funny, huh? record profits, yet need to raise rates, to cover "costs" - kinda like the oil/gas industry after Katrina

and people still find ways to apologize for this? let alone think it justified?

"The US system, covering only some of its citizens, is already spending more per capita, both in terms of dollars and in terms of percent of GDP, than other countries that cover their entire citizenry."

Yep. And yet we rank 38th in life expectancy (right after Cuba) and 33rd in infant mortality. That's what puzzles me about the cheerleaders for our current system. As you point out, they go on about market efficiencies, when by any objective measure, leaving health care in the hands of private, for-profit corporations is giving us a very bad return for our investment. It's a case of ideology blinding people to reality, and of propaganda causing regular citizens to be against something which would be in their own interests.

Kent-

Honestly, I don't think the standard conservative meme of "profit margins" "small business" "capitalism" or what have you, that Conservatives give for their opposition to nationalization is the real issue here. I used to think it was a matter of the Conservative fears of "Big government" "socialism" and "Orwellian beliefs". But, that isn't the truth either. The truth is, it's about WHO controls the goods and services. They don't mind big business, or big government, they even want big government, or big business, so long as it is THEIR big business and THEIR big government. It is all, completely, wholly about control, and the fear of loss of control of goods and services

At least that's how I'm beginning to see it

The problem is that the whole insurance model doesn't work for health care. It works for houses, cars, and boats. We insure our houses against loss, and the insurance company bets that a loss will never happen. Statistically, the likelihood of a house fire (or hurricane, or tree falling through the roof) is low. In all likelihood, the insurer will collect on your policy for YEARS and never pay you a dime. Their business model depends on it.

But medical care is different. We ALL have bodies, they ALL break down in some way or other. Show me anyone over 40 without a pre-existing condition of any kind. Can't be done. Everyone has something--that's the nature of a body.

The insurance model doesn't work. It can't.

Fudo, I think the rate increase is secretly to establish a comfortable baseline against which cuts can come if regulation happens. It occurs to me that the analogy to candy bar inflation is the right one here, where first they inflate the bar size, then raise the price, then gradually decrease the bar size until it's ripe to be re-inflated to the same old large size and get another cost increase again.

nanatehay, good point about being lower in life expectancy. I should have put that in, too, but that's why I have you guys out there as my safety net. :)

Placebo, I suspect that's really what's going on, but I didn't want to personalize it without more data. I asked the questions I did because they seemed defensible as questions and to call for answers. I suspect the answers will implicitly support what you say.

Bonnie, that's what my Fiduciary Duty vs. The Three Laws of Robotics is about. Yes, their boards are not only able to but required to vote selfishly.

There's some relation here, too, to my Medical Care and the Free-Market Catch-22, as well. Anyone who didn't see that article last August and wants more reading on this might want to flip over to there.

I totally agree with the term "predatory" because their tactics for improving profit margins are not limited to health insurance. Our auto insurance went up $100/vehicle last year "because of increasing claim costs", though we have never filed a claim against our auto insurance. When I phoned to question the increase, I was told that it was "across the board" regardless of your standing.

The big insurance companies are no better than Bernie Madoff. They take money from us, perform their corporate magic, line their own pockets first, and then ask us for another payment.

It's criminal.

Froggy, I think there's something to what you say. Although I think also that there are some ways in which we've allowed certain tactics into the system that confuse things, too. I wrote an article in my pre-OS days at my home site outlining why I think pooling is partly to blame. That was a kind of libertarian analysis to the problem, and I think it could be made to work, but to do so requires libertarians to acknowledge that some government regulation is essential for markets to work on things like this. It simply can't be the case that they're both free to do whatever they like and also allowed to use capitalism. Capitalism is not a beneficent overlord, it is a greedy tyrant. If you “program” capitalism to guard the things you care about, it will do a good job. But right now all capitalism is programmed to care about in the health care industry is “raw profit” and we are finding out the hard way what we should have known all along which is that raw profit and human health are not naturally aligned quantities. That's a lot of what that Catch-22 article I was alluding back to is about.

