Journalism in the Public Interest

Coming in January: Obamacare Rate Shock Part Two

High co-pays and deductibles may surprise health consumers after their new policies take effect next year under the Affordable Care Act.

Vincent Dunbar, right, sits with his mother as he speaks with a Sunshine Life and Health Advisors insurance agent about an insurance policy for his mother under the Affordable Care Act on Nov. 5 in Miami. (Joe Raedle/Getty Images)

Media reports about the Affordable Care Act have been dominated by two themes lately: The ongoing glitches with and the “rate shock” that some consumers now face after insurance companies canceled their policies.

But come January, a second rate shock may hit and could produce more bad news for Obamacare.

That’s when millions of Americans who select health insurance plans on the new marketplaces may realize that their new insurance plans don’t pay the bills right away. They come with high deductibles and co-pays.

In recent weeks, many people have focused on the monthly cost of buying a health insurance plan in the insurance marketplace. What I’m talking about is different: The out-of-pocket costs they may face when they go to use that new policy.

The president has promised to deliver affordable care to all Americans who want it. But the notion of what’s affordable may well be in the eye of the beholder.

Many low-income people who haven’t had insurance before will qualify for subsidies to lower their monthly insurance premiums and reduce their out-of-pocket costs. And some with current policies will find that their new ones are indeed more affordable.

But many won’t. Those on both the left and the right side of the political spectrum — and in between — acknowledge this may surprise consumers.

“So many people may feel they have a grip on their premium costs and think they have reasonable coverage only to encounter unpleasant surprises in the form of deductibles, copayments, and coinsurance amounts,” health care consultant Kip Piper told me in an email.

Consider a family of four making $59,000 a year. They will have to pay $400 a month toward their insurance premium, after receiving a subsidy, said industry consultant Robert Laszewski.

“But then, they will get a plan with a $2,000 deductible and hefty co-pays,” he wrote in an email. “The Democrats that say everything is going to be OK really need to go on one of the open exchanges and take a hard look at what consumers will see.”

It goes without saying that the Affordable Care Act reshapes the insurance landscape. It prohibits insurers from discriminating against those with pre-existing conditions and requires insurers to spend a minimum amount on health costs vs. marketing and profit.

Beyond that, the act provides subsidies to working-class consumers. Earlier this month, the New York Times boasted that up to 7 million people could qualify for “free” policies under the law. That’s going to cost about $1 trillion over the next decade.

Let’s take a brief, wonky diversion into some technical details (I promise it will be brief).

There are four types of plans being offered on the exchanges — bronze, silver, gold and platinum. As you move up the medal ladder, the premiums generally increase, as do the benefits.

Separately, there are two different kinds of financial assistance provided to people, depending on their income level.

  • Those with incomes below 400 percent of the federal poverty rate ($45,960 for one person, $94,200 for a family of four) qualify for tax credits that lower the cost of monthly premiums.
  • In addition, those with incomes below 250 percent of poverty ($28,725 for an individual, $58,875 for a family of four) qualify for help with their deductibles and co-pays.

You’ll hear the phrase “actuarial value” used a lot to describe the value of different plans. Essentially this means that a plan is structured to cover a certain percentage (say 60 percent or 70 percent) of the benefits provided to the population it is designed to serve.

OK, wonky diversion over.

A spokesperson for the Centers for Medicare and Medicaid Services, which oversees the marketplaces, said that when consumers apply for coverage, they will receive an eligibility determination detailing whether they qualify for tax credits and a cost-sharing reduction, as well as next steps to take.  

But the new coverage won’t be a panacea, experts say. The problems with the website, which handles enrollment for 36 states, has made communicating details of the new policies challenging.

“The website difficulties have meant that in much of the country people have yet to really see what the cost-sharing will look like in these plans, and they may be surprised for find out that the deductibles and co-pays in bronze and silver plans are higher than what one would find in typical employer-provided health benefits,” Larry Levitt, senior vice president of the Kaiser Family Foundation, said in an email.

“I think it remains to be seen whether people see these plans as offering them good protection against catastrophic health expenses — which they do — or are disappointed that they won’t generally provide much coverage for occasional visits to the doctor or prescriptions,” Levitt added.

