Several comments on past experiences. I’m a mental health professional. Different insurers limit reimbursement for my services and limit patient co-pays. I’m often paid half or less of what is considered a reasonable fee. I’m not sure that I make as much per year as plumbers and electricians. I could be wrong. I don’t have the data. We have a severe shortage of physicians, over 30,000 I have been told by a doctor. Insurers now cause problems by requiring authorization. I sat one afternoon and talked with my doctor, and he had some horror stories. He ordered a stress test for a patient (He was an internal medicine specialist.). It was denied. He added one word-angina- which the patient hadn’t experienced. The stress test was authorized. The patient had blockages in coronary arteries. He ordered an MRI and it was denied. The patient had to have physical therapy first. “You don’t understand. He can barely walk.” Can I talk to your physician. The MRI was still denied. My neurosurgeon told my wife he was reimbursed less than she paid a Veteranarian for a knee surgery on one of our dogs. I’m sure I will be challenged on some of this because this is all anecdotal and not based on data. I can’t comment on insurance premiums because I have Medicare and Tricare for Life. I pay the standard monthly amount on my Medicare, Part B. I never see it until I get my yearly statement. Hospital costs are very high. Equipment and instruments are expensive and medicines are ridiculously high. Many physicians spend little time with patients. Often I prefer a nurse practitioner because they spend more time and use the best tool in medicine- their ears. You point out accurately that developing a plan is a very complex process and could take years. I’m glad a think tank is working on it rather than members of the House or Senate.
I don't consider myself anti-capitalism in general, but the only thing a for-profit healthcare system does well is maximize the incentives for predatory insurance practices. I've lived with a serious, disabling disease since my late teens. I've had nearly two dozen surgeries. When it was well managed, I was able to earn a PhD, marry, and raise two children. And though It was tough at times, I was able to work full-time at a career I loved well into my 40s, before multiple setbacks forced me onto the disability rolls. I've dealt with medical care in all kinds of settings, including military bases (spouse was a career officer), and all kinds of insurance plans in eight different states. And it's always been a very rare luxury to go a week without making multiple phone calls about medical bills and insurance delays and denials. Up until the ACA passed, "deny first and hope the patient doesn't call in to argue" was extremely common insurance company behavior. The last 18 months or so, it's on the rise again. And it is a grossly unethical, inhumane attack on exactly those least able to fight back--our sick and elderly (as well as a major pain in the ass even for healthier folks).
My specialist spent this entire past year arguing with my insurance to get me on a new, promising medication. Insurance denied it, classifying it as experimental--even though the FDA had approved it's use specifically for my disease several months before the first request. During the year that bureaucratic war waged, I had two weeks-long hospitalizations that then necessitated follow-up in-home nursing and PT visits. My insurance, I guess, was hoping to save a few thousand bucks by denying the medication but ended up paying astronomically more. My health is worse off (though I'm starting to get stronger again), my husband and adult children have all taken time off work and endured major stress, and my community volunteer work mostly had to stop. None of this is a positive for anyone involved. And I have "good" insurance coverage compared to most Americans.
I know the introduction of Medicare-for-all will not miraculously cure me. And I can't say I'd have been able to work longer, been a more "productive" citizen--in that very American sense-- for longer, if it had been in place back when I was first diagnosed. But no one deserves to have their life derailed--or life itself threatened--because an insurance company says no.
Unless and until Medicare coverage is offered to everyone, nothing will change. The insurance companies are the problem and their lawyers, actuaries and accountants will always find a way to maximize profit. If the private sector is able to offer a better product at a better price, then let them prove it. But they will absolutely never try unless they have no other choice.
Nobody (with the exception of Bernie) is addressing the real problem here. Health care is a public good, more like roads and bridges, police and fire; you don't shop for health care in the middle of a myocardial infarction and even if you could, for something like a hip replacement, no one can tell you what it costs.
To bring down costs, the first thing to do is get rid of the middlemen who suck out 30% of our health care dollar for administration and profit.
