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Old 07-26-2014, 09:47 AM   #141
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I agree with what you say f the state wants to work with the Fed. I suspect they can fairly easily work around the problem in that case. I think that may apply to about 1/3, maybe even 1/2, of the states not operating their own exchanges. The rest will laugh as the subsidies disappear. They don't want the Feds paying for Medicaid, they won't want them paying for subsidies. And along with the subsidies would go employer mandates and penalties. Those blows to Obamacare will be irresistible to states that strongly object to it. We already have health care have and have not states -- if sustained, the DC Circuit analysis would make that an order of magnitude worse.
The huge flaw to this argument is that it was easy for the politically polarized states to reject Medicaid expansion because it was a new benefit that no one was getting. Now that everyone is getting subsidies it is a big stretch to say that it would be just as easy to take something away that has already been provided.

This is just a bump in the road for the ACA, IMO - the ship has sailed just as it did for Social Security and Medicare. Even if it goes to the Supremes I can't see them taking away the underpinning of the law a few years after doing the questionable 'tax' interpretation to make sure it stood in place. Chief Justice Roberts isn't going anywhere anytime soon, and he was the swing vote in the 2012 decision.
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Old 07-26-2014, 11:06 AM   #142
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I do feel that the mark was missed in this area in getting the word out. There was a lot of information and self education required in understanding the new healthcare bill, and I'm afraid many were not up to the task.
This has been the most widely and thoroughly discussed legislation in my lifetime. The internet makes information "pull" easier than it has ever been. 1-800 numbers and on-call assistance allow information to be provided to people who will not use the internet. If there's a failure of people to understand this law it is not due to "failure to get the word out", it is because of some combination of 1) failure of some people to make an effort to educate themselves and/or 2) the system is not readily understandable
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Old 07-26-2014, 11:31 AM   #143
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GTFan: This is just a bump in the road for the ACA, IMO - the ship has sailed just as it did for Social Security and Medicare. Even if it goes to the Supremes
Exactly. Congress can change the law, making it non-ambiguous. Then, the issue is resolved. The Judges did the right thing. If the law is not 100% clear, it goes to the least restrictive interpretation.

What might be a problem is getting a Dr Appointment at some time. The VA is not the only one that will have a shortage of Doctors.

To lessen the shortage, we could open up many more medical schools, and give free education to anyone that want to be a Dr. It really doesn't take that much knowledge to be a doctor for a specific area, it's the long hurdle getting to that point makes it tough.

Do we really need that much education to pull out a set of tonsils? Most operations could be handled by a much lower level nurse, rather than a Dr. Maybe even a robot.
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Old 07-26-2014, 05:57 PM   #144
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This has been the most widely and thoroughly discussed legislation in my lifetime. The internet makes information "pull" easier than it has ever been. 1-800 numbers and on-call assistance allow information to be provided to people who will not use the internet. If there's a failure of people to understand this law it is not due to "failure to get the word out", it is because of some combination of 1) failure of some people to make an effort to educate themselves and/or 2) the system is not readily understandable
Actually Samclem. I disagree. Most people were aware that the bill afforded a premium subsidy to lower income folks. However, the cost sharing subsidy was not widely spoken of, and there were not a lot of sites that explained it in full detail that was understandable, nor a lot of media coverage about it specifically.

As for the ease of using those 800 numbers, I don't know what state you hail from, but where I was involved in helping someone get information and signed up and calling an 800 number, I was put on hold for hours. Tried three times, same problem. Got a recording stating that someone could get back to me in a couple of days ( never did) When I finally did make contact, I was told they could not give me any numbers until I completed application and all numbers were submitted on my end. So easy - NO, and I am one persistent puppy who doesn't have to go to work.