Chris Jacobs, a senior policy analyst at the conservative Heritage Foundation, brings up another point. The sequester law, which calls for spending cuts in the federal budget, requires reductions to the cost-sharing program. But the Obama administration has not said how it will carry those out — whether it will cut the cost-sharing subsidies or make insurers absorb the cuts.

“Someone (either carriers, consumers, or both) isn't being told by this administration that they're going to have to pay more — billions of dollars more,” Jacobs wrote to me. “And just as millions of people didn't like discovering in recent weeks that the ‘like your plan’ promise was hollow, they won't like learning about other hidden costs not being disclosed either.”

Jacobs has written more about the issue, as has Kaiser.

Ken Wood, a senior adviser to Covered California, the state’s exchange, said that officials tried to structure their plans so they don’t rely on deductibles as much as co-pays. They offer lower co-pays for trips to primary-care physician visits than to specialists and lower co-pays for visits to urgent-care than to emergency rooms.

“Even with high deductibles, consumers stop paying retail for health care since they get the advantage of the health insurer’s negotiated rates, and no plan has a higher out-of-pocket maximum than $6,350 (per person),” he said. “That is a lot of money, but it probably will not drive people into bankruptcy. “

Has your insurance been canceled? Have you tried signing up for coverage through the new exchanges? Help us cover the Affordable Care Act by sharing your insurance story.

I think you’ve hit on a point that is not being covered by the news media; deductibles, co-pays and out-of-pocket expenses.  If the premise of this “Affordable Healthcare Act” is dependent upon the youth of this country we have another problem.  For instance, myself as a two time cancer survivor, with a deductible of $3,500 and an out-of-pocket of $5,000, I delayed going to the doctor for a lingering pain in my lower back.  I didn’t want to pay for scans costing $1,200 a pop.  In doing so, I neglected a cancer recurrence causing me to have significant bone loss in my pelvis.  I’m 53 years old.  My daughters are in their 20’s and cannot affort to seek medical attention because of these high deductibles let alone the premiums being forced upon them in a job market post college leaving them with high student loans and low income.  I support President Obama, but, now what?  The youth will chose to pay the fines imposed until the cost outweighs it’s benefit.

Yea, the $6k won’t drive them into bankruptcy.  The insurance companies have an IV into everyone’s cash flow, bleeding them but not killing them.  I’d prefer an honest across the board tax that pays into universal health care.  Limit the bs.  And after that, at least in the big cities, have the government run non-profit hospitals.

I think it would have been more accurate for Jacobs to say that $6K in out of pocket expenses wouldn’t send anyone he knows into bankruptcy.  In fact, when compounded with loss of income due to illness, $6K could easily push a family who is maintaining a stable home life through the inadequate social safety net into homelessness—without appearing on any bankruptcy roll.

The misnamed Affordable Care Act does virtually nothing about the actual cost of care: that’s why the insurance premiums for unrated policies are so high.  And as we are seeing, the premiums for the insurance we need to cover the high cost of care are unaffordable for most of the target market.  The premiums become “affordable” only through expensive government support in the form of Medicaid and subsidies.

Even with subsidies though, the sample family you cite will be paying almost 8% of its gross income (with after tax dollars no less) just for premiums.  If anything serious happens during the year, they could well end up spending an additional $3K for routine treatment.  That could indeed spell disaster for the family.

1. More than 500,000 have signed up for insurance overall. Avalere Health, a consulting firm tracking sign-ups, estimates that at least 440,000 people have signed up for Medicaid and another 49,000 people enrolled in coverage in 12 states and the District of Columbia that are operating their own exchanges. Significantly, that state number don’t appear to include enrollment from California, Massachusetts, or Oregon. Thus, all told, more than 529,000 have enrolled in coverage.

This is an important observation. The media, as has been the case all along with the ACA, will be a few steps behind but come early/mid-2014 we’re going to start reading about horror stories of families crippled by premiums, co-pays, deductibles, etc. So far, virtually all the news on the ACA has been bad, and we’re in the enrollment stage. When you talk to people who have had health insurance in the past, you very rarely hear complaints about enrollment. Sure it might be confusing. Sure you might feel like you can’t decide. Sure you may think costs are going up. But still, enrollment is the painless part. Wait until people start looking for doctors. Wait until they get their monthly premium bills. Wait until they see huge co-pays and deductibles. Wait until they end up spending hours and days disputing claims and reimbursements. This is the ugly part of the insurance model and the ACA hasn’t even gotten there yet.