Mother, I have nothing to add to your remarks but agreement.

Kent, I'm on your side, but we have to be accurate when we quote statistics:

Anthem's gross revenues for Q4 of 2009 was indeed $2.7 billion....but net income for the quarter was $331.4 million after adjustments for a final net profit margin of 12.27%. Before adjustments for losses, net income was $681.9 million, which is a gross profit margin of 25.25%.

By contrast, the average supermarket chain works on a markup of less than 5% .

According to Wellpoint's audited annual report, the benefit expense ratio for Q4 of 2009 was 84.8 percent.

These numbers become important because they reinforce my findings that, nationwide, across the board, for-profit health care providers earn an average net income of 15-20% of their gross revenues.

Therefore, by extension, the most we can expect to save by shifting to a nonprofit model is approximately that same 15-20%....which isn't enough to fix the problem.

In order to fix health care, we have to reduce the cost of health insurance to the point where at least 85% of the electorate can afford to purchase the insurance, so the question is how much can a minimum wage earner allocate for health care.

On average, this number comes to around $100-$150 a month, but even at $100, purchasing health insurance will be an extreme hardship for anyone making $10 an hour or less.

I am all in favor of forcing for profit health insurance companies out of business....however, I don't believe that government should or could achieve that objective.

The only way to solve the health insurance dilemma is by creating a better alternative, private, not-for-profit, membership owned health care insurance collaboratives.

The statistics seem to indicate that, without changing anything else, a nonprofit health care provider could provide identical coverage for approximately 15% less in terms of annual premiums.

If this is the case, and it appears to be, then why hasn't anyone done it?

The answer to this is that those people who would like to establish a nonprofit health insurance provider don't have the capital resources to underwrite the company....and the only means of securing that capital would be by issuing stock...or, perhaps, with a government grant.

I have been researching the history of health insurance and, guess what, the first health insurance programs were established by nonprofit organizations. The second wave of health insurance programs were mutual insurance ventures, without shareholders, which operated as nonprofit organizations do.

Some of the largest Blue Cross Blue Shield operations in the country are still organized as nonprofit corporations....but their membership fees are not significantly lower than those charged by for-profit corporations. (I'm still researching this, by the way.)

The problem with nonprofit or government operated health insurance schemes is that they won't substantially reduce costs to the consumer because they would have to protect themselves from the extraordinary costs generated by a relatively small number of subscribers.

This is off the top of my head, but I recall that 85% of the costs incurred by health insurance programs e generated by 15% of the program's members.

The concept behind mutual health insurance is to spread the cost of extraordinary care for those who are very ill across the entire membership of the health plan, which means that a relatively large number of relatively healthy people must be enrolled into the health plan in order for the plan to remain financially viable.

As outrageous as the profits earned by health insurance programs are - and they are - they are a small percentage of the overall cost of health care insurance to the consumer.

A national, mandatory health insurance program would probably reduce overall costs by approximately the same percentage as the profit margin enjoyed by for-profit health insurance vendors.
These programs were established long before medical costs skyrocketed to their present levels.

The only way to reduce health care costs, and therefore the cost of health care insurance, is to reduce the overhead and operating costs charged by health care providers.

The major differences between health care costs in the United States and the cost of health care in the rest of the world are the costs of malpractice insurance, the related expenses from malpractice lawsuits, the cost of medications, and the costs of innovation.

At the high end of the spectrum, the United States has the best health care in the world. That’s why people come from all over the world to get state-of-the-art health care here. At the low end of the spectrum, however, the state-of-the-art doesn’t trickle down to the ordinary, everyday patient. The cost of maintaining that state-of-the-art care is spread out across the entire health care system, so that people receiving low-end care at inflated prices are paying those inflated prices to underwrite high end care.

There’s a persistent and incorrect perception that the cost of high-end care subsidizes the cost of low end care, but that simply isn’t true.

Unless we control these costs, we are not going to solve this problem.
Solutions exist for all of these problems. The political will to implement doesn’t exist….yet.

