What comes after the ACA?

[tct]

“What if 30 percent of the public had Health Savings Accounts?” said Paul. “What do you do when you use your own money? You call up doctors and ask the price… if you create a real marketplace, you drive prices down.”

Haha, yeah, I'm having a heart attack right now -- better get on the phone and shop prices! :)

Oh no wait, even better, let's be proactive and shop stent prices BEFORE I have a heart attack, even though I appear to be in perfectly good condition.  "Hello, yes, I would like to know the price of a stent, and also the cost to implement it.  What's that you say?  There are a ton of factors that could affect the final cost other than just the hardware cost of the stent?"

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

I doubt it because I have an HSA and therefore tried to shop around.  Very few places could even access a price list.

I experienced the same thing when we tried to shop around for my daughters hernia surgery. I believe we should enact laws that required healthcare providers to publish prices.

[tct]

Just this week I got a bid to replace a bathroom vanity. The contractor gave me a bid knowing that on average it takes half a day to replace. In my case there were lots of unforseen problems that caused it to take a full day. I just got charged the original bid, and the contractor is fine with this, because sometimes everything goes exactly as planned and it only takes 2 hours.

Your argument makes a lot of sense so long as the cost of heart surgery is comparable to the cost of replacing a bathroom vanity.  That's not been my experience.

My argument is about publishing/charging patients an "average" price for a service (heart surgery). It doesn't matter at all whether the cost is comparable to a bathroom vanity. It still works. I'm being somewhat simplistic here by assuming any "heart surgery" would be categorized as just heart surgery. Realistically there would be many different categories of heart surgeries that a patient might go in for.

[Rufus.T.Firefly]

If pricing health care is so difficult, how are any insurance companies still in business? Clearly some very smart people are on the job and can predict health expenses with reasonable certainty.

The system is intentionally opaque so as to confuse the end-user and prevent competitive pricing.  Sure no one will comparison shop in the middle of an emergency. But after the fact, it could be established that the hospital was price-gouging. The unhappy patient who paid $30,000 too much could post this information online. Negative reputations would be created about that hospital. Eventually, if the practice was widespread, common sense regulations could be passed to avoid price-gouging.

Where will you first go if your car suddenly breaks down? It's an emergency and you don't have time to do formal research. However, if you remember your friend telling you how terrible "shop x" was, but the people at "shop y" were great, you'll go to "shop y."

[Gin1984]

Just this week I got a bid to replace a bathroom vanity. The contractor gave me a bid knowing that on average it takes half a day to replace. In my case there were lots of unforseen problems that caused it to take a full day. I just got charged the original bid, and the contractor is fine with this, because sometimes everything goes exactly as planned and it only takes 2 hours.

Your argument makes a lot of sense so long as the cost of heart surgery is comparable to the cost of replacing a bathroom vanity.  That's not been my experience.

My argument is about publishing/charging patients an "average" price for a service (heart surgery). It doesn't matter at all whether the cost is comparable to a bathroom vanity. It still works. I'm being somewhat simplistic here by assuming any "heart surgery" would be categorized as just heart surgery. Realistically there would be many different categories of heart surgeries that a patient might go in for.

You really don't understand medical procedures do you?  Have you had any experience with major medical procedures?

[tct]

I experienced the same thing when we tried to shop around for my daughters hernia surgery. I believe we should enact laws that required healthcare providers to publish prices.

No one is arguing that, in theory, pricing transparency wouldn't lead to a reduction in prices and more informed shopping -- both good things.  But in practice, the cost is very difficult to determine.  The cost of heart surgery for a 25 year old could be quite different than the cost of heart surgery for a 75 year old.   

And this still prompts the question: Are you seriously expecting the 25 year old that is having an unexpected heart attack to do anything other than go immediately to the nearest hospital?  While he's unconscious and she's giving him chest compressions, is his wife  supposed to YELP heart hospitals?

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

[tct]

Just this week I got a bid to replace a bathroom vanity. The contractor gave me a bid knowing that on average it takes half a day to replace. In my case there were lots of unforseen problems that caused it to take a full day. I just got charged the original bid, and the contractor is fine with this, because sometimes everything goes exactly as planned and it only takes 2 hours.

Your argument makes a lot of sense so long as the cost of heart surgery is comparable to the cost of replacing a bathroom vanity.  That's not been my experience.

My argument is about publishing/charging patients an "average" price for a service (heart surgery). It doesn't matter at all whether the cost is comparable to a bathroom vanity. It still works. I'm being somewhat simplistic here by assuming any "heart surgery" would be categorized as just heart surgery. Realistically there would be many different categories of heart surgeries that a patient might go in for.

You really don't understand medical procedures do you?  Have you had any experience with major medical procedures?

I only experienced minor surgeries myself, but have been involved with cancer treatment of a family member who eventually passed away because of the cancer. I'm open to hearing what you have to say and learning something new

[tct]

If pricing health care is so difficult, how are any insurance companies still in business? Clearly some very smart people are on the job and can predict health expenses with reasonable certainty.

The system is intentionally opaque so as to confuse the end-user and prevent competitive pricing.  Sure no one will comparison shop in the middle of an emergency. But after the fact, it could be established that the hospital was price-gouging. The unhappy patient who paid $30,000 too much could post this information online. Negative reputations would be created about that hospital. Eventually, if the practice was widespread, common sense regulations could be passed to avoid price-gouging.

Where will you first go if your car suddenly breaks down? It's an emergency and you don't have time to do formal research. However, if you remember your friend telling you how terrible "shop x" was, but the people at "shop y" were great, you'll go to "shop y."