An issue I see as a major factor in the downfall of this system is that the masses are being dumped onto the medicaid system that doesn’t have enough doctors as it is.  I have a relative that had to go 2 1/2 hours to see a doctor when there were 5 in the town (none who took medicaid).  What is Obamacare doing to guarantee doctors will take ANY of the plans, and not overload the few that do and the hospitals? This will impact everyone except the rich who can pay for private care!

Herb Ruhs, MD

Nov. 12, 2013, 4:32 p.m.

If we step back from the drama, real and manufactured, we can see that for decades now no legislation is consistent with its name, but then realistic titles like The Health Insurance Industry Enrichment Act, or The Banking Theft and Fraud Enablement Act would be too much of an embarrassment to the big corporate lobbyist and attorneys who write these things in the interests of their employers.  The details remain hidden in a fog of propaganda and secrecy that make then inaccessible to working journalist.  Thanks for trying, but we only have one story in this country right now, the failure of Constitutional government, with increasingly common symptoms of distress in every segment and activity in the society.  And when you tune out the noise from all the reported drama, what one sees is a feeding frenzy by organized criminal activity that is destroying the nation and foreclosing on the futures of the young.

They are wrong about the $6K max deductible.  A friend of mine applied and was told $12K deductible per person + $350 a month for the premium.  The person is in his 20’s, just starting out in life - $350 a month is a nice car payment.  He opted for the penalty.

It is about time someone brought up the co pays & deductibles. Thank you!  Avoiding the subject is one more duplicitous evasion by Pres Obama - for whom I voted, once.  His plan is messy, confusing, inadequate, expensive and does nothing to rein in ill health costs - holding out for medicare for all, in spite of opposition would have been preferable if explained properly and inexorably , something this president has proved incapable of.

Yeah. If you think the website sucks, wait until you see the deductibles, co-pays, and monthly premiums. They’re absolutely exorbitant for my wife and I, and there is no way in the world we can afford it on our income after mortgage, car payment, prop taxes, car insurance, utilities, and groceries. We’ve already decided to just pay the fine, do as much preventive care as possible (exercise, healthy diet, etc), and hope to stay healthy.  If God forbid either one of us gets sick or injured, i guess we’ll have to use my state’s Indigent Fund to cover the costs.  This insurance is NOT for middle-class, 30-50 year-old working people. I think it’s geared mostly toward the poor, and the previously uninsured/ uninsurable. I’m an Obama-voting Dem who’s very disappointed in what the ACA is offering us.

Anyone who quotes the Heritage Foundation for the Politically Insane in an article about the ACA is not worth listening to. That is the same foundation which “invented” the ACA and then, in an effort (along with many others) to get America to fail, disowned their own creation.

Everyone here is whining about themselves. Mike, for instance, is so self-centered that he’s willing to allow the rest of you to pay for his health care. Mike is ignorant enough to believe that Emergency Rooms actually cure disease.

I have my health care through the Federal Government. It costs me about $250 a month for my wife and myself. We have deductibles and copays. My wife had cancer a couple of years ago. Her treatments cost $80,000. I had a co-pay of $8,000. The hospital allowed me to pay it off and never charged interest.

All these complaints are bullshit. This article is bullshit. Many of us would have preferred single-payer but compared to what insurance companies offered before the ACA, the ACA is great. And, like the vast majority of Americans, my health insurance will NOT change in January unless I choose to change it.

George, i’m happy that some of those who were uninsured or uninsurable previously will now be covered. Good for them. Yes, this part of the ACA is a big improvement. However, the coverage that is now being offered is unaffordable and unattainable for me and my wife at our stagnant income level. We both work full-time (i’m an electrician, she’s a waitress) and in a good year, we’ll take home about $58k combined. We just don’t have $875 per month premium + hefty co-pays + $5,000 yearly deductible to be able to afford buying into this plan. It’s just far too expensive for us, not even close. We’ll pay the 1% fine as required by the law, and then deal with the consequences if we have to. If that makes us “selfish” then so be it. We don’t have another option under this plan.