Sage, I'm all for having the stats corrected. I'm just going by what I found in several news stories, but I take your word if you've dug deeper. Those are still big profits any way you cut it, and I agree a 25% profit margin is high. Supermarkets may do 5% but I think some other companies do 15%. But even so, it's not clear what insurance companies are providing as a virtue. The question about profits could again be applied to health care providers, yes. But again alluding back to my Medical Care and the Free-Market Catch-22, it's just not going to happen. So the markets may be the right tool in principle, but without heavy regulation they are not the right tool in practice. Personally, I'd rather just see health care taken over by the government. But I'm not trying to be dogmatic about that. What I want is a system where I can look at an explanation of the system and have some reasonable reason to believe it will cover everyone for an affordable price, exactly because it's been done elsewhere. So when I see profits coming out, I have to believe that one reason we're not getting to where we want to get is that someone is focusing on the wrong problem. It's not just the amount, it's the endeavor of spending any board room time at these places trying to figure out how to optimize cash flow to stockholders. That's the problem.

And yes, the fact that there's good high-end health care doesn't mean anything to me. To be honest, if faced with a serious problem, I'd rather just find that I couldn't be covered knowing that anyone in my same situation couldn't be either, and that it was a fair system, than have it be the case that what stood between me and coverage was my political connection or my elite monetary status or my willingness to get on the phone and call a million people because the answer is individually decided different ways at different times for different people. I suspect there is a massive drain on the economy in terms of productivity due to family/friends having to take time out to do that phone/application thing when someone gets sick and that the increase in productivity of simply not having to fuss about such things would more than pay for a lot of this stuff we're fussing about. But in any case, I think fairness has to be central or else I think we should stop calling ourselves the land of equality.

Kent,

A couple of thoughts I’d like to add on some of your points.

“If you make a profit, how can you claim your costs are too high? “
Not to defend WellPoint, but I think this is a little too simplistic. Of course you know that investment and risk are important factors in this “cost” equation as well. I can make a $100 profit at a casino by laying down large sums of money with very little chance of return. The fact I made a $100 doesn’t mean that I can’t claim the “cost” of doing it again is too high.
“What benefit is the public getting from this for-profit business?”
I can’t get my head around the contradiction implied by the fact that a large number of the public current buys this “product”. Are they ignorant of the fact they may never get the services they are paying for because they don’t read or understand the contract they are entering into? If this is happening on a large enough scale, why isn’t this just consider fraud and dealt with through existing judicial mechanisms?
“The ordinary argument for the free market is that it achieves certain efficiencies better than the government would”.

I believe the ordinary argument is sound, but is just being inappropriately applied in the case of the insurance industry’s impact on healthcare.

The insurance industry has become more efficient. This is without question. They’ve become more efficient at insurance, which is after all their business. They are not in the business of healthcare so why do the free-marketeers think that any efficiencies would be realized in healthcare?

I would love to see a free-marketeer design a healthcare system from scratch and justify how adding insurance would increase the efficiency of the system.

I don’t think it could be done.

sorry, the site messed up my spacing as I cut and pasted my comment.

No problem mark. By the way, the thrust of the article I alluded to from my pre-blog days is that indeed the insurance companies have gotten more efficient but what they've gotten more efficient at is removing the risk. They do this by pooling, and decreasing pool sizes where they can, trying as best they can to get you into a situation where the cost of offering you insurance is the cost of being you (plus a tidy markup, of course). I agree with you about the fraud issue to some extent, but the problem becomes as in any shell game that everything is so complicated it's hard to prove that you didn't get what you were entitled to, since it's hard to know what you are entitled to, and you're paying for possibilities, not for outcomes. On an individual basis, what else could you do? But that's the point of universal care: only by very large numbers, by a single large pool, can you get to the place where you can link costs to outcomes because over a large enough group you can average over the individual variances... (A similar argument explains why personal savings accounts for retirement or for health care sound good but may leave individuals in a severe problem on a case-by-case basis even if their average performance is ok.)