Completely agree with this. Glad to see others are realizing this as well. I clicked on this thread in hopes that others had the same ideas.

[fuzzy math]

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Fortunately I work in heart surgery. I will now present you with a list of questions that you will answer with all the vast knowledge you seem to have on this subject and you will enlighten us how to fix all these things.

1) What is the method by which the hospital bills for your procedure? Are you billed a bulk room charge or does your facility charge each item including all bags of fluid and syringes used?

2) Did you get the fast or slow surgeon today? Should it matter that a staff of 7 people is working your case for 8 hours instead of the 4 hours that it takes the faster Dr to do it?

3) Do you want the heart valve that the surgeon has been implanting into people for the past 20 years or some new item that your hospital is pushing on the physicians that might be harder to implant? If you choose the cost saving one, are you prepared to possible need a redo operation if you still have valve leakage? Should you be forced to choose a mechanical valve over a porcine valve? What are your preferences for life long anticoagulation if so?

4) Do you live in a state that requires 2 surgeons on hand or 2 of other allied health professionals such as myself? Are you prepared to move away from that state to save money if so?

5) Are your anesthesiologist and cardiologist employed by the hospital? Do you have requirements for in house standby in case of emergency (perforation of the heart etc) for a multi disciplinary team while you undergo your pre op cardiac catheterization to diagnose what is wrong with your heart?

5) How long is it going to take you to metabolize your anesthesia and wake up from the procedure? Should the ICU nurses remove you from the ventilator before you are ready so you can save money? Should they deny you pain medication so you are less groggy to accomplish it? You can't get out of the ICU and into the cardiac step down unit (the lower acuity unit from where you will ultimately be discharged) until you are breathing on your own. It's $10k on average per day in the ICU.

6) If your heart goes to shit and the choice is to let you die on the table or put a mechanical assist device to pump your blood and give your heart the chance to recover, do you understand the implications? Do you have an extra $100k for this therapy? Should we charge that to everyone so it's standardized so there are no surprises if you wake up with one?

I, and every hospital CEO eagerly await your informed answers so we can standardize things for you.

[nereo]

I experienced the same thing when we tried to shop around for my daughters hernia surgery. I believe we should enact laws that required healthcare providers to publish prices.

No one is arguing that, in theory, pricing transparency wouldn't lead to a reduction in prices and more informed shopping -- both good things.  But in practice, the cost is very difficult to determine.  The cost of heart surgery for a 25 year old could be quite different than the cost of heart surgery for a 75 year old.   

And this still prompts the question: Are you seriously expecting the 25 year old that is having an unexpected heart attack to do anything other than go immediately to the nearest hospital?  While he's unconscious and she's giving him chest compressions, is his wife  supposed to YELP heart hospitals?

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Again, no.  Your analogy doesn't hold up: any US citizen can choose Vanguard, but unless you live in a densely populated area you don't get to choose, because there are limited options within your geographic area.  It isn't a matter of more health-care providers "opening up" in an area because there's the question of volume... you need x # of people for there to be enough of a need for a heart surgeon to keep one on staff.  Roughly 40% of the US lives in 'rural' areas - that's ~125MM people. Those people will never have the choice necessary to allow comparison shopping assuming they knew enough about the procedures they needed in advance to do said comparison and assuming it wasn't a medical emergency. 

I do agree that more pricing transparency would be good, but currently insurance companies negotiate for the lowest rates and ironically these 'market forces' wind up making the whole thing more opaque.

[tct]

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Fortunately I work in heart surgery. I will now present you with a list of questions that you will answer with all the vast knowledge you seem to have on this subject and you will enlighten us how to fix all these things.

1) What is the method by which the hospital bills for your procedure? Are you billed a bulk room charge or does your facility charge each item including all bags of fluid and syringes used?

2) Did you get the fast or slow surgeon today? Should it matter that a staff of 7 people is working your case for 8 hours instead of the 4 hours that it takes the faster Dr to do it?

3) Do you want the heart valve that the surgeon has been implanting into people for the past 20 years or some new item that your hospital is pushing on the physicians that might be harder to implant? If you choose the cost saving one, are you prepared to possible need a redo operation if you still have valve leakage? Should you be forced to choose a mechanical valve over a porcine valve? What are your preferences for life long anticoagulation if so?

4) Do you live in a state that requires 2 surgeons on hand or 2 of other allied health professionals such as myself? Are you prepared to move away from that state to save money if so?

5) Are your anesthesiologist and cardiologist employed by the hospital? Do you have requirements for in house standby in case of emergency (perforation of the heart etc) for a multi disciplinary team while you undergo your pre op cardiac catheterization to diagnose what is wrong with your heart?

5) How long is it going to take you to metabolize your anesthesia and wake up from the procedure? Should the ICU nurses remove you from the ventilator before you are ready so you can save money? Should they deny you pain medication so you are less groggy to accomplish it? You can't get out of the ICU and into the cardiac step down unit (the lower acuity unit from where you will ultimately be discharged) until you are breathing on your own. It's $10k on average per day in the ICU.

6) If your heart goes to shit and the choice is to let you die on the table or put a mechanical assist device to pump your blood and give your heart the chance to recover, do you understand the implications? Do you have an extra $100k for this therapy? Should we charge that to everyone so it's standardized so there are no surprises if you wake up with one?

I, and every hospital CEO eagerly await your informed answers so we can standardize things for you.