It’s the Unaffordable Care Act, brought to you by the insurance industry and the Heritage Foundation via a Democrat administration.

Four years ago I was at a Capitol Hill Rand Corp. briefing about what was to be Obamacare. CSPAN was there. At the Q&A, I asked a two-part question, the second part asking whether “price controls were off the table.”

I was at home when the briefing aired on CSPAN. I heard myself speaking. And I heard the second part of my question edited out.

Single payer health care is price control. Wow, how threatening.

Something else that’s not being addressed is having to pay for deductible before the insurance co. starts to pay anything.  If you’re unfortunate enough to have one of those $6,350 deductibles if could take you almost through the year before anything is actually paid on a medical bill.  Example…If you have a MRI and a colonoscopy they’ll have to be paid in full and the amounts are applied against your deductible.  You can’t get by with just paying a co-pay.  Most folks will have to set up a payment schedule.  Once it’s paid then depending on what level insurance you have it will pay 80% / 20%.  If you have the bronze plan it pays 70% / 30%.  This is far from being affordable.

The HCA is the largest social change since Medicare.  Why are people so surprised that not every nuance has been anticipated?  They could pass a law and grandfather pre-existing plans not in compliance with current plan standards.  Is it really necessary? Or desirable? The system was failing before.  Something had to change.  Suppose enrollment is lower than expected - then projected subsidies will be lower as well.  There may be other factors at work as well.  Those in the underground economy don’t want to get flushed out into the open.  The HCA increases pressure on them to disclose income.  Over time, with appropriate fine tuning, we can get to a better place once the reform process - including cost controls, has been fully implemented.  And while they’re ramping up enrollment, why not 1) open up a parallel site for pro forma comparisons and 2) why not stage enrollment by age or geography or last name to give the system time to digest applicants.

I don’t get the premise of this article.  If someone is surprised that their new insurance has a $2k deductible and co-pays, what on earth was their old policy?  Did they have a more generous policy before switching?  People who have a generous policy from a generous employer aren’t shopping on the new exchanges.  Instead, it’s people like my wife and I (we pay almost $900/month for a indiv. policy with $10k/person deductibles and co-pays) who are looking for a better deal.  We’d be thrilled to see a $2k deductible!

My current deductible is 5 k and would go down to 2.5 k. My plan costs 700/ month and that would go down too

Jerry Greenwald

Nov. 13, 2013, 7:08 a.m.

“Even with high deductibles, consumers stop paying retail for health care since they get the advantage of the health insurer’s negotiated rates, and no plan has a higher out-of-pocket maximum than $6,350 (per person),” he said. “That is a lot of money, but it probably will not drive people into bankruptcy. “


Does that mean person member of a household under that policy? That’s more than $25,000 for a family of four! Even if it means per household, that could take a huge chunk out of the budget. That bit about not driving people to bankruptcy is rather condescending. Most people budget to pay their bills and save a bit, not to keep out of bankruptcy court.

Get rid of health insurance companies and go to single payer- everyone would be happier. Premiums go up every year because people are living longer and will need more care- why pay a middleman that is a for profit, public entity? Their actuaries will tell them, ” we have to charge more” every single renewal opportunity. All my doctors are dropping all insurance participation so these new plans are pretty much useless.

What we now have is medical apartheid. People like George, who gets coverage paid for by the taxpayer, and the rich who can afford the Cadillac plans are fine with Obamacare.

For the rest of us it’s unaffordable.

My policy was cancelled. What they offered me instead is a $1,000 per month premium, $10,000 deductible policy on me and my wife.

And back in 2009 when Obama, Ed Shultz, Rachel Maddow and all the rest of the Democrat propagandists were selling us the idea, they all said in unison, “If you don’t like Obamacare, you can keep the policy you have.”

They knew full well at that time that was a lie.

I’ll never support either of the major parties again. I’m sure they are all happy with their Cadillac plans while the rest of us can go lay down in a ditch and die as far as they’re concerned.

What ccrider27 is reporting is an offer from an insurance company.

  I wish the website was working consistently because maybe then he could check out other plans and see what he might get from other insurance companies.

    However, do note that a $1000 a month premium for two is comparable to the monthly premium paid by employer and employees for a couple in many companies.