Second, bar private equity from owning providers. Their track record shows they monopolize hospital systems and nursing homes, cut costs to the bone, jack up prices, and provide lousy service. They took over 70% of Colorado's anesthesiology practices until the AG sued. You can read about it here:
All the granular and broad details and debates boil down to the same ethical question: is healthcare a basic human right? Or not. Until that question has been definitively answered, we'll be forever waffling and wavering. The public good vs the private insurance industry.
I’m sorry but no. Not enough by much. The health of a human being does not have a value that varies with the market place. The very idea is obscene! I also disagree vigorously with the idea that expanding healthcare coverage has to take a back seat to goals focused solely on cost. The shift gives Republicans more time to beat us over the head about costs as they take more and more coverage away from the neediest of people. In other words, this whole discussion is meant to take our attention away from the real issue, that affordable healthcare is a human right and not subject to the vicissitudes of the market already rigged against patients in favor of return on investment.
Thanks Jonathan. It’s people like you folks and others who are willing to work together, no matter some of the politics, for the good of everyone. It gives all of us a positive vibe
Recently I heard Heather Cox Richardson say she would never have thought she would be on the same team as Bill Kristol
Am I the only one that sees INSURANCE as an entity not to be given political power. We can live without the politicians that can't live without the insurance lobby.
I’m for two things: improving medical results AND paying for the care. To the extent the government, at some level, needs to chip in to help pay for services, taxes need to be increased. Anyone that thinks taxing only the “rich” will be enough is simply wrong. I’m happy to pay higher taxes. You should be too.
There are no easy fixes to healthcare because the more you regulate often times the worse the unintended consequences are. Health insurance since the ACA have become too standardized. Some ideas that could help fix healthcare (some agreement with the views of CAP) are:
1. Get rid of prior-authorizations and insurance reviews of treatments and medications except in major healthcare decisions like surgeries.
2. Allow the FDA or some medical board like it to force insurances to cover new technologies when they are deemed safe and beneficial. Too often an insurance company will know a new technology is optimal but will delay covering it for a year or two waiting for others to cover it.
3. Force insurance companies to cover 50+% of a drug cost to consider the drug as covered. Having a drug covered by insurance meant it was almost paid for. Now when a doctor pushes for a drug that isn’t covered to be covered an insurance company will agree to cover it only to find out it’s a minimal discount so it’s not really covered.
4. Turn medical insurance more like car insurance. Don’t do periods of open enrollment or restrict that open-enrollment to people getting subsidies. People should be able to buy a plan whenever they want and switch coverage when they aren’t being subsidized.
5. And like car insurance allow people to cover the services they want. Drop the essential list of benefits back down to 5 instead of 10. If you want mental health, physical rehab, substance abuse, etc then add the benefits the same way you can with auto insurance. Allow premium and deductible adjustments where lowering one raises the other. Allow those large network plans companies like Anthem had prior to the ACA kicking in.
The reality is healthcare can’t be fixed because the opposite sides won’t agree to fix the parts they agree on. They always want huge reforms not to admit reality.
Republicans need to understand that healthcare is a necessity for virtually everyone and a free market system is not possible because if we did that we would have to deny care in the ER or jail/tax lien people that couldn’t pay. That’s not America.
By contrast, Democrats need to adjust to reality and understand that the ACA no matter how well intentioned has severely narrowed networks and raised deductibles and premiums. Universal healthcare like Canada or UK is a non-starter in a country as populated and expansive as the US.
When Democrats take power and inch toward reform like this CAP proposal they still suffer the political costs of being labeled socialists. The republicans called the ACA socialism. They’ll call anything socialism. Democrats need to be bold and advocate for single payer, the only meaningful solution to this problem. The republicans will attack them no matter what, so they may as well go all the way and deliver the transformative change the voters actually want. Or at least put up a good fight. The republicans don’t split the difference. They pass massive tax cuts for the rich, drastically cut social programs to pay for it, reshape the judiciary and gut regulations. They do all this with thin majorities, often with no bipartisan support. And they do it fast, before the democrats can organize against them. Democrats need to take a page from the republicans and fight like hell for the policies they claim to believe in. I’m beginning to wonder if democrats really understand politics.