You likely weren't trying to be funny, but you've got me laughing. Healthcare is very complicated as you just pointed out. I didn't intend to come off as someone with "vast knowledge" on this subject. I'm just interested in the topic of this thread "What comes after the ACA" and wanted to float some of my ideas, as I didn't see them represented.

[nereo]

You likely weren't trying to be funny, but you've got me laughing. Healthcare is very complicated as you just pointed out. I didn't intend to come off as someone with "vast knowledge" on this subject. I'm just interested in the topic of this thread "What comes after the ACA" and wanted to float some of my ideas, as I didn't see them represented.

I think lots of us here are trying to come up with a different, more sensible way, and there's a broad range of expertise within this thread.
Unlike SSI, the challenges of 'solving' health care are inherently complex.

[tct]

I do agree that more pricing transparency would be good, but currently insurance companies negotiate for the lowest rates and ironically these 'market forces' wind up making the whole thing more opaque.

Yeah, I've had a few conversations with family members regarding insurance practices that I don't like. 1) One works for health insurance company. 2) The other is a Dentist

1) Health insurance worker tells me "its cheaper/easier for us to raise your rates than it is to fight/reduce claims". I think this is a major reason why health insurance costs have skyrocketed.

2) Dentist tells me that insurance companies always negotiate paying a percentage of the cost for a certain procedure. The Dentist raises the cost of a procedure to account for this. This negatively affects the person who comes in with no insurance. The dentist must charge them the higher rate. There are no exceptions, otherwise the insurance companies will sue them for artificially raising the prices in order to gouge the insurance company.

[NoStacheOhio]

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Fortunately I work in heart surgery. I will now present you with a list of questions that you will answer with all the vast knowledge you seem to have on this subject and you will enlighten us how to fix all these things.

1) What is the method by which the hospital bills for your procedure? Are you billed a bulk room charge or does your facility charge each item including all bags of fluid and syringes used?

2) Did you get the fast or slow surgeon today? Should it matter that a staff of 7 people is working your case for 8 hours instead of the 4 hours that it takes the faster Dr to do it?

3) Do you want the heart valve that the surgeon has been implanting into people for the past 20 years or some new item that your hospital is pushing on the physicians that might be harder to implant? If you choose the cost saving one, are you prepared to possible need a redo operation if you still have valve leakage? Should you be forced to choose a mechanical valve over a porcine valve? What are your preferences for life long anticoagulation if so?

4) Do you live in a state that requires 2 surgeons on hand or 2 of other allied health professionals such as myself? Are you prepared to move away from that state to save money if so?

5) Are your anesthesiologist and cardiologist employed by the hospital? Do you have requirements for in house standby in case of emergency (perforation of the heart etc) for a multi disciplinary team while you undergo your pre op cardiac catheterization to diagnose what is wrong with your heart?

5) How long is it going to take you to metabolize your anesthesia and wake up from the procedure? Should the ICU nurses remove you from the ventilator before you are ready so you can save money? Should they deny you pain medication so you are less groggy to accomplish it? You can't get out of the ICU and into the cardiac step down unit (the lower acuity unit from where you will ultimately be discharged) until you are breathing on your own. It's $10k on average per day in the ICU.

6) If your heart goes to shit and the choice is to let you die on the table or put a mechanical assist device to pump your blood and give your heart the chance to recover, do you understand the implications? Do you have an extra $100k for this therapy? Should we charge that to everyone so it's standardized so there are no surprises if you wake up with one?

I, and every hospital CEO eagerly await your informed answers so we can standardize things for you.

You likely weren't trying to be funny, but you've got me laughing. Healthcare is very complicated as you just pointed out. I didn't intend to come off as someone with "vast knowledge" on this subject. I'm just interested in the topic of this thread "What comes after the ACA" and wanted to float some of my ideas, as I didn't see them represented.

Also, what method will you be using for payment? Visa, Mastercard, Discover, American Express and the various banking institutions have all negotiated individual prices and terms on behalf of their members.

[tct]

I experienced the same thing when we tried to shop around for my daughters hernia surgery. I believe we should enact laws that required healthcare providers to publish prices.

No one is arguing that, in theory, pricing transparency wouldn't lead to a reduction in prices and more informed shopping -- both good things.  But in practice, the cost is very difficult to determine.  The cost of heart surgery for a 25 year old could be quite different than the cost of heart surgery for a 75 year old.   

And this still prompts the question: Are you seriously expecting the 25 year old that is having an unexpected heart attack to do anything other than go immediately to the nearest hospital?  While he's unconscious and she's giving him chest compressions, is his wife  supposed to YELP heart hospitals?

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Again, no.  Your analogy doesn't hold up: any US citizen can choose Vanguard, but unless you live in a densely populated area you don't get to choose, because there are limited options within your geographic area.  It isn't a matter of more health-care providers "opening up" in an area because there's the question of volume... you need x # of people for there to be enough of a need for a heart surgeon to keep one on staff.  Roughly 40% of the US lives in 'rural' areas - that's ~125MM people. Those people will never have the choice necessary to allow comparison shopping assuming they knew enough about the procedures they needed in advance to do said comparison and assuming it wasn't a medical emergency. 

I do agree that more pricing transparency would be good, but currently insurance companies negotiate for the lowest rates and ironically these 'market forces' wind up making the whole thing more opaque.

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

[JLee]

Coming from a guy who referred to vetrans as

...

I did nothing of the sort.  I spent that whole post praising existing veterans and supporting their benefits, and then suggested that in the future new recruits should receive fewer benefits, because there should be fewer of them.

But I'm not surprised that you would quote me so horribly out of context.  I no longer expect anything more from you.