It was a former Wellpoint VP working on Senator Baucus' staff that wrote the so called health care reform legislation. It is all connected. monkey fingered.

My father lived to almost 88. My mother is now 83. I will not live as long because the medical care that has kept them going is being priced out of my reach.

Decreasing the risk by denying coverage to the most problematic patients is not just illegal (violates the Equal Protection clause) but immoral in the deepest sense of the word.

However, once we commit ourselves to providing equal care for everyone, we have to be prepared to deny certain kinds of care to everyone....because the system can't afford the cost.

Think about it. Can you justify spending $250,000 on a heart transplant for one 62 year old man (namely, me) against spending the same $250,000 to cover $1000 worth of care to each of 250 needy children?

I can't either.

How is it that other countries can have universal health care and we can't?

I have to run...lucky you.

By the way, the answer is that they practice exclusion. They have smaller populations, and they more closely control their borders and access to care than we do. AND, they pay as much more in taxes as we pay for health care.

In principle, I agree that we need universal coverage. In practice, a government-sponsored health care program that requires all citizens to buy into the plan is discriminatory against the young and the healthy, who may not need health care, and certainly don't need to spend what a universal health care plan will cost.

It's like Social Security. The Social Security System was originally designed to be a pay as you go plan, with surpluses being invested against future expenses, but is now a Ponzi scheme of musical chairs in which the current generation of retirees are going to receive disbursements from the funds being contributed by the next generation of workers.

Sooner or later, the system will collapse, and someone will be left holding the bag.

Health Care operates under the same paradigm. The reason that health care generates so much more concern is that health care is so much more immediate a concern while Social Security is way off in the distance for most people....until they get there.

Ultimately, when the dust finally settles, the current effort to reform health insurance will fail....oh, they will pass something, but like Medicare Part D, it will be another rip-off.

Sooner or later, however, it will become inescapably obvious that the government will have to nationalize the entire system, probably under some emergency power agreement, and we will end up with a hybrid built on the foundation of the Veteran's Administration and Medicare.

Unfortunately, this won't come to pass until thousand of dying people march on the capital, some of them being pushed along in wheel chairs and hospital beds.

Right now, as a nation, we're bankrupt and living on money borrowed from our adversaries around the world....and we did this to ourselves by pretending that everyone can have everything.

Of course, there's graft and corruption rampant across the land....but there's nothing we can do about that. It's built into the system..

We should have a symposium and discuss the matter in real time. Can we do that on this thing?

Now I really have to run.....

Sage, you are now officially way off topic and using more than your fair share of this resource here. You are commenting on issues I have not raised. Health care is a big issues and I have not intended to discuss all of it here, but to pick off a particular issue which is whether the engine of “profit-making” is a good vehicle for getting coverage to people. You've implicated all kinds of additional issues that are not related, like who gets how much coverage. And you've suggested (falsely) that I'm saying everyone should be covered some specific amount and then you've argued against various straw men you've created. I'm not prepared to have those arguments here. Please take them to another thread if you want to talk about them. They're important, but this is not an “anything goes” thread about health care.

I will say I think the notion that it is some form of discrimination to say that the young and healthy should pay disproportionately for health care is ridiculous; of course they should. For one thing they will not always be young, and they may not always be healthy. But certainly you cannot expect that a good health care system will be paid for by the elderly and the sick. It is precisely my point that ability to pay ought not be the key feature behind a good health care system. That is not the same as me saying that we should spend infinitely, by the way. It just means that for however much we do spend and whatever way we divide it up, some sort of ability-to-pay system ought not be the mechanism for deciding who gets what. Please let's solve the problem of divvying up the money another day and focus strictly on the question of whether commericial competition is helping the insurance part. I don't see that it is.