I will agree with you on one point. There were also a number of people who didn't care enough to get the information. What percentage they represented, I couldn't say.
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Old 07-26-2014, 07:34 PM   #145
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I think there are a lot of people who have no idea about how to start with all of the details. Just because the information is available doesn't mean that many have the skills/knowledge of how to use it.
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Old 07-26-2014, 07:48 PM   #146
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I have no idea why healthcare is so expensive anyway. In 2007, DS had a plate put in with 6 screws. It was all made of titanium. We were billed ~$180/screw. I forget what the plate cost--probably a whole lot more. Current price for titanium is $6.10/100 gm. For a < 1 gm gm screw that is about 5 cents raw material. It's a fricken screw, for God's sake!. Anyway, we/insurance (about 50/50) paid not only $180 per screw but also $180 per drill bit, one for each screw hole.
...
They gave us the plate--a tiny thing, and the screws. The whole thing weighs 6 gm. So we paid over a thousand dollars for 30 cents of material, molded in a simple plate, and autoclaved for sterility.

This is a ripoff. The hospital and the supplier got to keep the extra ridiculous amount of money. The doctors get paid their fee--also too high IMHO. I am a doctor. Pediatricians charge about $70 for an outpatient visit, more for check-ups.
Do you have a "hard time" understanding why a car windshield - composed primarily of sand, which costs a whopping $.06/lb - costs hundreds of dollars?

Do you have a hard time understanding why a microprocessor costs hundreds of dollars, yet is only composed of raw materials that costs a few bucks?

Perhaps you have found a new business opportunity. Simply manufacture titanium plates and screws with a press in your garage in your spare time, and you'll be able to make a mint!
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Old 07-26-2014, 09:15 PM   #147
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Do you have a "hard time" understanding why a car windshield - composed primarily of sand, which costs a whopping $.06/lb - costs hundreds of dollars?

Do you have a hard time understanding why a microprocessor costs hundreds of dollars, yet is only composed of raw materials that costs a few bucks?

Perhaps you have found a new business opportunity. Simply manufacture titanium plates and screws with a press in your garage in your spare time, and you'll be able to make a mint!
+1

Similar thing for drugs. Why does a wonder drug that only costs $3 in chemicals to manufacture cost tens of thousands of dollars?

Why not make the cure yourself then? Ignore the fact that 10,000 compounds fail for every one that gets approved...
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Old 07-26-2014, 09:23 PM   #148
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+1

Similar thing for drugs. Why does a wonder drug that only costs $3 in chemicals to manufacture cost tens of thousands of dollars?

Why not make the cure yourself then? Ignore the fact that 10,000 compounds fail for every one that gets approved...

I'm pretty much take your side of the argument, but it does burn me to see prices of meds for the same product/manufacturer way more expensive in US, than in other countries. That seems a bit like a racket to me. Fortunately I am on no meds so I guess it shouldn't bother me... Until I have to pay for it, then I guess I will hunt out of country for it and hope for the best it is not a chalk/arsenic compound.


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Old 07-26-2014, 09:53 PM   #149
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I'm pretty much take your side of the argument, but it does burn me to see prices of meds for the same product/manufacturer way more expensive in US, than in other countries. That seems a bit like a racket to me. Fortunately I am on no meds so I guess it shouldn't bother me... Until I have to pay for it, then I guess I will hunt out of country for it and hope for the best it is not a chalk/arsenic compound.


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Well there are a few reasons for that. One is there are some countries (India for example) which just do not have the resources to pay for a wonder cure for their significant population. If you totally price them out of the drug there is a good chance they will declare your patent invalid and start manufacturing the drug for their people. Technically then the world trade organization should sanction that country but this would be hard to get approved. Easier to offer the drug to a country based on the ability of the government/population to pay. In essence it is subsidized healthcare on a worldwide scale.
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Old 07-26-2014, 10:59 PM   #150
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....Easier to offer the drug to a country based on the ability of the government/population to pay. ...
What about our ability to pay? And also that US taxpayers end up subsidizing the pharmaceuticals in that they get tax deductions for their R&D costs.
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Old 07-26-2014, 11:23 PM   #151
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What about our ability to pay? And also that US taxpayers end up subsidizing the pharmaceuticals in that they get tax deductions for their R&D costs.
Is getting tax deductions for R&D that unusual in other industries?

As far as our ability to pay, USA, Canada, Europe, Japan, Australia have a much higher level of wealth per citizen than most third world countries. We think nothing of paying $5 for a latte when that can buy a week's worth of food in other countries.