The numbers I think about whenever the topic of fixing health care comes up:

1.  If you break an arm, it’ll cost about twelve thousand dollars at the hospital, where they’ll basically set the bone, tie you to a splint, and give you aspirin.  A Boy Scout can do that for, what, the price of aspirin and access to a straight stick?

2.  Oncologists make around a quarter-million dollars per year.  Assuming weekends and vacation off like a corporate drone like myself, that comes to ten thousand dollars per day or $1,250 per hour.

I bring up the former point because it shows how insanely overpriced things are when a group like the AMA gets to set the prices and the supply of doctors, knowing we don’t have a choice of care.

I bring up the latter point to show that a possible solution would be to hire a doctor for a group of people that pay him outright.  If we know the average amount of time someone needs to be directly treated, we could estimate the bill per person.  (Prices of equipment and the like are estimated by assuming that everybody always needs an oncologist, if you’re curious.)

When the mob says “it’d be a shame if something happened to your nice shop,” the solution isn’t to buy insurance to cover their protection costs.

Herb Ruhs, MD

Nov. 13, 2013, 1:52 p.m.

You seem to be pointing at some salient facts about our situation, and from my perspective of over four decades of involvement in numerous aspects of the US system, this is exactly what is missing in the public discussion.  It didn’t used to cost so much to have a trained and experienced physician examine you to determine if you were one of those small percentages of people who need special treatment because of anticipated gross complications, such as nerve entrapment causing permanent disability.  As I traveled in many poor, underserved parts of the world, I always noticed these things as measure of adequacy and availability of trained care.  For instance, breaks in the elbow region are at high risk of entrapping nerves, and if they do, the nerves leading to muscles of the arm die at the point of entrapment and the muscles innervated by those nerves wither.  It is called the bucket handle deformity.  Where this deformity is present there is also a class of entitled people that do not have it, have access to high cost exclusive care that is equal, or better, than our so called developed countries.

Some very poor countries have excellent health care.  In those countries you don’t see bucket handle deformities in people going about their daily lives, because they were dealt with by someone trained to detect the problem and correct it before the complication develops, which needs to be as soon as possible in this case to preserve nerve function.  Another good one is club foot deformity.  There are many such markers of medical care adequacy.  Statistics, honestly gathered, is what we usually look at when considering population health.

What I am looking at are poor countries that provide good care at a very low cost and the US that, from a population point of view, provides a poor standard of care (last time I checked ranked 35th and falling) at a cost that tis multiples of the next most expensive system. 

Young people have a hard time, I know I did when I was young, understanding how radically everything has changed in recent decades.  I discourage youth from considering a career in medicine these days as a result of what has become of the system I loved and dedicated my life to.

But it is not just medicine.  It is all the professions. Another way to put it is that we are coming to resemble some of those poor unequal societies where adequate medical care is the privilege of the wealthy.

Unfortunately that idea of a group hiring a physician has been tried.  The State prosecutors go after them as not meeting the legal requirements of a medical insurance company, big money basically.

This so called health care system that has evolved under the plutocratic rule of the last few decades has systematically made good, affordable health care possible in the pursuit of profit.  I often refer to what we have now as the Health Care Extortion System.

Herb Ruhs, MD

I think you mean “buckle fracture”

But do you have any evidence ot the interesting claim that “Where this deformity is present there is also a class of entitled people that do not have it, have access to high cost exclusive care that is equal, or better, than our so called developed countries.”

What you are referring to may actually be the only part of the new law that actually discourages health care inflation.  In general, the new law increases the amount of money spent on health care so in general, the new law won’t inhibit cost increases.  However, the increased incidence of high deductibles and co-pays will discourage some spending because people will be paying for medical expenses out of their own pockets.

I’m an Engineer that purchases my own insurance, my wife is on Medicare Advantage (which O’Care stomps on and will try and kill in 14).  I had what I thought was a catastrophic medical plan 2K deduct, 50% copay until 7K out of pocket.  But it was with Blue Cross and has full coverage out to 2 Million lifetime.

The Bronze plans in WA Exchange all were 5K deductible, 30% copay until 6.25K max was reached. Limited networks or HMO and over 200/month more than my current.  I scooted back to Regence Blue as their plan has the full network, I went Gold as it will be less money if my costs are over 4K in a year.