Frankly, large parts of the forum have been kind of disappointing lately.  I miss the early days of the forum, when civil discourse was the norm instead of the exception and the population of members was slightly more willing to listen instead of just talk.

I'm sorry that you find it disappointing that this forum has progressed and that new ideas and broader points of view are being expressed.

Blatant straw man. C'mon.

[nereo]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition. 

[Schaefer Light]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition.

People who live in rural areas have fewer choices in just about everything, though.  Sure, they can purchase some things online.  But if their car breaks down or they need a repair at their house, they certainly don't have as many choices as people in more populated areas.  And in these scenarios (car and home repair), most consumers probably don't know exactly what they need until after they've consulted with an expert.

[tct]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition.

You sound like the naysayers commenting on recent MMM post on community planning with limited/no infrastructure for cars. It's only "completely unrealistic" in your eyes. You have yet to see the light on this one.

[Classical_Liberal]

I understand the point you're making, but consider this analogy. A few years ago I moved all of my money to a Vangaurd fund. I didn't need to shop around to determine who had the lowest fees. Word of mouth and reading this blog would assure me that the best bang for my buck would be Vangaurd. So it would be with healthcare.  Everyone would know that if you want super fancy care, then you pay extra and go to the Mayo Clinic. For those of us who want the best value, we would choose the "Vangaurd" of healthcare.

Fortunately I work in heart surgery. I will now present you with a list of questions that you will answer with all the vast knowledge you seem to have on this subject and you will enlighten us how to fix all these things.

1) What is the method by which the hospital bills for your procedure? Are you billed a bulk room charge or does your facility charge each item including all bags of fluid and syringes used?

2) Did you get the fast or slow surgeon today? Should it matter that a staff of 7 people is working your case for 8 hours instead of the 4 hours that it takes the faster Dr to do it?

3) Do you want the heart valve that the surgeon has been implanting into people for the past 20 years or some new item that your hospital is pushing on the physicians that might be harder to implant? If you choose the cost saving one, are you prepared to possible need a redo operation if you still have valve leakage? Should you be forced to choose a mechanical valve over a porcine valve? What are your preferences for life long anticoagulation if so?

4) Do you live in a state that requires 2 surgeons on hand or 2 of other allied health professionals such as myself? Are you prepared to move away from that state to save money if so?

5) Are your anesthesiologist and cardiologist employed by the hospital? Do you have requirements for in house standby in case of emergency (perforation of the heart etc) for a multi disciplinary team while you undergo your pre op cardiac catheterization to diagnose what is wrong with your heart?

5) How long is it going to take you to metabolize your anesthesia and wake up from the procedure? Should the ICU nurses remove you from the ventilator before you are ready so you can save money? Should they deny you pain medication so you are less groggy to accomplish it? You can't get out of the ICU and into the cardiac step down unit (the lower acuity unit from where you will ultimately be discharged) until you are breathing on your own. It's $10k on average per day in the ICU.

6) If your heart goes to shit and the choice is to let you die on the table or put a mechanical assist device to pump your blood and give your heart the chance to recover, do you understand the implications? Do you have an extra $100k for this therapy? Should we charge that to everyone so it's standardized so there are no surprises if you wake up with one?

I, and every hospital CEO eagerly await your informed answers so we can standardize things for you.

No one needs to answer this question.  It has already been done by medicare.  It's called a DRG.

[Jammu]

I have a Bronze ACA plan. My dentist recommended seeing an ent specialist after finding something suspicious on my x-ray. I want to get by as cheaply as possible, given my deductible is 7k.

I call the ent clinic...

"How much to bring in a x-ray and have the doctor take a look?"

Crickets.

They can't say. They won't say. It might be look at the x-ray. But it might be take the scope in there send have a look-see. Or maybe needs a cat scan maybe not. Impossible to quote a price.

I call another place. Crickets there too.

I want a price list published on the Web just like lots of you do, but I don't know if that's possible.

[nereo]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition.

You sound like the naysayers commenting on recent MMM post on community planning with limited/no infrastructure for cars. It's only "completely unrealistic" in your eyes. You have yet to see the light on this one.

Unless you can give an actual scenario where it would work you are just trolling. 

[tct]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition.

You sound like the naysayers commenting on recent MMM post on community planning with limited/no infrastructure for cars. It's only "completely unrealistic" in your eyes. You have yet to see the light on this one.

Unless you can give an actual scenario where it would work you are just trolling.

Requiring healthcare providers to publish pricing will create competition and drive down prices in a majority of cases. Sure, there are exceptions and you keep pointing them out as reason to disregard this solution. There are examples/scenarios of competition driving down prices all around you and I already pointed to some in previous posts. The exceptions you keep pointing out are NOT reason to abandon competition in healthcare.

[nereo]

Your argument is that if it doesn't work equally for everyone then it's not a good solution. It's unlikely there is one solution that serves everybody equally. Sometimes you have to choose the best solution. Some will pay higher healthcare premiums for living in a rural area. Some will pay higher flood insurance premiums for choosing to live on the coastline. This should not prevent us from pursuing cost effective solutions that may not benefit everyone equally.

not exactly.  What I am saying is that the idea market forces - in this case choice between where you have medical proceedures done - cannot work precisely because choice itself is inherently impossible in the health care system.  There are many reasons (all provided above) why people cannot choose, from the nature of emergencies to a lack of providers to the complete unknown about what services a person needs.

these are inherent to health care, and cannot be removed without completely reorganizing humanity.  As such its a completely unrealistic proposition.