Investors poured nearly a billion dollars into drug maker Affymax and it is going bankrupt after it's FDA approved drug caused fatal reactions in some patients. Investors might get back about $0.08 to $0.10 a share. This is just one example. A profitable drug coming to market is such a rare event, it has to be priced at a level to make up for all of this failed research or investors will not be willing to spend those billions on Affys. What you get then is very few new drugs.
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Old 07-27-2014, 07:38 AM   #152
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You're totally missing the point. As I understand it certain drugs are much less even in Canada and their ability to pay is no different from ours. US consumers get gouged by the drug companies.

While R&D deductions are available in other industries, that doesn't have anything to do with the point. The point is that since the drug company gets a tax benefit for the cost of US R&D in effect US taxpayers end up subsidizing the development of these drugs and then the drug companies turn around and sell them ate preferential prices abroad.

I would like to see the playing filed leveled more and pricing be consistent worldwide. In today's world economy, US consumers and taxpayers shouldn't be subsidizing the exportation of drugs outside the US.
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Old 07-27-2014, 08:19 AM   #153
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You're totally missing the point. As I understand it certain drugs are much less even in Canada and their ability to pay is no different from ours. US consumers get gouged by the drug companies.

While R&D deductions are available in other industries, that doesn't have anything to do with the point. The point is that since the drug company gets a tax benefit for the cost of US R&D in effect US taxpayers end up subsidizing the development of these drugs and then the drug companies turn around and sell them ate preferential prices abroad.

I would like to see the playing filed leveled more and pricing be consistent worldwide. In today's world economy, US consumers and taxpayers shouldn't be subsidizing the exportation of drugs outside the US.
In today's world economy, US consumers pay much less per gallon of gasoline than Canadians. Would you like to see that playing field leveled and pay $6 a gallon (or even $9 a gallon as in Europe?). Prices are different in different countries due to regulations and other factors. Deal with it.
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Old 07-27-2014, 08:24 AM   #154
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Do you have a "hard time" understanding why a car windshield - composed primarily of sand, which costs a whopping $.06/lb - costs hundreds of dollars?

Do you have a hard time understanding why a microprocessor costs hundreds of dollars, yet is only composed of raw materials that costs a few bucks?

Perhaps you have found a new business opportunity. Simply manufacture titanium plates and screws with a press in your garage in your spare time, and you'll be able to make a mint!
I would call this a false choice argument. The two choices are not sell for the cost of materials or for an exorbitant amount. That is why you can buy an iPad for less than a couple of medical screws.
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Old 07-27-2014, 08:28 AM   #155
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One thing that would make drugs, and medical costs, go down is to reduce the need for a doctors prescription for most drugs. You can go to a Dr. if you want, but if you think you need one of the drugs you see on TV, why not just mail order it? There is plenty of information on credible website to diagnose many issues. Then, volume of the drugs would go up, and the companies could make more on overall.

I have even seen a asthma patient in CO be prescribed medical marijuana to smoke before recreational pot was legal. So, a doctor's prescription is not an answer to curbing abuse.

Most of these drugs are not habit forming, and you could sign a waiver of risk. Even having legislation reducing lawsuits would go a long way. Even some recreational drugs could be developed to help reduce costs on medically necessary drugs.

When I was visiting Mexico, many years ago, I needed a prescription. I just stopped into the pharmacy there, and about $3 later, the pharmacist diagnosed and prescribed me a medication. I did not waste an hour of a clinic time and have a bunch of expensive lab tests done.

Letting more Doctors into Med School would go a long way too. Anyone that wants to get into Med school should be able to. Why limit the number of Doctors being trained?
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Old 07-27-2014, 08:39 AM   #156
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I would call this a false choice argument. The two choices are not sell for the cost of materials or for an exorbitant amount. That is why you can buy an iPad for less than a couple of medical screws.
I am sure if the medical screw manufacturer gets an order for 10,000,000 screws in a quarter like Apple does with Ipads, they would be willing to drop the price a tad. Are you saying you will place that order?
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Old 07-27-2014, 09:08 AM   #157
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I would call this a false choice argument. The two choices are not sell for the cost of materials or for an exorbitant amount. That is why you can buy an iPad for less than a couple of medical screws.
Anything related to the medical industry is involved with multiple layers of sterile handling and record keeping to prove chain of custody and sterility. (Add $). Your iPod/iPad/iPhone doesn't care if it's exposed to a few drops of rain on the package, or is packed in an environment that has just any old ambient humidity in some dirty Chinese warehouse or number of human hairs falling into the package.