“Thus, all told, more than 529,000 have enrolled in coverage. ” - Michael

This is terrible news for supporters of the law, given that 440,000 of those have been medicaid enrollees.  This law is fiscally unsustainable under that ratio of fiscal outlays to fiscal contributions.  Medicaid covers some of the least healthy segments of our population, requiring the most care.  Yet it demands no fiscal contribution whatsoever from those covered.  Yes, I understand that’s how it’s designed to function.

That said, it means 83% of all the enrollees so far are 100% fiscal outlay, with a significant portion of the 17% remainder having some portion (in some cases most, as those who receive the highest level of subsidy have the most incentive to enroll) of their premiums paid for out by taxpayers as well. 

At this rate, the law is going to be a fiscal disaster.

Reap what you sow-in this case, as Dr. Ruhs points out more politely, the logical development of capitalism. Its been going on for some time now. Remember the Ole’ Gipper? “Let the invisible hand of the market do its thing…” “Trickle down economics”, No more regulations, break the unions? Yeah, good times.

I too work in “health care” with a Ph.D. (I love what I do and would do it if I were rich) and I’ve had to purchase my own insurance for some time. As it is working in California, I saved about 400/month (while adding a child) and my deductibles, maximum out of pocket have lowered and significantly there is no more refusal of coverage for “pre-existing conditions” for a PPO. The provider networks also seem to leveling out. Having had to be aware of insurance for awhile, I think many of you are finally getting around to figuring out what is happening.

In California the State “Insurance Commission” has no power to regulate the insurance industry. My policies used to cost 30%more per year with less coverage each an every year.  Its a big business that attracts a lot of smart people who work hard to make money. Guess what? They don’t care about anyone else, or cost containment, (fill in the blank with your own euphemism, ideology, whatever). Its how things go in today’s society.

The only thing that is being attempted here is to add some regulation back to what was lost. The general public is so stupid about all this that they can only bleat, “Government is trying to oppress us!” What the hell do you think they have been doing? Yes, it shocking to awaken from your stupor.

Though I tend to agree with the good doctor that things are very bad right now (I’d even up the ante but that would take too long) this country has a fine tradition of people putting their asses on the line for rights. How do you want to be in the world and relate to other people? If what is happening now isn’t to your liking, we’re going to have start fighting for it. Please stop sitting on your ars# saying how it’s not going work.

Mary Askew: However, do note that a $1000 a month premium for two is comparable to the monthly premium paid by employer and employees for a couple in many companies.

That may be true but the coverage from a company is much more comprehensive than anything available on the exchange.  The premiums, co-pays, and deductibles are just the tip of the iceberg.  How many individual policies include vision, hearing, durable medical equipment, etc.?  Although many corporate provided policies do cover these items, they usually have very high co-insurance rates (if they are covered at all) in the individual market.

I really love all the liberal anecdotal ‘evidence’ and their new, improved health care situation post ObamaCare. The most comprehensive review of policy costs that spanned 49 states showed that premiums under ObamaCare will rise 40 percent.

Can’t wait to see what happens when the corporate mandate expires and 30-40 million more people lose their current coverage. This is the inevitable failure of the conceit of the central planner elites. They will tell you what you need (hysterectomy coverage for a 61 year-old single man) because you are too stupid to know what’s best for you. Clearly, only the hopelessly inept and boundlessly arrogant would ever presume to think they are smart enough to manage the complexity of health care requirements and delivery for 320 million people.

This entire mess is politically-motivated. The left wants millions more public employees and ObumbleCare will deliver: the NHS in Britain is the third largest employer in the world…in a country of only 80 million people. More bureaucrat drones and more control over our lives.

Herb Ruhs, MD

Nov. 14, 2013, 3:38 a.m.

Dear farble,

No, the type of fracture is a Supracondylar fracture of the humerus. Nerves can be trapped between the fragments of the bone.  If untreated this results in the inability of the person to rotate their lower arm resulting in a deviation of the elbow from normal with the plam facing forward.  Most US doctors have never seen this long term complication.  You only see it where people are not treated, hence more common in places without such care.

The word bucket is used to describe many conditions in medicine.  The use here is because this deformity results in the person looking like they are carrying a bucket by the handle.  Netter has a good illustration in one of his books.  This is hard to find on line.  Probably because it is only seen where surgical treatment of supracondylar fractures is not available, hence in poor countries without an accessible health care system.