You sound like the naysayers commenting on recent MMM post on community planning with limited/no infrastructure for cars. It's only "completely unrealistic" in your eyes. You have yet to see the light on this one.

Unless you can give an actual scenario where it would work you are just trolling.

Requiring healthcare providers to publish pricing will create competition and drive down prices in a majority of cases. Sure, there are exceptions and you keep pointing them out as reason to disregard this solution. There are examples/scenarios of competition driving down prices all around you and I already pointed to some in previous posts. The exceptions you keep pointing out are NOT reason to abandon competition in healthcare.

The problem I have with your explanation is that these are not rare exceptions, but rather the general rule.  The largest medical expenses come from emergencies, not routine care.  About 40% of the country lives in rural areas where a choice of healthcare does not exist due to simple population density. Patients cannot know the intricacies of various medical procedures enough to 'shop around' - as fuzzy math summed up.  At the heart of each of these matters is that most people most of the time don't get choice.  And choice is what drives free market competition. 

I do agree with you that requiring healthcare providers to publish pricing (and putting that on patients invoices) would be a good thing - I even talked about that upthread.  But to say that it would "creat competition and drive down prices in a majority of cases" seems utterly false to me.  It's the kind of thing that gets brandied about with no evidence or logic to back it up.  It's clickbait; "this one thing will stop healthcare cost increases forever!"

You are conflating healthcare insurance with healthcare when you talk about higher premiums in rural areas (which, btw, are already a thing)

[Metric Mouse]

I disagree that it's often urgent.  How many times have you been to a doctor's office or hospital in your life?  Of those times, how many were truly urgent?  Personally, I've only had one instance when I needed medical attention right away.  I could have shopped around all the other times.  Even the one time when it was urgent, I might have driven a bit further if I'd known I could get a better deal somewhere else.

1.  Whether you acknowledge them or not, those urgent visits are likely the ones that are driving a disproportionately large share of total health care costs.  So if you don't fix that problem, you're just tinkering around the edges.

2.  Most people wouldn't know what to shop for.  It's not like they are picking up a pair of socks from Target. They are buying a surgery whose cost could be influenced by a hundred variables specific and contingent to the unique health of the customer.

Maybe a hospital could publish average cost of a heart replacement surgery for 2016... is that kind of what you are thinking?  But even then I'd expect the variance in that average to be pretty high.  Which kind of defeats the purpose of getting the average cost in the first place, right?  If it can't be relied on, then what's the point of having it?

If this kind of information is unavailable, how is there any price controls? Insurance companies would not be able to predict spending based on risk pools because "there's no way to know what X care is going to cost" and programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

[Metric Mouse]

Coming from a guy who referred to vetrans as

...

I did nothing of the sort.  I spent that whole post praising existing veterans and supporting their benefits, and then suggested that in the future new recruits should receive fewer benefits, because there should be fewer of them.

But I'm not surprised that you would quote me so horribly out of context.  I no longer expect anything more from you.

Frankly, large parts of the forum have been kind of disappointing lately.  I miss the early days of the forum, when civil discourse was the norm instead of the exception and the population of members was slightly more willing to listen instead of just talk.

I'm sorry that you find it disappointing that this forum has progressed and that new ideas and broader points of view are being expressed.

Blatant straw man. C'mon.

I agree.

[Classical_Liberal]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

[Metric Mouse]

The problem I have with your explanation is that these are not rare exceptions, but rather the general rule.  The largest medical expenses come from emergencies, not routine care.  About 40% of the country lives in rural areas where a choice of healthcare does not exist due to simple population density. Patients cannot know the intricacies of various medical procedures enough to 'shop around' - as fuzzy math summed up.  At the heart of each of these matters is that most people most of the time don't get choice.  And choice is what drives free market competition. 

I do agree with you that requiring healthcare providers to publish pricing (and putting that on patients invoices) would be a good thing - I even talked about that upthread.  But to say that it would "creat competition and drive down prices in a majority of cases" seems utterly false to me.  It's the kind of thing that gets brandied about with no evidence or logic to back it up.  It's clickbait; "this one thing will stop healthcare cost increases forever!"

You are conflating healthcare insurance with healthcare when you talk about higher premiums in rural areas (which, btw, are already a thing)

What percentage of those people are treated through the full course of their emergency by their tier IV hospital? These are the areas that don't have choice, and a vast majority of true emergencies are going to be transported to another, larger hospital anyway. Again, it won't solve all the issues, but saying that people in Burns, Kansas won't be able to shop for emergency medical services because they only have one local clinic is untrue, and unhelpful.

[Metric Mouse]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

Exactly my point - so there are 'price sheets' for services, which the poster was claiming would be impossible for a hospital to create due to the complexities of operations.

[Classical_Liberal]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

Exactly my point - so there are 'price sheets' for services, which the poster was claiming would be impossible for a hospital to create due to the complexities of operations.

Sorry, I  reread and misunderstood. 

[brooklynguy]

Congressional Republicans released a new white paper fleshing out the "A Better Way" plan that Sol outlined in the OP but which, importantly, is limited to those items that can be effected through the budget reconciliation process (and therefore require no Democratic support).  The NY Times has a pretty good analysis of it here.  There's not too much additional detail beyond the skeleton summarized in the OP, but, as the NY Times said, "this proposal, with the imprint of every major [Congressional] committee working on health care, seems likely to set the terms of the discussion."

One detail in the outline that will be noteworthy to many is that the refundable tax credit that would be made universally available under the plan (without regard to income) is "not available to be used for plans that cover abortion" (which would effectively remove abortions from insurance coverage on the individual market, for what insurance plan would ever choose to cover abortions when the effect of doing so would be to increase that plan's effective premiums by the full amount of the tax credit?).

