An article published in the current issue of Health Affairs reports on pricing for self-pay patients, one of the only parts of the health care business that is largely “unregulated.” The author, Gerald Anderson, reports that people who pay their own hospital bills get charged more for care than those whose bills are paid by insurance companies or have Medicare or Medicaid coverage.
That’s not a surprise, of course. We’re accustomed to bulk discounts and buying clubs—the “membership has its privileges” sort of thing. Yet the magnitude of the difference should capture your attention: on average, patients without public or private insurance pay three times the Medicare-allowable cost. Anderson doesn’t report the average for New York but in New Jersey self-pay patients are charged a whopping 4.56 times the Medicare-allowable cost. Pennsylvania is right behind with a charge-to-cost ratio of 4.33. California, Alabama and Nevada round out the rest of the top five. At the other end of the scale Wyoming and Maryland hospitals charge self-pay patients 1.85 times and 1.23 times the Medicare-allowable cost. Note: Let me suggest that “cost” is in the eye of the beholder (or, at least, the beholder’s accountant). I don’t claim here that the Medicare number is the right way to define cost—hospitals don’t think so—but I do want to call attention to the discrepancy.
The article isn’t describing a new problem, but it is getting worse. In 1984 the average ratio was 1.35.
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Last fall I wrote two columns on the mechanics of the state’s property tax system—how assessments are established, why we have this process of “equalization,” and how uneven is the administration of the system. Boring stuff, no? Worse, I can’t claim that fixing the problem would actually cut property taxes, just shift the burden around. Oh, a perfect reform would cut back the amount of money spent by the state on the equalization process, but better administration would probably cost more in the beginning (think “deferred maintenance”) and not save any in the long run.
Is there a constituency out there for fairness and transparency? Probably not, but Assemblywoman Sandy Galef (from Westchester, the epicenter of bad property tax administration) is trying. She chairs the NYS Assembly Committee on Real Property Taxation and has sponsored or co-sponsored a number of bills aimed at fixing the mess.
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I’m not in the “tax as theft” school. How else can we come together to fund public schools, get our streets fixed and plowed, and finance support for the needy? Sure, some of that could happen without coercion, but I’m not one to campaign for a radical shrinkage of the public sector. Taxes are a necessary evil.
If you are still with me, then the question turns on how to tax and what to tax. Odd as it sounds, I write today in defense of the poor, embattled property tax. In recent forums sponsored by CGR’s New York Matters campaign on Long Island and in Rochester, several participants spoke in favor of shifting from the property tax to the income tax, particularly for the support of public education. The sales tax, too, is clearly preferred by voters to an increase in the hated property tax. Elected officials have certainly gotten this message—counties across the state choose an increase in the sales tax over a property tax hike when money is tight.
Why should we keep the property tax?
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In the 1960s and 1970s, every country wanted an auto industry. In a world obsessed with the automobile, being in the car business was central to national pride. In today’s economy, the chip fab seems to have taken the place of the auto industry. Nations and U.S. states offer dramatic incentives to capture these massive manufacturing facilities. A modern chip fab—those producing 300 mm wafers—cost more than $3 billion to build and incorporates the latest manufacturing technology.
Enticing a chip fab has long been a goal of the Pataki administration. The Luther Forest Technology Park in Saratoga County received substantial state and federal money to support site assembly, permitting and infrastructure. The Luther Forest brochure promises “up to 10,000 good paying jobs for our young people” for the estimated 2 million square feet of manufacturing space. So far, so good.
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Visiting Yosemite National Park last October I encountered a vacationing Brit at the park campground, driving a motor home the size of a city bus. “Must be tough to fuel up with these terrible gas prices, eh?” Looking at me blankly, he replied, “I don’t know what you mean. I could never drive a rig like this in England. Petrol’s a bargain here.” Eager to continue the conversation with my new acquaintance, I blathered on, “But the crude oil price went up worldwide. Your prices must be really awful now.” “Oh, they’ve gone up a bit, I suppose. Haven’t noticed, don’t you know?”
Well, the morning coffee finally kicked in and it all made sense. You see, of the $6.20 per gallon the British were paying last October, $4.05 was tax. Our taxes, on the other hand, average about $.39 per gallon. Remove the tax and gasoline was actually more expensive in the U.S. last October—an average of $2.75 per gallon v. $2.15 per gallon in the U.K. From the beginning of 2004 to October 2005, gas prices had gone up 85% for Americans while the average price paid by the Brits had gone up only 20%.
Yes, you guessed it: I’m going to suggest that we raise the gas tax. Keep reading anyway.
What’s wrong with cheap gas? Let me count the ways:
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“Dad, I’m at the emergency room.”
Oh, great. Send your daughter off to college—across the country, for heaven’s sake—and one thing you notice right away: You have REALLY lost control. Unless you own a Lear or a nice $20m Gulfstream, there is no way to get to California quickly in a crisis.
OK, maybe not a crisis. Turned out she was fine—too much caffeine, too little sleep. They put in an IV, did some blood tests, then sent her back to campus.
I wish I could say that there was nothing wrong with ME when I got the bill! Are you sitting down? The hospital sent me a bill for $2,335. If that wasn’t bad enough, I soon got the bill for the “accessories,” like the extras you get with some gadget on a late night infomercial: “But that’s not ALL! Buy the hospital visit today for only $2,335 and get a doctor for ONLY $547! And don’t miss the lab work! Call the toll free number on your screen and get your personalized pathology report (YES, we test YOUR OWN BLOOD) along with your hospital visit WITH the doctor for a mere $354.25! That’s right—the whole emergency room visit for just $3,236.25!!
Many of you have had a similar experience. What’s my point?
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Need drugs? The legal kind, I mean? I think you’ll agree that there is no shortage of sources. I did a quick check of the phone book and found ten places to buy prescription drugs within a two mile radius of my house (3 Eckerds and 2 Wegmans plus Tops, Rite Aid, CVS, Kmart, Walmart and Medicine Shoppe). And there are more planned—Target & Walgreens will be in the radius by the end of the year.
Doesn’t this seem rather odd? Let’s put aside the places that do drugs as part of a one-stop-shopping model, such as the grocery and department store chains. It is the stand-alone pharmacies that puzzle me. How can Eckerds make money with three stores in my backyard? I can’t remember a time when these places were particularly busy. Waiting at the check-out is a rare event. Offhand, this doesn’t look like an efficient model. So either they are ready to go bankrupt (Ah, that must be why Walgreens is entering our market—they want to share in the losses!) or the margin between the price they pay and the price we pay is pretty rich.
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