Kent-
Grrrrrrrr! In 1993, as a member of a mulidisciplinary clinical team, I attended an "informational" meeting with our Executive Director, Medical Director, Nursing Director, Chief Psychologist and Clinical Director. The topic was the impending shift to managed care.
Most of the points you state were discussed that day as "probable outcomes," along with inevitable shortened lengths of patient care AND physician incentives: Pay for Performance. These "mangled care" provisions set up a direct conflict of interest between doctors' own financial interests and delivery of patient care. In effect they were to be paid MORE for doing LESS. One example: Doctor X was to be issued a lump-sum incentive of, let's say, $3 million, at the beginning of the fiscal year. Each procedure he/she ordered was then to be deducted from that sum. At the end of the year, Doctor X would retains whatever funds remained. To a staff member, our jaws hit the floor. I do not know if that particular policy was ever adopted, but I am certain that "Pay for Performance" was pervasive during the early years.
So it's not just capitalist insurance interests involved here...it goes ever so insidiously deeper...
Keep fighting the good fight!
-rated-

Mothership, that's dreadful, but very interesting.

filthy, kent. 2.7 billion in a quarter for one company.

and raise joe the plumber's rates by 39 percent.

we are done. we are done done done. there are still not enough angry people out there.

"efficiently fleecing the American public"

yep, that's the efficiency advocates of unregulated markets are talking about, it's got nothing to do with Adam Smith

jane, admittedly the odds are stacked against the common person.

Roy, indeed—I've been intermittently listening to The Wealth of Nations (audiobook) while commuting to work and I'd swear I've heard several remaks in favor of maintaining a healthy workforce that have made me think “what went wrong?”

Kent, we all have different styles of writing for different topics and this is your polemic style where you ask really broad but biased questions. They are sometimes fun but are hard to comment on. I will try by making a few really broad comments although one will probably meet your definition of "boilerplate."

1. How is it any of the government's business to decide what can be for-profit or not? If every business demands a government approved "rationale" then we no longer live in a free society.

2. If you don't like health insurance, then don't buy any. Oh, guess what? You can't afford to pay your own medical bills when you get sick. Well, maybe that insurance is a valuable service to have after all. Gee, I wonder if anyone would provide that service if it cost them more to provide than they took in? Answer: No.

3. The reality is that the insurance markets are certainly not free and in some states are not markets at all. Where states only have one insurer, it is illogical to criticize the free market. Instead, logic would say that the state's poor results would be the fault of single payer healthcare. Elsewhere, there are so many regulations on insurers that there is little opportunity to provide product differentiation. Lastly, under the employer provided insurance model, most people do not get to compare and choose the insurance company they want. So, tie these three together and there simply is no free market. Given that people hate the current non-free market system, one might think we could get some people to try the free market rather than keep doing the same government mandated monopolies.

Just sayin...

I gotta chuckle that Google has chosen to offer an ad for Anthem in the ads on the right hand column. “Get Coverage from a Trusted Company.” Hmmm.

Steve, it's the business of Government to do what people cannot do for themselves. Yes, you can say it's up to me to buy health care, but if it cannot be properly pooled and hence properly priced unless everyone is in one pool, then I cannot do it myself. You could likewise tell me if I want a defense, I should hire my own bodyguards, but I can't do that either for similar reasons.

We do (I think) agree that employer-provided health care is a bad thing. It's the government that should provide health care, not employers. That would free employers to do what they do best: work on the product they make or the service they offer.

Ken:

I took a look at the Wellpoint 10K -- the latest available being the 2008 10K.

You can find it here:

http://ir.wellpoint.com/phoenix.zhtml?c=130104&p=irol-sec

A few facts from there published financials.

At the end of 2008, they had 35 million insureds -- 1 in 9 Americans. Out of that 18.5 million were "self funded" Vs. 16.5 million who were "fully insured". Self funded means, in general, that a large group plan (like an employer) pays all costs plus an administrative fee to Wellpoint.

In 2008, they had $62 billion in operating revenue. There net income was $2.1 billion. The profit comes to $71 per insured.

In order to earn that $2.1 billion, Wellpoint had 'equity' of $21 billion. That is a return of 10%.

These are just baseline facts from published, audited figures.

As far as regulation goes, they are regulated by the State Insurance Departments of the various states they operate in.