[Metric Mouse]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

Exactly my point - so there are 'price sheets' for services, which the poster was claiming would be impossible for a hospital to create due to the complexities of operations.

Sorry, I  reread and misunderstood.

Not at all. I thank you for providing an excellent source to back up what I arguing. Thank you.

[NoVa]

I have a Bronze ACA plan. My dentist recommended seeing an ent specialist after finding something suspicious on my x-ray. I want to get by as cheaply as possible, given my deductible is 7k.

I call the ent clinic...

"How much to bring in a x-ray and have the doctor take a look?"

Crickets.

They can't say. They won't say. It might be look at the x-ray. But it might be take the scope in there send have a look-see. Or maybe needs a cat scan maybe not. Impossible to quote a price.

I call another place. Crickets there too.

I want a price list published on the Web just like lots of you do, but I don't know if that's possible.

This has been my experience also. I recently had minor outpatient surgery on my hand. There was also anesthesia. I had insurance through my work, but was curious what the bill would be. No one at the outpatient clinic could tell me. The only thing they knew was my co-pay, and couldn't even tell me that for the anesthesia, you would have to call someone else.

When the bill finally came it was ridiculous. NOT including the anesthesiologist it was just over $8,000. My insurance company basically said "that's nice, we give $1,060 for this procedure, plus the co-pay (less than $100)." The outpatient clinic accepted that amount. WHAT????? From $8,000 to just over $1,000?????? And everyone just shrugs and moves on like this is some kind of normal day? The system is broken.

[NoStacheOhio]

This has been my experience also. I recently had minor outpatient surgery on my hand. There was also anesthesia. I had insurance through my work, but was curious what the bill would be. No one at the outpatient clinic could tell me. The only thing they knew was my co-pay, and couldn't even tell me that for the anesthesia, you would have to call someone else.

When the bill finally came it was ridiculous. NOT including the anesthesiologist it was just over $8,000. My insurance company basically said "that's nice, we give $1,060 for this procedure, plus the co-pay (less than $100)." The outpatient clinic accepted that amount. WHAT????? From $8,000 to just over $1,000?????? And everyone just shrugs and moves on like this is some kind of normal day? The system is broken.

My favorite is when my employer removes the facility fee they're charging themselves because we're a self-insured hospital. It's a giant circle jerk.

[golden1]

Seems like we can answer the question of price transparency by looking at other developed countries who have better outcomes with lower costs.  Do they have price transparency?  (Serious question - I don't know.) 

[nereo]

Seems like we can answer the question of price transparency by looking at other developed countries who have better outcomes with lower costs.  Do they have price transparency?  (Serious question - I don't know.)

Well in Canada each province has its own universal health care system administered by the Province. We know from tax revenue that the total amount spent on health care is roughly half what is spent per capita in the US, and outcomes are pretty comparable.

Strange thing is: NOBODY has a CLUE what anything costs (except accounting, i guess).  Not the patients, not the nurses who do most of the care, and certainly not he doctors.  Proceedures are all billed out, almost* everything is approved, and you don't pay anything out of pocket.  Many of my Canadian friends think paying $40 "just to see a doctor" is outrageous. The only time you learn what something costs is when you are denied coverage and/or don't have the provincial health care card.  At which point there's lots of fumbling around to get you an invoice, and it's about as expensive (in my eyes) as paying out of pocket in the US.

[Monkey Uncle]

Seems like we can answer the question of price transparency by looking at other developed countries who have better outcomes with lower costs.  Do they have price transparency?  (Serious question - I don't know.)

Well in Canada each province has its own universal health care system administered by the Province. We know from tax revenue that the total amount spent on health care is roughly half what is spent per capita in the US, and outcomes are pretty comparable.

Strange thing is: NOBODY has a CLUE what anything costs (except accounting, i guess).  Not the patients, not the nurses who do most of the care, and certainly not he doctors.  Proceedures are all billed out, almost* everything is approved, and you don't pay anything out of pocket.  Many of my Canadian friends think paying $40 "just to see a doctor" is outrageous. The only time you learn what something costs is when you are denied coverage and/or don't have the provincial health care card.  At which point there's lots of fumbling around to get you an invoice, and it's about as expensive (in my eyes) as paying out of pocket in the US.

They may not have price transparency, but they have something that matters more: price control.

The single payer has complete control over the price, therefore no price gouging.

The closest we can come to that in the U.S. is the negotiated prices that the insurance companies get, per the example cited above by jfolsen.  But insurance companies don't have enough bargaining power to truly cut out the gouging, because if a provider doesn't like the reimbursement that is offered, it can simply refuse to participate in the insurer's network.  They know that even if they drive off all of the insurance companies, people aren't going to quit having emergency surgery.

[nereo]

Seems like we can answer the question of price transparency by looking at other developed countries who have better outcomes with lower costs.  Do they have price transparency?  (Serious question - I don't know.)

Well in Canada each province has its own universal health care system administered by the Province. We know from tax revenue that the total amount spent on health care is roughly half what is spent per capita in the US, and outcomes are pretty comparable.

Strange thing is: NOBODY has a CLUE what anything costs (except accounting, i guess).  Not the patients, not the nurses who do most of the care, and certainly not he doctors.  Proceedures are all billed out, almost* everything is approved, and you don't pay anything out of pocket.  Many of my Canadian friends think paying $40 "just to see a doctor" is outrageous. The only time you learn what something costs is when you are denied coverage and/or don't have the provincial health care card.  At which point there's lots of fumbling around to get you an invoice, and it's about as expensive (in my eyes) as paying out of pocket in the US.