These guys secret sauce is proposing policies that change little and nothing. We need a public option and system, not yet another survival kit for health insurance for profit. It doesn't work.
Well, I guess it is the adult thing to do. Acknowledge reality, and proceed with the modest gains that will be possible from small changes.
And, acknowledging the lack of social solidarity in the country, so going for changes that will affect most of the people--those with an employer plan or a Medicare Advantage--right now. (No use, as well, relying on people understanding that their employer insurance is for them, for now, but at some later time, the only possibility of coverage might be ACA coverage without the expanded subsidies, at a cost of $40,000 a year, as it is, right now without the expanded subsidies, in Wyoming, for a couple aged 62, with an income of $88,000 a year. (For the cheapest plan, with a $20,000 out-of-pocket max.)
We've seen this sort of thing before, with the ACA, passed in 2010. A very modest, politically- realistic plan, designed to not upset any of those with too little social solidarity to risk giving up their employer plans. And not to anger the politically powerful insurance industry or any other powerful special interest group.
The ACA "family glitch" has been fixed, but otherwise, at the moment, we are a bit worse off than at the outset. (Because of, if nothing else, the work requirements and verification entanglements from OBBB. Yes, the sixteen year war.) Other problems, such as excessive copays, and a Medicaid estate recovery on some of the expanded Medicaid (see https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing) that were part of the ACA since its inception have not been fixed.
Several comments on past experiences. I’m a mental health professional. Different insurers limit reimbursement for my services and limit patient co-pays. I’m often paid half or less of what is considered a reasonable fee. I’m not sure that I make as much per year as plumbers and electricians. I could be wrong. I don’t have the data. We have a severe shortage of physicians, over 30,000 I have been told by a doctor. Insurers now cause problems by requiring authorization. I sat one afternoon and talked with my doctor, and he had some horror stories. He ordered a stress test for a patient (He was an internal medicine specialist.). It was denied. He added one word-angina- which the patient hadn’t experienced. The stress test was authorized. The patient had blockages in coronary arteries. He ordered an MRI and it was denied. The patient had to have physical therapy first. “You don’t understand. He can barely walk.” Can I talk to your physician. The MRI was still denied. My neurosurgeon told my wife he was reimbursed less than she paid a Veteranarian for a knee surgery on one of our dogs. I’m sure I will be challenged on some of this because this is all anecdotal and not based on data. I can’t comment on insurance premiums because I have Medicare and Tricare for Life. I pay the standard monthly amount on my Medicare, Part B. I never see it until I get my yearly statement. Hospital costs are very high. Equipment and instruments are expensive and medicines are ridiculously high. Many physicians spend little time with patients. Often I prefer a nurse practitioner because they spend more time and use the best tool in medicine- their ears. You point out accurately that developing a plan is a very complex process and could take years. I’m glad a think tank is working on it rather than members of the House or Senate.
This is very exciting. But don’t forget about drug prices. A migraine medication I pay $200-$300 (for 8 tablets) at home in Canada is $900-$1200 here.
That’s crazy! Thank goodness my husband was going home for a few days and was able to bring some back to Florida.
I don't consider myself anti-capitalism in general, but the only thing a for-profit healthcare system does well is maximize the incentives for predatory insurance practices. I've lived with a serious, disabling disease since my late teens. I've had nearly two dozen surgeries. When it was well managed, I was able to earn a PhD, marry, and raise two children. And though It was tough at times, I was able to work full-time at a career I loved well into my 40s, before multiple setbacks forced me onto the disability rolls. I've dealt with medical care in all kinds of settings, including military bases (spouse was a career officer), and all kinds of insurance plans in eight different states. And it's always been a very rare luxury to go a week without making multiple phone calls about medical bills and insurance delays and denials. Up until the ACA passed, "deny first and hope the patient doesn't call in to argue" was extremely common insurance company behavior. The last 18 months or so, it's on the rise again. And it is a grossly unethical, inhumane attack on exactly those least able to fight back--our sick and elderly (as well as a major pain in the ass even for healthier folks).