Their business in very highly regulated -- and includes not only rate regulation, but also all sorts of rules regarding what must be included in policies, market conduct regulations, etc.

The State of California must approve any rate increase, and is looking into Anthem's filing.

Per Anthem, the reason for the increase is that they have lost insureds because of the recession, and the insureds that they lost tended to be the healthiest, and those remaining are more costly.

Their SG&A or expense ratio is about 14% of revenue.

By the way, Ken, from the New York Times:

"Christopher J. Truffer, an actuary at the Centers for Medicare and Medicaid Services and the main author of the report, predicted that public spending for doctors’ services, hospital care and prescription drugs would grow faster than private spending in the coming decade.

As a result, Mr. Truffer said, the public share of total health spending — 47 percent in 2008 — is expected to exceed 50 percent by 2012 and then reach 52 percent by 2019."

So, right now, the government is spending almost half of all health care dollars. This (I believe) includes Medicare, Medicaid, VA, Department of Defense, and Federal Employee health benefits.

http://www.nytimes.com/2010/02/04/health/policy/04health.html

The "so what" of the facts listed above are:

1. The government heavily regulates the health insurance industry.

2. Most health insurance has nothing to do with insurance or risk transfer. It is simply claims administration.

3. Once you get above 6 zeros, people tend to get lost in figures. $2 billion sounds like a lot of money, but $70/insured per year isn't enough money to revolutionize anything.

4. Since public spending is 1/2 of all health care spending, why aren't the grand cost saving ideas being implemented unilaterally by the government? This is, of course, a rhetorical question. But, seriously, the government is already so deep into health care that they can't simply attempt to place the 'blame' on insurers that are already heavily regulated.

"If you make a profit, how can you claim your costs are too high?"

Anthem is claiming that the costs of insuring Californians is much higher in 2010 than 2009 and 2008. They are simply stating what they estimate costs will be. Customers and government officials are saying the cost is "too high."

In addition, costs and profit are only two variables. The third is revenue or premium and it is very possible for a service or product to be 'too expensive' and also profitable.

"Moreover, having this question come up all the time undermines the public trust. At minimum, there's a serious conflict of interest going on here."

All business profits are paid for by their customers. How is this any different than any other business? You may not like corporations or profits, but labeling it a conflict of interest is inaccurate.

"Is there something complicated about this? Profit means taking something out of the business system and returning it to the investors as unnecessary to the operation of business. Rate increases are a way of saying that your present income is not adequate to maintain the current operation of business. These two are just incompatible."

The way to think about health insurance is to view it as a system that primarily performs administrative functions, charges for them, and passes through its costs to its customers. It is primarily a "cost plus" model. Over half of their insureds are covered explicitly based on "cost plus." The remainder's premiums are based on estimates of costs which tend to be reasonably accurate. There are no hurricanes or earthquakes -- the estimates are likely to be accurate within a couple of percent.

Nick, the reasons health care costs so much in this country, whether that cost is borne by individuals or by the government, go way beyond insurance companies. The insurance companies are parasites whose disappearance wouldn't be mourned, but it's the entire for-profit medical/industrial complex which needs to be systematically changed. We spend 17% of GDP on health care, and that's projected to hit 25% in a relatively few years. It's simply not sustainable.

The bottom line, for me at least, is that we need a health care system which is geared towards providing people with health care, as opposed to one which is geared towards maximizing profit. We've tried the for-profit system, and it's a fucking mess. We need to try something else, and we need to give all Americans access to decent health care, period. Canada, the UK, Australia, and other Western countries extend health care to all their citizens; why can't we? I'm not being facetious when I ask that; you're a numbers guy, I'm not, so I'm interested to hear your take on it.

Great post! Every year the insurers lower their payments to me! This year there was a 36 percent reduction in reimbursement for nuclear stress test exams. But the same insurers that are loweing doctor's payments are raising their own premiums! Where the hell is the money going to? I can tell you its not going to the decent docs out therer
Big pharma
Administrative cost
Big hospitals

Have a look at my latest Blog and let me know what you think

Nick, I only have a few minutes just now and not time to do a detailed reply. I appreciate your going through all of that. Curiously, though you don't realize it, you basically made my case.