They may not have price transparency, but they have something that matters more: price control.

The single payer has complete control over the price, therefore no price gouging.

The closest we can come to that in the U.S. is the negotiated prices that the insurance companies get, per the example cited above by jfolsen.  But insurance companies don't have enough bargaining power to truly cut out the gouging, because if a provider doesn't like the reimbursement that is offered, it can simply refuse to participate in the insurer's network.  They know that even if they drive off all of the insurance companies, people aren't going to quit having emergency surgery.

No arguments there - I was just responding to a question about the transparency issue of other countrys' health care. Yes, there is more control over price (though it's worth noting that Canada's refusal to allow R&D expenses in drug prices is highly controversial between Canada nad the US).

I think any health care reform will need price controls to be successful in the long term.

[okonumiyaki]

President Trump said on Saturday that a plan to replace the Affordable Care Act will come "in a couple of weeks."
"We are going to be submitting in a couple of weeks a great healthcare plan that's going to take the place of the disaster known as ObamaCare," he said at a campaign rally in Melbourne, Fla. "It will be repealed and replaced."
"Just so you understand, our plan will be much better healthcare at a much lower cost," he added. "OK? Nothing to complain about."

So, that's alright then

[sol]

President Trump said on Saturday that a plan to replace the Affordable Care Act will come "in a couple of weeks."

Yea, right.  Remember when he said he would release his tax returns "as soon as I win the nomination"?  Remember when he was going to reveal his new tax plan "before inauguration day"?  Remember when he was going to reveal his Obamacare replacement plan "next Wednesday or Thursday"? 

This guy is a serial liar.  He's only buying time, because he knows that giving a fake but specific date gets everyone off his back in the immediate future and then they'll forget or be distracted by some new scandal when his self-imposed deadline actually arrives. 

My golden dream for this election is that he spends four more years doing this exact same thing, and never actually gets around to ruining America.

[fuzzy math]

No one needs to answer this question.  It has already been done by medicare.  It's called a DRG.

DRGs are used by Medicare, not private insurance. While the largest percentage of heart patients are on Medicare, there are still thousands of patients a year with private insurance. And Medicare only could quote  the easily expected portions of hospital bills. Drs get flat reimbursement etc. Everything else is still billed by the hospital, the difference is written off. For the unexpected large expenses for more invasive therapies, the charge to the patient doesn't just disappear. The patient will still pay the 20% of the allowed amount of the unexpected expense.

You had better believe with private insurance that the highest allowed charge will be billed, and negotiated to the contracted rate. This is the essence of why it is so difficult to find out what things will cost. 2 hospitals in the same town could charge the patient significantly different amounts for the same procedure for all the reasons I listed. The insurance company will probably have different contracted rates. It's all a racket.

[fuzzy math]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

Again, it's not that simple. If the patient has to stay in the hospital longer than expected, or has an event and ends up in the ICU, the amount changes. These predetermined charges are for things like "how much will we pay for the knee hardware if the standard set is used?" "How much will we pay the anesthesiologist?" Etc.

[DavidAnnArbor]

Thank you Fuzzy Math for clarifying that because there are a million variables with respect to the costs of health care, it's virtually impossible to have a "price list" for medical procedures.

In my personal experience of getting a preventive colonoscopy performed, I had a choice of going to the local University of Michigan clinic with it's good reputation, or I could go to these small clinics 30-40 miles away and get paid by the insurance company some small amount of money for choosing these small far away clinics. Since I as a health care consumer had no way to know whether these smaller clinics have a high rate of quality or safety, I chose to go to UM's colonoscopy clinic.
The colonoscopy was paid for by Obamacare/ACA - it's one of the procedures that is covered when you turn 50 years old. I paid nothing for it (because the procedure showed no problems).

So not only would one want a price list, I would think health care consumers would want a safety and quality comparison.

In other words I want to not only know the price but also the quality of health care providers - this complicates the decision making process even more. The health care consumer will have an asymmetric level of information -  therefore, the free market system fails when it comes to health care. This failure of free markets is explained in a first level Economics class. The free market fails in many markets, like public goods for example. It's completely reasonable then for the government to step in, and ameliorate the market failure to help allocate resources as equitably as possible.

The government helps finance research to determine whether some medical procedures are even effective.

[Classical_Liberal]

... programs like Medicare could not say "We are paying X amount for a knee surgery". Since I find this hard to believe that these programs would function with literally no idea on what prices are until the patient is on the table, I believe your argument has little merit.

This is wrong, Medicare does exactly that.  They make a payment based on DRG's.  The hospital knows exactly what they are going to make on a knee replacement under the given circumstances.

Edit:  https://en.wikipedia.org/wiki/Diagnosis-related_group

Again, it's not that simple. If the patient has to stay in the hospital longer than expected, or has an event and ends up in the ICU, the amount changes. These predetermined charges are for things like "how much will we pay for the knee hardware if the standard set is used?" "How much will we pay the anesthesiologist?" Etc.

This is only partially true. If an additional DRG is paid it is related to a different diagnosis which may or may not have been a "complication" from the original procedure.  Generally speaking, if it is a known complication (ex pain not controlled requiring an additional day of hospitalization), the hospital is NOT reimbursed for the stay.  Additionally, if a readmission takes place within 30 days related to the previous payment, no additional compensation is paid to the hospital for treatment. 