My specialist spent this entire past year arguing with my insurance to get me on a new, promising medication. Insurance denied it, classifying it as experimental--even though the FDA had approved it's use specifically for my disease several months before the first request. During the year that bureaucratic war waged, I had two weeks-long hospitalizations that then necessitated follow-up in-home nursing and PT visits. My insurance, I guess, was hoping to save a few thousand bucks by denying the medication but ended up paying astronomically more. My health is worse off (though I'm starting to get stronger again), my husband and adult children have all taken time off work and endured major stress, and my community volunteer work mostly had to stop. None of this is a positive for anyone involved. And I have "good" insurance coverage compared to most Americans.
I know the introduction of Medicare-for-all will not miraculously cure me. And I can't say I'd have been able to work longer, been a more "productive" citizen--in that very American sense-- for longer, if it had been in place back when I was first diagnosed. But no one deserves to have their life derailed--or life itself threatened--because an insurance company says no.
Unless and until Medicare coverage is offered to everyone, nothing will change. The insurance companies are the problem and their lawyers, actuaries and accountants will always find a way to maximize profit. If the private sector is able to offer a better product at a better price, then let them prove it. But they will absolutely never try unless they have no other choice.
Nobody (with the exception of Bernie) is addressing the real problem here. Health care is a public good, more like roads and bridges, police and fire; you don't shop for health care in the middle of a myocardial infarction and even if you could, for something like a hip replacement, no one can tell you what it costs.
To bring down costs, the first thing to do is get rid of the middlemen who suck out 30% of our health care dollar for administration and profit.
Second, bar private equity from owning providers. Their track record shows they monopolize hospital systems and nursing homes, cut costs to the bone, jack up prices, and provide lousy service. They took over 70% of Colorado's anesthesiology practices until the AG sued. You can read about it here:
https://www.dmagazine.com/healthcare-business/2025/01/why-colorado-broke-up-this-dallas-anesthesia-groups-monopoly/
All the granular and broad details and debates boil down to the same ethical question: is healthcare a basic human right? Or not. Until that question has been definitively answered, we'll be forever waffling and wavering. The public good vs the private insurance industry.
I’m sorry but no. Not enough by much. The health of a human being does not have a value that varies with the market place. The very idea is obscene! I also disagree vigorously with the idea that expanding healthcare coverage has to take a back seat to goals focused solely on cost. The shift gives Republicans more time to beat us over the head about costs as they take more and more coverage away from the neediest of people. In other words, this whole discussion is meant to take our attention away from the real issue, that affordable healthcare is a human right and not subject to the vicissitudes of the market already rigged against patients in favor of return on investment.
MEDICARE FOR ALL!!! NOW!
Thanks Jonathan. It’s people like you folks and others who are willing to work together, no matter some of the politics, for the good of everyone. It gives all of us a positive vibe
Recently I heard Heather Cox Richardson say she would never have thought she would be on the same team as Bill Kristol
Am I the only one that sees INSURANCE as an entity not to be given political power. We can live without the politicians that can't live without the insurance lobby.
I’m for two things: improving medical results AND paying for the care. To the extent the government, at some level, needs to chip in to help pay for services, taxes need to be increased. Anyone that thinks taxing only the “rich” will be enough is simply wrong. I’m happy to pay higher taxes. You should be too.
There are no easy fixes to healthcare because the more you regulate often times the worse the unintended consequences are. Health insurance since the ACA have become too standardized. Some ideas that could help fix healthcare (some agreement with the views of CAP) are:
1. Get rid of prior-authorizations and insurance reviews of treatments and medications except in major healthcare decisions like surgeries.
2. Allow the FDA or some medical board like it to force insurances to cover new technologies when they are deemed safe and beneficial. Too often an insurance company will know a new technology is optimal but will delay covering it for a year or two waiting for others to cover it.