(Probably the reason you don't realize it is that I've not made my case as clearly as I might. I had another pending post on a related matter that I didn't see so clearly as related until you wrote this, so I thank you for that.)

I started to reply to you directly here but ended up cutting&pasting them into a file of notes about what would go into a separate post on the matter because I don't want it to get lost.

Open Salon probably won't feature that post on the cover either, but I'll try to remember to send you mail so that you, at least, can come read it. The others who have read your reply and think that perhaps it's not getting answered will have to fend for themselves finding what I write later.

I'm so tired of writing things not to be seen. I've really got to find somewhere else to write that bothers to feature these things. Health care is a mess, and Open Salon wants us to respond to bake sales to help its employees, and it doesn't see its responsibility to feature discussion of these serious matters. Instead it's got a cover full of fluff while people it purports to care about are, quite literally, dying around it for reasons that it could be taking a stand about.

@nanatehay -- Seems like once we get beyond a few surface differences, we are in agreement. Especially regarding the over riding question -- provide universal (or close to it) care, at high enough quality, for a reasonable chunk of the GNP. Right now, it is sort of like a balloon, in that as soon as you apply pressure to one part, the others move. I have some ideas -- one of which is that anything that significantly upsets the current equilibrium has a pretty good chance of improving things. That is either an informed hunch or wishful thinking -- and I prefer to think it is the former. I will think more about this.

@Kent:

"I'm so tired of writing things not to be seen. I've really got to find somewhere else to write that bothers to feature these things."

Just one suggestion. You are trying to make an extended, detailed argument about something that is exceedingly complex. I think the OS blog format isn't the best approach. There is an inherent limitation to the linear nature of the medium.

You are forced to lay out your case in more or less the same fashion as the main stream media -- in a long column. But you don't even have the advantage of providing graphics adjacent to your column.

On the other hand, the web gives you the ability to hyperlink and potentially develop dialogue in a multi threaded structure.

This is just a thought -- It doesn't really address your complaint. However, if you really want traction, you have to do better than the New York Times. I would suggest that it is unlikely unless you adopt structures that they haven't come close to perfecting.

Re -- the bake sale. I have something coming out very soon on that. It is pathetic in a sense, although people's motives are the best. As usual, we are racing to hell on good motives.

Nick, I don't think graphics are really the issue. I can include small graphics here and if I thought it necessary, I could hyperlink offsite as I've done in some other pieces. I have my own web site and can provide auxiliary documentation where required. I'm here in spite of limitations because it has the potential (often unrealized because of editorial disinterest) of reaching an audience that I cannot easily reach from my own site. My real barrier here is people's attention spans, although the reason I don't mind confronting that is that that's a real barrier. So I'm aware I'm chunking up something that needs to be more coherently presented. And the focus on trying to find pithy ways to bring across what can be said more long-form can't really hurt me.

I regard what I do here as a public conversation toward perhaps a different ultimate end. But nonetheless, a lot of that conversation is specifically tied to events of the day, and even within the limitations of the venue, I should be able to do better if I could only get some visibility. My pieces seem to have good resonance with the peopel who find them, but the hard part is them finding them. I have limited time for banging my head against the wall. I write based on a theory it might get seen, and they select based on a theory that I'll just keep writing even if they don't bother to care. I value my work more than to put up with that over the long haul. I'd rather invest in something that's going to care about me personally and the serious work I'm trying to do.

I didn't pick this place at random. It didn't used to be a tabloid recipe site. If it had been, I'd never have bothered in the first place. It seems to be deliberate drift from what it used to be, and I think that's s shame.

"The ordinary argument for the free market is that it achieves certain efficiencies better than the government would."

Herein lies one of the most pernicious lies of this whole discussion.
THERE IS NO SUCH THING AS A FREE MARKET. Sorry, I dont know how to make the fonts bold in a comment, so I have to use caps.

