need to in this area to maintain competitiveness against other nations. It's even worse for startups.

[maxerickson]

The ACA should have relaxed employer requirements and pushed people to exchanges; instead, it increased employer requirements.

It also probably should have used subsidies instead of Medicaid expansion. Expensive, but a bunch of healthy people would have been good for the exchanges (Medicaid expansion almost by definition was for healthy working people).

[chasing]

> it feeds my conspiracy thinking that the Democrats are actually largely indistinguishable from Republicans

Have you been watching anything that's been happening with the healthcare debate over the past, oh, 25 years? The Democrats have been trying with varying degrees of success to inch this country in the direction of a more sensible healthcare system and the Republicans have pitched a generation-long hissy fit about it.

[hkmurakami]

From my observations, neither side has done much to reign in the cost of the cost of hospital services and doctor/nurse compensation, which are out of line with our developed world peers.

On the coverage side, the two parties have contrasting stances.

Healthcare and Health Insurance are related but distinct topics.

[chasing]

Obamacare does include a bunch of tools to help keep overall healthcare spending down. As far as I'm aware, they have helped. But there's a long way to go.

I'm actually not sure the BHCA or AHCA or whatever it's called now has much in it besides slogans and major spending cuts which aren't aimed at making care less expensive -- they're aimed and reducing the overall amount of care provided by shifting costs to those less capable of bearing them.

That's a pretty big contrast.

[hkmurakami]

Correct, the GOP plan only seeks to "correct" (in their minds) the extent to which a wealth transfer occurs through the health insurance vehicle, via federal programs, direct aid to states, subsidies, etc.

Cost of healthcare, other than the occasional conversation about drug prices and definitions of necessary care (which continues to be abused by practitioners), continues to take a back seat.

For what it is worth, my personal opinion is that the medical professional lobby is a single issue voting constituency that is just as powerful as the NRA and the teachers unions.

[mistermann]

I'd challenge anyone to present a link to a substantial article or video where a noteworthy democratic politician actually addresses in detail some of the very big problems in the current system, rather than just speak in feel-good generalities that if implemented could easily allow corporations to continue charging at current levels for delivery even under a single-payer system.

Until then, I will continue to believe democrats and republicans serve the same master and only differ in language to provide an illusion of choice.

[kobeya]

Take your politics elsewhere.

[chasing]

That's more of a history lesson than a political one. Democrats and Republicans have wildly different perspectives on healthcare. Democrats tend to believe it's a universal human right. Republicans seem to think whatever solution the free market decides is the right solution, even if it means not everyone gets access to healthcare.

It's been that way for decades.

[heartbreak]

Well the progressives including President Obama pushed for single payer (or a public option) which would eliminate abuse on the billing side, at least to the insured.

[jazzyk]

The single-payer option was quickly dropped by the Democrats in Congress. Their sponsors (the health-"care" industry) did not like it.

[dankohn1]

Joe Lieberman single-handedly killed the public option. He was able to do so because he was the 60th vote the Democrats needed.

Source: http://voices.washingtonpost.com/ezra-klein/2009/12/the_deat...

[joe_the_user]

If the democrats were serious, they could have deployed the "nuclear option" on this (suspend Senate rules). But of course there was more than one person's objection going on.

[dankohn1]

There are far less than 50 votes from either party to suspend the 60-vote filibuster rule because it gives more power to each individual senator.

By contrast, Lieberman single-handedly killed the public option.

[joe_the_user]

Ipso facto there weren't enough votes to suspend the 60-vote in the health care case.

But that's not always the case - Neil Gorsuch was confirmed by a vote to suspend the 60 vote rule. So the rule is available for things that a strong party consensus.

https://www.nytimes.com/2017/04/06/us/politics/neil-gorsuch-...

[albinofrenchy]

It was dropped because it was politically impossible and it wasn't worth burning political capital on it. Even just the public option wasn't able to gain traction; single payer was never going to happen in 2009.

[joe_the_user]

I would just note that "...it was politically impossible" and "the Democrats were never serious in saying they wanted it" are two ways to frame the same reality. Both are true. Take your pick.

[albinofrenchy]

I'm not saying any democrats at the time were willing to go all in on it, but the two statements would only be two ways to frame the same reality if democrats had the ability to make unilateral decisions in the senate. They never did.

[joe_the_user]

The nuclear option - changing the rules to allow majority votes to override a filibuster - has existed in potentia for a long time. The republicans have used it lately for things they consider crucial to their agenda. If the democrats wanted single payer and considered it crucial to their agenda, they could have done that. Of course neither of those "ifs" are true and we can use the lack of action to judge this.

[dboreham]

As I recall, the rough idea was to adopt a Republican plan (RomneyCare) in order to achieve bipartisan support (and "stake holder" support). And then it became the evil spawn of the Democrats...

[jazzyk]

Strictly speaking, it was politically possible - the Democrats had majority in both the Congress and the Senate.

Public option is a great solution, because it does not prevent the people who prefer (and can afford) to pay for private services from doing so.

[albinofrenchy]

Not really, they only had a filibuster proof majority for a very short period of time -- http://www.outsidethebeltway.com/did-the-democrats-ever-real....

And that is counting Lieberman as a D; a person who backed McCain for president and who later personally killed the public option.

I do think we will get to the public option at some point. It just makes too much sense not to and would strengthen the healthcare as a whole while allowing people more choice.

[enraged_camel]

Public option is unlikely to happen in the near future. Too many people start frothing at the mouth and yelling "socialism!" every time it is proposed.