Herb Ruhs, MD

Nov. 14, 2013, 3:49 a.m.

Dear farble,

No, the type of fracture is a Supracondylar fracture of the humerus. Nerves can be trapped between the fragments of the bone.  If untreated this results in the inability of the person to rotate their lower arm resulting in a deviation of the elbow from normal with the plam facing forward.  Most US doctors have never seen this long term complication.  You only see it where people are not treated, hence more common in places without such care.  The Latin term is cubitus valgus deformity.  The word bucket is used to describe many conditions in medicine.  The use here is because this deformity results in the person looking like they are carrying a bucket by the handle.  Netter has a good illustration in one of his books.  This is hard to find on line.  Probably because it is only seen where surgical treatment of supracondylar fractures is not available, hence in poor countries without an accessible health care system.


Anyone who has done a deep dive into the workings of the health insurance industry knows that nothing matters more than the bottom line.  Our error is to involve public for-profit corporations in the provision of healthcare.  They short providers, play semantics with “medical necessity”, and hike premiums at every opportunity. “Healthcare” is a misnomer - this is an insurance industry that has profit, not healthcare, as a motive. Their most valued employees are actuarial analysts and they depend utterly on ever increasing profits to maintain their stock prices.  Why else is American health care the most expensive in the industrialized world?  The expansion of Medicare is one solution.  But the members of Congress who represent the health insurance companies will fight it for personal, financial reasons. Unfortunately, there is no “public interest” in Congress anymore; private interests have won the day.

Dr. Ruhs, I actually did vaguely remember that the “private co-op” model had been banned, and didn’t mean to imply “we should do this.”  I was thinking more in terms of using what a doctor makes to guide the cost.  On the other hand, I do know that this approach was often used for lodges and clubs…oh, about a hundred years ago, was it?

Anyway, I also agree:  Every young doctor I’ve met looks like he’s about to keel over, and most of them were in financial trouble.  I wouldn’t recommend it to anybody, either, if we didn’t need people doing the work.

Herb Ruhs, MD

Nov. 20, 2013, 5:47 p.m.

That is my point.  The work is not getting done.  It is being replaced by a facsimile manufactured in marketing departments that creates the illusion that the work is going well.  It most definitely is not.  Profits soar as the real work of medicine is left undone.

What a crock pot full of stinky material ,
Obama did not read this and it proves he did not read it This Chicago Mob Insurance Fraud would make Al Capone jealous , and make Burney Madeoff look like a shoplifter, This is the same paper that Hillary was caught trying when “Bill” was president,
The R.I.C.O. Act was written for this very reason, as well as the 28th Amendment to the Constitution ,Not one politician will pay the 15% of their salaries into this, Hillary, Polosi , Reid, Not a one read this embarrassing P.O.S,

Ellie Dempster

Nov. 24, 2013, 4:57 a.m.

My husband Steve is only 59 years old, and next year he will have to come off our group plan and go onto and individual medicare supplement plan.  He has been disabled since 2009, and was eligible for Medicare part A & part B in 2011.
    When I tried to get prices for the medicare supplement plan in 2014 I was told the F plan would normally be only $110.00 for a normal healthy 65 year old, but because my husband will be only 60 years old and not 65 and has pre existing conditions and is disabled he will have to pay $350.00 per month for the same exact plan.
    How can this apply to the new law?  The new law states in 2014 that health insurance plans cant refuse to cover you or charge you more just because you have a pre existing health condition.
    Then why are they charging my husband more money?  Does the new law not apply to all Disabled Americans who are not 65 years old who are younger and need a supplement to their medicare plan?
  I called HealthCare.Gov, and they did not know, they told me to call Medicare.  I called Medicare and they did not know anything about the prices on medicare supplement plans, and they could not help me.
      There are so many millions of Disabled Americans who are younger than 65 and are in need of a policy to cover what medicare does not and why the law does not help these people is just crazy!!!  The people that need it most who are disabled get no help from this new law?

If you have any questions or comments please call me at 805-409-6052 or 805-523-0565, or email me at:  .(JavaScript must be enabled to view this email address)


Mr & Mrs. Steve & Ellie Dempster

debbie palley

Dec. 3, 2013, 7:35 a.m.