Markets only exist within government regulation. No, regulation, no safe market to play in. No regulation looks a lot like Somalia where you risk your life to acquire a loaf of bread because there is no government, and therefore they have the freest of markets! But here in the US, the free market does not exist nor would anyone want it to if it meant they could expect to get raped going out for firewood.

So then the argument needs to be reframed as to why does the government (read "you, me and everyone else who is a citizen") HAVE TO allow for profit companies whose model is to rape us on the way to acquire basic necessities of survival? The answer is they dont ~ Medicare for all would fix that ~ but they do allow health insurance because someone yells "I want my free market" if the govt tries to take away their ability to profit from the suffering of real people.

Sorry for the rant, and if I'm off your topic Kent, I apologize. But as someone who makes their living in insurance (not health) I just dont understand why we allow health insurance companies to exist, at least for the basic neccessities tier of health care. We need something that looks like Switzerland or Germany rather than Somalia.

the system allows this kind of behavior. you don't like this behavior. but you won't change the system.

you have no notion of what to do, or are keeping it a secret. i presume your outrage is real but until you have a suggestion of action, it's just futile.

Tim, regarding the notion of needing at least some regulation even in a so-called free market, see my article Medical Care and the Free-Market Catch-22. As to your other point, I think I'll partly cover that in the response I said I'd do to Nick, which will come in a separate post. But these are some good points—thanks.

al, I'd like single-payer universal health care. "Medicare for all" if you like. I'd bargain down to the public option as an interim approach. I've also made some more modest suggestions. But if you're speaking about the Congress and not me personally, yeah, they're moving slowly. The Republicans are determined to hold things up and the Democrats are confused about how to get past that, perhaps because they're under the mistaken notion that politeness is appropriate here.

Remember, the cost of the the insurance industry is only one side of the coin. The other side is the cost that hospitals and clinics incur from having to deal with literally thousands of different insurance companies and plans.

At the hospital where I used to work the patient accounts office had around 100 employees. There was also a contracting office whose staff managed the insurance contracts. There were also analysts and accountants in the financial office that reported on the contracts -- my particular job.

And then there was the "charge description master." This is a computer file containing information on all the line items that the hospital charged. This contained around 60,000 line items, all of which had to be maintained, with rates set for each individual item.

And on top of all that were literally hundreds of hospital employees who were involved in generating patient charges, either on paper forms that had to be hand-entered into the patient accounting system, or computer-generated charges. Every year the hospital generated over 3 million line item charges.

Multiply all of the above by all the hospitals and clinics in the country and you get some idea of the cost of the current process.

So anything, such as single payor, that simplifies processes and reduces cost on the insurance side also simplifies processes and reduces cost on the hospital side.

The problem is that all of this billing and payment activity is non-value-added with respect to providing medical care. While it is never possible to eliminate non-value-added activity the common sense thing is to reduce it as much as possible. Instead of that it seems that many of our "leaders" have chosen to nourish and protect it.

Mishima, thanks for adding that bit of perspective!

My apologies if some of you have already read my posts on this subject, but others may find it interesting:

Let's compare Public and Private health care costs, eh? (This one is an eye opener.)

Let's Spread the Risk! (I mean Health care; Not Flu.)

Expensive health care is not always the best health care

The last one shows that we are on the verge of bankruptcy (second update).

Great post, BTW!

Kanuck, thanks for sharing the links. :)

My rates by Blue Cross just went up by that exact 39% or they offered me a new "deal" whereby I would start a new plan with a deductible of $3500, or if one counts correctly, $7000, since it would be $3500 for me and $3500 for my child.

I hate them and wish them to all burn in hell presently. I'm sure that'll pass and I'll only hate them and think them horrifically evil, without wishing them to hell, as I'm not the violent type, but they make me sick.

And anyone who supports them makes me sick, too. I'm really tired of my "fellow" Americans who are either too selfish, too stupid, or too mean and support these monsters.

Odette, I'm not kidding when I say that's a pretty measured way of expressing what is certainly an appropriate degree of ire over an insufferable situation. Thanks for chiming in.