[protomyth]

Well, if it works anything like IHS[1], then the system would run out of money before the end of the fiscal year and then you end up paying for it anyway or not getting the treatment. I find people who say "but it will be different for us" to need some proof from the US and not other countries.

1) Indian Health Service - the US agency tasked with providing and paying for Native American health care on reservations or "health service areas". http://www.richheape.com/american-indian-healthcare.htm

[mistermann]

> which would eliminate abuse on the billing side, at least to the insured

How does single payer fix that? If the hospital gives you a bill and won't negotiate down, how does the government "fix" this? Which is kind of what my question is: were specifics given in the ACA on how that problem will be fixed?

[rpenm]

A single buyer negotiating with multiple sellers can force prices down to cost. Whether it actually does so is a public choice problem.

[heartbreak]

Well since single payer typically refers to the government being the single payer, the bill goes to the government because you the insured are not the payer of the bill.

[mistermann]

The bill goes to the government, who gets its funding from the people. This in no way stops any systemic over-billing that may be occuring.

[kirrent]

Well, in my country, the government would laugh, and then only pay a standard amount.

[kalleboo]

I thought that was what medic(aid/are) in the US already pretty much did.

[ssambros]

And unless they pay enough no providers will do the procedure unless you somehow force them.

[rangibaby]

See: Japan where the government decides the price of procedures.

On national health insurance (monthly cost depends on your salary but for an average person it is a few hundred bucks per month) the hospital pays 70% and patient pays 30%.

It means basic visits to the doctor or dentist are very cheap here. Like $20 for consultation + medicine. ER+X-rays and MRI (appendicitis, sigh) was a little bit over $100.

[dboreham]

Yes there were attempts made in the ACA to control costs (hence the first 'A'). However 1. the clock ran out on the bill drafting due to people voting for republicans in mid-terms and 2. Corruption.

[tunetine]

Were there attempts very early on because I remember them drafting a bill no one even had time to read. Republicans were going to vote anything down and it seemed like Dems waited out the clock so it would be forced in at the last second, either way.

[maxsilver]

> My perception is that the problem is typically framed as a lack of insurance problem for financially challenged people, but the "abuse" on the billing side to me seems like at least as big of a problem.

If anything, the billing abuse is a much, much larger problem than lack of insurance. At least, that has generally been true since the ACA/"Obamacare" changes passed.

[protomyth]

Billing abuse (care provider) and billing fraud (bad agents) are two aspects of the system that need some serious time devoted to them.

My thought experiment for some of this. Suppose the US government had a rider on every insurance policy in the US that said the government would pick up the tab for any amount over say $100,000 (think catastrophe insurance). Now, you would make the assumption that looking at the actuarial tables this would reduce the cost of health insurance because no insurance company is on the hook over $100,000 (thus no need to worry about the million $ payout).

I am more and more convinced that hospitals would screw this up with over billing for every damn thing and every visit requiring a stay would get jacked to > $100,000.

[notyourday]

> Billing abuse (care provider) and billing fraud (bad agents) are two aspects of the system that need some serious time devoted to them.

We have a solution. It is called "make it a personal criminal liability". Go after individuals. No matter how low they are on a totem pole and no matter how high they are on a totem pole. Committing such fraud should lead to bankruptcy ( all assets wiped out ) and jail time.

You would be amazed how quick those "accidents" and "mistakes" stop happening.

Unfortunately, as the society we do not want to throw Suzi the billing clerk into the slammer, which means that Mike, the Billing Manager, does not get a slap on the wrist, which in turn means that Jack, the VP of Billing Revenue Optimization, does not get Jackie his wife go bananas on him when their bank accounts, house and kids college fund is seized which means that Jack is represented by the public defender and ends up in a slammer together with Suzi, who actually pushed the buttons, Mike, who told Suzi to do it, and Jack, who came up with this wonderful idea.

[zghst]

Enforcement seems very resource intensive and complex.

[hockley]

It was a problem before ACA; it's a problem now. The law didn't really change that aspect of the system.

[mistermann]

This is my uninformed impression of the matter as well, and if true (please, anyone with a rebuttal please weigh in), to me it is further proof that the true motive of the ACA is to line the pockets of health care provider donors, by spreading the costs over the entire population and get rid of the politically damaging stories of overcharges causing individual bankruptcy.

Socializing this theft turns it into Just Another Crisis among the hundreds of others the US has.

[sethrin]

Having an expansive definition of theft merely serves to raise the noise floor.

The "true" purpose of the ACA was to do something about spiraling health care costs. What was passed was a "compromise" where the people pushing for a public option got nothing and the most onerous restrictions on the monied interests were rolled back. This has not been an effective solution in many senses. I decline to further characterize the issue, however; this is extremely close to a political discussion, and those are ban-worthy here.

[hockley]

There were provisions that addressed cost containment (ACOs, Quality-Based reimbursement models for Medicare). In fact, medical cost inflation has come more in line with general inflation since about 2009/2010. But, you're right, the market based reforms like cost and quality transparency were left to fight another day. The ACA focused more on access to coverage than it did cost.

I would not put too much weight on conspiracy theories though. The healthcare system is massively complex. It will take multiple reforms to eat this elephant.

[burkaman]

https://en.wikipedia.org/wiki/Patient_Protection_and_Afforda...

[mistermann]

Thank you, looks like some initiatives were underway.

[maxerickson]

It's well enough understood that the cost side is also a problem.

http://www.cnbc.com/2015/11/20/obamacare-architect-high-dedu...

The previous administration was working to move to different payment models to try to address it (it's not clear that the different models will have much long term impact):

http://www.reuters.com/article/us-usa-healthcare-reform-idUS...