Being insured vs not, insured is better. If we did not think this would make a financial difference, we were living in la la land. The implementation of the new health care law leaves much to be desired. Yes healthcare for everyone because its the humane thing to do and because it makes financial sense. A simple example would be a person with healthcare goes to the doctor, diagnosed with high blood pressure, prescribed medication, takes medication, follows up with doc, avoids kidney failure, heart attack etc. That has to be much less expensive than no to little access to care, untreated high blood pressure, subsequent kidney failure, and dialysis.

Unfortunately our government is not truthful, partly because our elected officials are always on the campaign trail and dont want to offend their constituents and risk not being re-elected and partly because large money interests ie corporate powers own said elected officials.

The truth is health care is expensive in this country for many reasons and many are interconnected. If all involved parties would compromise, cost could stabilize.

On a fundamental level, individuals play a large part in the cost of healthcare. Over 1/3 of adults in the US are obese. Obesity directly contributes to diabetes, high blood pressure, cardiovascular disease, degenerative joint disease, etc, all expensive illnesses to treat. We have personal responsibility to take care of ourselves, this message has to be emphasized !

Herb Ruhs, MD

Dec. 3, 2013, 5:17 p.m.

Good thinking.  Hard to separate the various threads of this densely woven catastrophe that medicine in the US has become.  With Civilization, the way we have been taught (erroneously) that problems are addressed is to divide issues on terms of that professional group specially trained to look at those sorts of problems.  Specialization are us.  The first big missing trained element is what we used to call Public Health.  Laurie Garrett, in her 2000 book Betrayal of Trust: The Collapse of Global Public Health, describes what has been lost.  Trained professional Public Health people are gone, essentially.  All the things you may have assumed are being dealt with that are threats to segments of the population, or the entire population, are being underserved or entirely unaddressed.  Most improvements in general health of populations are the result of these now mostly missing people, as Laurie describes.  For instance, obesity, and a host of other things, are associated with two products that, on public health grounds, should be excluded from everyone’s diet, partially hydrated fats and high fructose corn syrup.  Far from being combated, this so called representative government heavily subsidizes their use.

The question to be or not to be insured is harder the fewer resources you have to draw on.  On the extremes we have people who pay cash and don’t ask how much and people essentially expelled from the system for a variety of reasons.  For the great many in the middle for whom health insurance is a good idea, I totally agree, having it is essentially bowing to the reality of being trapped in an extortion scam, especially as one accumulates dependents.  He who hath wife and child is hostage to fate (per Bacon).

Even your choice of emblematic medical encounters has developed sinister features.  The average patient will leave the encounter with more than the blood pressure medicine.  Once in the maw of corporate medicine enforced by governmental monopolies, incentives arise to do things to the patient that may not be in the patient’s interests.  I always feel sorry for the docs I see.  Going in seldomly and refusing stuff like cholesterol lowering agents, I actually damage them by reducing their score on government approved quality ranking, for instance.  There are so many of these artificial incentives and aversive reactions from regulatory bodies that health care itself has become hazardous.  That said, do not get in a car without the Card.  Extortion.  this is part of the reason that I now say that MD now stands for Marketing Deputy.  The TV weaves such a powerful spell that folks can not see this, most doctors can not see this.  All insurance becomes dangerous to use and dangerous to be without.  Irony soooo deep.  From someone who has been involved in medicine for close to fifty years, please believe me, it was not always so.  Not perfect by far, by not a Hollywood horror script like now.  Don’t get me started about what one buys access to for such a large fraction of ones after tax income.

There unfortunately no moral space where compromise with this system can me made.  This is Market Fundamentalism.  If it increases profits it is good. Period.  Corporations, and their guiding executives, are compelled by law to act to increase shareholder value.  Eichman like, these executives plead that the Market made them do it.

Good health habits AND self health education has never been more valuable.  Unfortunately this too is a feature of this sort of society.  Those who can afford to eat well and the time to self educate, particularly those of us on this side of the digital divide, are offered survival as a class perk.


This article is part of an ongoing investigation:
Obamacare and You

Obamacare and You

The Rollout of the Affordable Care Act has been marred by glitches and political opposition.

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