No one needs to answer this question.  It has already been done by medicare.  It's called a DRG.

DRGs are used by Medicare, not private insurance. While the largest percentage of heart patients are on Medicare, there are still thousands of patients a year with private insurance. And Medicare only could quote  the easily expected portions of hospital bills. Drs get flat reimbursement etc. Everything else is still billed by the hospital, the difference is written off. For the unexpected large expenses for more invasive therapies, the charge to the patient doesn't just disappear. The patient will still pay the 20% of the allowed amount of the unexpected expense.

This is correct, as with other gov't and private pay situations (see drug costs in Candada vs US), the private side ends paying more, subsidizing  the reduced payment structure of the other.  The point being though, if the largest national insurer (Medicare) can essentially create a healthcare menu with costs, why cant the same be done in the private market? The secondary consideration to this would be whether or not this would do any good.  Doesn't it then become a "price fixing" situation?   

All of these solutions may be helpful, but are only optimizations.  The bottom line is that modern healthcare is expensive and we need to figure out ways to make it less expensive.  IOW a budget can only be optimized to a certain degree (which US health care has not yet).  After optimization, one has to begin to make sacrifices.  What are we, as a society, willing to sacrifice to keep costs low enough for universal participation? 

[NoStacheOhio]

This is only partially true. If an additional DRG is paid it is related to a different diagnosis which may or may not have been a "complication" from the original procedure.  Generally speaking, if it is a known complication (ex pain not controlled requiring an additional day of hospitalization), the hospital is NOT reimbursed for the stay.  Additionally, if a readmission takes place within 30 days related to the previous payment, no additional compensation is paid to the hospital for treatment. 

This is sort of the sledgehammer approach though. A 30-day readmit may or may not be reasonable, or even the hospital's fault. Say the patient is taking longer to recover than what they're willing to pay for post-op inpatient care, so they get turfed to a nursing home, where they can't handle it, and the patient's condition deteriorates. Yep, that's totally on the hospital for sucking. Don't even get me started on nursing staff screwing up insulin (one of the most dangerous drugs around).

[DavidAnnArbor]

Ryancare proposal is

1. Flat subsidies to pay for health insurance regardless of your income. The subsidies would increase with age but it's unclear by how much.
2. The amount you can put in an HSA will increase.
3. Millions will lose their Medicaid.

Are we going to also go back to the bad old days where insurance companies can drop you like a hot potato if you suddenly get sick and need the health insurance?

And to undermine the existing ACA, the tax penalty for not enrolling in insurance  has been suspended - potentially leading to a death spiral in health insurance premiums.

https://www.nytimes.com/2017/02/19/opinion/ryancare-you-can-pay-more-for-less.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region&_r=0

[protostache]

Ryancare proposal is

1. Flat subsidies to pay for health insurance regardless of your income. The subsidies would increase with age but it's unclear by how much.
2. The amount you can put in an HSA will increase.
3. Millions will lose their Medicaid.

Are we going to also go back to the bad old days where insurance companies can drop you like a hot potato if you suddenly get sick and need the health insurance?

And to undermine the existing ACA, the tax penalty for not enrolling in insurance  has been suspended - potentially leading to a death spiral in health insurance premiums.

https://www.nytimes.com/2017/02/19/opinion/ryancare-you-can-pay-more-for-less.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-right-region&region=opinion-c-col-right-region&WT.nav=opinion-c-col-right-region&_r=0

Congress can't pass a bill that removes the ban on medical underwriting and restrictions on recision without either busting the filibuster or getting 8 more votes in the Senate so those components will likely stick around. As you note, removing the individual mandate (apparently this can be passed in a budget reconciliation bill) will almost certainly lead to death spirals in the individual markets so that point is sort of academic.

[infogoon]

President Trump said on Saturday that a plan to replace the Affordable Care Act will come "in a couple of weeks."

Yea, right.  Remember when he said he would release his tax returns "as soon as I win the nomination"?  Remember when he was going to reveal his new tax plan "before inauguration day"?  Remember when he was going to reveal his Obamacare replacement plan "next Wednesday or Thursday"? 

This guy is a serial liar.  He's only buying time, because he knows that giving a fake but specific date gets everyone off his back in the immediate future and then they'll forget or be distracted by some new scandal when his self-imposed deadline actually arrives. 

My golden dream for this election is that he spends four more years doing this exact same thing, and never actually gets around to ruining America.

Still waiting for the amazing secret plan to defeat ISIS his first month in office.

[nereo]

Still waiting for the amazing secret plan to defeat ISIS his first month in office.

It's a secret.  If he told anyone it wouldn't be effective.  If ISIS still exists in two years it's someone else's fault.  Probably HRC's.  Somehow.

[NoStacheOhio]

Still waiting for the amazing secret plan to defeat ISIS his first month in office.

It's a secret.  If he told anyone it wouldn't be effective.  If ISIS still exists in two years it's someone else's fault.  Probably HRC's.  Somehow.

She probably gave them the other 80% of our Uranium.

[obstinate]

So many dismiss the advantages that shopping for healthcare will provide using your argument. I believe it will create competition and drive down prices. The experience of shopping for healthcare will eventually become similar to shopping for a tv. If it's not an emergency, I can check amazon, target, walmart, etc, and get the best price on my tv. If it is an emergency and I need a tv right now for super bowl weekend, then I can likely go pick one up at the local walmart and can be confident that I'm not getting gouged too much.

It didn't work before the ACA. There is little reason to believe it will work after the ACA has been repealed. All the other countries that have lower costs than we do? None of them use this "shopping around" system either.