3. Force insurance companies to cover 50+% of a drug cost to consider the drug as covered. Having a drug covered by insurance meant it was almost paid for. Now when a doctor pushes for a drug that isn’t covered to be covered an insurance company will agree to cover it only to find out it’s a minimal discount so it’s not really covered.
4. Turn medical insurance more like car insurance. Don’t do periods of open enrollment or restrict that open-enrollment to people getting subsidies. People should be able to buy a plan whenever they want and switch coverage when they aren’t being subsidized.
5. And like car insurance allow people to cover the services they want. Drop the essential list of benefits back down to 5 instead of 10. If you want mental health, physical rehab, substance abuse, etc then add the benefits the same way you can with auto insurance. Allow premium and deductible adjustments where lowering one raises the other. Allow those large network plans companies like Anthem had prior to the ACA kicking in.
The reality is healthcare can’t be fixed because the opposite sides won’t agree to fix the parts they agree on. They always want huge reforms not to admit reality.
Republicans need to understand that healthcare is a necessity for virtually everyone and a free market system is not possible because if we did that we would have to deny care in the ER or jail/tax lien people that couldn’t pay. That’s not America.
By contrast, Democrats need to adjust to reality and understand that the ACA no matter how well intentioned has severely narrowed networks and raised deductibles and premiums. Universal healthcare like Canada or UK is a non-starter in a country as populated and expansive as the US.
Sounds like the start of a good plan. Thanks for the report!
Thanks for digging into these issues and reporting!
When Democrats take power and inch toward reform like this CAP proposal they still suffer the political costs of being labeled socialists. The republicans called the ACA socialism. They’ll call anything socialism. Democrats need to be bold and advocate for single payer, the only meaningful solution to this problem. The republicans will attack them no matter what, so they may as well go all the way and deliver the transformative change the voters actually want. Or at least put up a good fight. The republicans don’t split the difference. They pass massive tax cuts for the rich, drastically cut social programs to pay for it, reshape the judiciary and gut regulations. They do all this with thin majorities, often with no bipartisan support. And they do it fast, before the democrats can organize against them. Democrats need to take a page from the republicans and fight like hell for the policies they claim to believe in. I’m beginning to wonder if democrats really understand politics.
but wait. Won't trump be announcing the best health care plan ever in two weeks?
These guys secret sauce is proposing policies that change little and nothing. We need a public option and system, not yet another survival kit for health insurance for profit. It doesn't work.
Well, I guess it is the adult thing to do. Acknowledge reality, and proceed with the modest gains that will be possible from small changes.
And, acknowledging the lack of social solidarity in the country, so going for changes that will affect most of the people--those with an employer plan or a Medicare Advantage--right now. (No use, as well, relying on people understanding that their employer insurance is for them, for now, but at some later time, the only possibility of coverage might be ACA coverage without the expanded subsidies, at a cost of $40,000 a year, as it is, right now without the expanded subsidies, in Wyoming, for a couple aged 62, with an income of $88,000 a year. (For the cheapest plan, with a $20,000 out-of-pocket max.)
We've seen this sort of thing before, with the ACA, passed in 2010. A very modest, politically- realistic plan, designed to not upset any of those with too little social solidarity to risk giving up their employer plans. And not to anger the politically powerful insurance industry or any other powerful special interest group.
The ACA "family glitch" has been fixed, but otherwise, at the moment, we are a bit worse off than at the outset. (Because of, if nothing else, the work requirements and verification entanglements from OBBB. Yes, the sixteen year war.) Other problems, such as excessive copays, and a Medicaid estate recovery on some of the expanded Medicaid (see https://normspier828307.substack.com/p/an-affordable-care-act-defect-needing) that were part of the ACA since its inception have not been fixed.
Very, very, slow. It's very, very, frustrating to proceed so slowly. Without even a chance of some kind of universal nursing-home insurance coverage, like many other developed countries have (see https://normspier828307.substack.com/p/paying-for-nursing-homes-and-long .)
But, I guess it is the adult thing to do!