Anything related to the medical industry is always involved with the potential of lawsuits. (Add $). True, if it's pure titanium that has been approved by the FDA for human implants, they have a good defense...but it's a given that ALL lawyers will go after the "deep pockets" theory, and sue EVERYONE that has an ability to pay, not just a doctor that messes up an operation. And even if no one is at fault, the medical device manufacturer will either settle for some money to put the litigation to rest and move on to save legal fees, or pay the legal fees to defend themselves in court and have to increase their cost of production for those legal fees.

Anything that does not have high volume will, of course, have higher marginal production costs, compared to a higher volume product. (Add $). Note: all of your subcontractors that make these small screws must have a separate machine in a sterile environment for this production. They also must factor in the lawsuit item that I mention below, as well. So that's a double Add $. No one's going to sell a screw for $5 that cost them $4.50 to make, if they get sued 1 time and have to settle for $100,000 in partial liability. Just $100,000 for 1 settlement means you have to sell a hell of a lot of screws just to break even!

Anything with a relatively smaller volume will also have, on a unit basis, a higher overhead/distribution cost per item, with various levels of management and sales reps. (Add $).

Anything that is an FDA approved impact must go through various FDA tests, perhaps even clinical trials. (Add $)

Anything that is sold must have some design and R&D in order to get to the finished product. (Add $)

Anything that is sold usually has additional future R&D to make the product even better, and/or to meet other competitors' advances when they bring competing products that might be even better to the market. (Add $)

Odds are, whatever you have as the finished product could easily have had several other competing designs from the company that was shelved because it didn't work, and that R&D cost and other costs associated with that development were lost forever. (Add $).

Add up all of those - and more factors! - and you suddenly have a product that must have quite a bit of money added to every unit sold in order to produce profits to the company. Many of the above factors are either not present at all, or not present to the same high degree (like lawsuits) as in nearly any other industry.

Of course - if you think that cost is extreme, there's no one holding a gun to your head saying that you HAVE to have a titanium implant put into your body. You can go through life with a destroyed hip joint, or wrist, or knee, or shoulder, and live with the pain of not being able to use it, and/or confined to a wheelchair. Or fly to some other country to have the implant installed there.

(yes, there are some people that have reactions or don't like their implants...but overall, the # of people that have kept them obviously must be greater, or there wouldn't be a market for these devices after a while....)

Do I think some aspects of the healthcare system are overbloated and could be more efficient (including medical implants)? Of course. But to simply make blanket statements comparing a product's raw material cost to the finished product (especially for a medical implant) is preposterous.
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Old 07-27-2014, 09:13 AM   #158
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I am sure if the medical screw manufacturer gets an order for 10,000,000 screws in a quarter like Apple does with Ipads, they would be willing to drop the price a tad. Are you saying you will place that order?

If I read previous posters comment correctly, it did not say anything about the manufacturer charging the price. It was the hospital charging the cost. Which goes back to the $20 aspirin, etc.. Which goes back to people showing up to hospital for treatment and not paying.. Which goes back to .....


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Old 07-27-2014, 09:41 AM   #159
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Let's be fair. There are plenty of things that are free market when you can shop for and know the cost of before you purchase so it isn't the fact that medical services are free market that is the problem. Medicine needs to and is heading in the direction of being more transparent albeit frustratingly slowly.

Part of the problem is that patients often have more wrong with them than the doctor can tell upfront or suffer from complications.


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Old 07-27-2014, 09:51 AM   #160
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I am sure if the medical screw manufacturer gets an order for 10,000,000 screws in a quarter like Apple does with Ipads, they would be willing to drop the price a tad. Are you saying you will place that order?
Another false choice argument.

Medical care in this country is simply overpriced and the titanium plate cost is just one example. When we, as a nation, start delivering equivalent outcomes for equivalent costs to other wealthy nations, I'll believe the industry's complaints.
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