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Posted on 11/16/2025 10:36:56 AM PST by E. Pluribus Unum
Insurance companies challenged GOP orthodoxy on Obamacare. It’s not going well.
The pressures facing insurers and pharma are emblematic of tensions across corporate America as companies scramble to navigate an administration that has upended traditional levers of influence and free market orthodoxy while triggering a record windfall for K Street, Washington’s lobbying corridor.
“This president has decidedly chosen to bring insurance and pharmaceutical industries to the table, to make them do things they don’t want to do. That’s a really different world,” said Peggy Tighe, a former insurance representative who now lobbies for providers and patient groups at Powers Law.
Two roads diverged
Players across the health care system have poured record amounts of money into Washington this year as Republicans cut into health programs to finance tax cuts, immigration enforcement, and defense. Spending by AHIP in the first nine months of the year is more than $13 million, already topping totals for all of 2023 and last year, while year-to-date spending at the Pharmaceutical Research and Manufacturers of America, the brand name drug lobby, is near $30 million, exceeding annual totals for nearly every year in the past decade.
Individual companies have also ramped up activity. UnitedHealth spent $9.2 million so far this year, exceeding the annual totals of any year in at least a decade, and Elevance spent $2 million on lobbying in the third quarter, its highest for the period in four years. Spending from July to September from drugmakers Amgen, Gilead, Johnson and Johnson, and Regeneron, meanwhile, was the highest on record for the period.
Insurance lobbyists said they spent much of the year discussing with Congress and the White House the impact of nearly $1 trillion in Medicaid cuts in the GOP’s One Big Beautiful Bill Act. Signed into law in July, it’s expected to leave 10 million Americans uninsured...
(Excerpt) Read more at politico.com ...
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It's probably more like 6 or 7 and united Healthcare also takes a cut. To do my paperwork.
An operation takes place in a room.
This is a nurse with a gown on and a cart with a set of scalpels, some hand tools such as clamps, some suture material and sometimes a stapling device and staples. She also has a suctioning device.
The patient is placed on a bed and draped.
There is a surgeon. He has gown on. He will refer to an imaging display device.
There is an anesthesiologist. He has an anesthesia machine, a heart and breathing monitoring machine, some gas tanks and tubing, a CO2 absorption container and material, and a mask for the patient. He will also have a few syringes and a vial with an off-patent pre-induction drug. He will also have airway management inserts and off-patent drugs in case there is a problem.
Sometimes, there will be a heart bypass machine and a nurse to man it.
Sometimes, samples of tissue such as from lymph nodes which might have cancer cells will have to be sent to a pathologist for examination.
It might take about 15 manhours for these people to do their work on the patient, on average.
The patient might have worked 80,000 manhours.
via DuckDuckGo:
Google Play
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Fresha for customers - Apps on Google Play
4 days ago
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4.9/5(40K)
If you run a real business, I recommend you sign up for proper software, like Mangomint (the highest-rated platform right now).
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Healthcare pricing is based on systemic violations of decades-old consumer protection laws which are normally applied in every other industry.
These include the Robinson-Patman act of 1935 and the Clayton Antitrust act of 1914, and the Sherman antitrust act of 1890.
We already have laws which forbid most of what the Healthcare industry routinely does in pricing. How about enforcing them?
For health care, bring on market force:
1. Break most hospitals into two highly competitive entities
2. Convert other hospitals into real estate leasing entities with competing surgical suites and nursing wings
3. Separate out drug coverage so hospital systems can run care coverage systems and cut out insurance company overhead and meddlers. Hospital system plans might charge an age-related fee if you lack a drug plan listed by the hospital system plan.
4. Create interstate drug plans that don’t have to cover every drug. To qualify for exchange listing and federal subsidies, they would have to most (~80% or more) in all important types (large volume recombinant, small volume recombinant, breakthroughs under patent, etc.). Group and exchange plans to offer vouchers at plan set amounts for out-of-formulary drugs. Plans without minimums (or vouchers) could be vended directly to individuals and families.
5. These plans would be all the doctors (and AI) prescribe for formulary drugs with co-pays equal to manufacturing cost
6. Have drug patents limited by government sourced product revenue and overall domestic government health care spending and not by time [so drug companies have an incentive to minimize government health care funding]
7. Require Kirchoff patent collapse to a single entity upon FDA marketing approval of a covered entity
8. reform medical education, breaking down medicine and dentistry into simpler chunks and start it in the first year of college
9. replace most primary care doctoring with AI
(human doctor would confirm AI diagnosis, orders for expensive tests[MRI, genetic], prescribe radiation imaging/treatment, and voucher/government co-pay drugs)
10 - The ability to obtain a PPO plan nationwide, so you can healthcare shop nationwide.
....
To confirm your appointment for Tuesday, 11/18/2025 for 30 minutes, you will need to pay your co-pay at this time.
....
Doctor Primary, to receive autopay, you must submit your daily billing for all coverage providers to CMS by clicking on SUBMIT. This is done via a CMS contractor to cut down on fraud.
....
CMS $2457 billed
Aetna $1895 billed
UHC $1265 billed
UHC $1265 paid
Aetna $1895 paid
CMS $2457 paid
As you are aware, providers may object to and eventually claw back unjustified claims within 30 days of payment. If you have more than the contracted for amount of clawback requests, you will have to wait for payment by human clerical means.
If that fellow in NY had not killed the United Health Care CEO someone else would. Just a matter of time.
My experience with that outfit has been minor compared to what some others may have faced but for two years now I have been arguing with them over getting our accounts straight. They have randomly applied two separate checks, one for my account and one for my wife’s, to each of the accounts and blame everyone but themselves. The state insurance board has been surprisingly helpful and United fears them but the company is completely screwed up. Just a first class mess.
Where would anyone start to reform the health care mess? Perhaps with the insurance by state, introduce competition, return to not for profit hospitals? Is there any model in the world that works at reasonable cost?
The back-shooting assassin didn't even have insurance with United Health Care.
UnitedHealthcare CEO murder suspect was not an insured member, company says
“10 - The ability to obtain a PPO plan nationwide, so you can healthcare shop nationwide.”
I doubt Snakeville General Hospital’s plan would generally pay for care at the Mayo Clinic.
You would probably have to buy a Mayo Clinic (or insurance company) plan and then get reduced co-pays if you got care at a cheaper hospital system.
There is the matter of out-of-network care. The patient co-pays are going have to be higher for such care. The out-of-network stick is the negotiating tool insurance companies have.
Splitting hospitals into two will reduce the out-of-network problem.
Only states can fix the out-of-network problem. The federal government can only provide carrots & sticks via PPACA subsidies and Medicaid percentages.
I don’t think that matters.
If I want to appeal my county property tax assessment, I have to pay the tax the county wants before the appeal is argued.
So you approve of assassinating people if you disapprove of what they do for a living?
I have to live in 2 states, 1,000 miles apart, which is a joy with Obamacare.
Since you mentioned Mayo: If you’re on a Medicare Advantage plan, you may find Mayo isn’t accepting Medicare Advantage plans on 1/1.
In my youth, my mom took me to a place with 5 doctors total and 2 receptionists on duty.
As I recollect, it had weekday evening and Saturday hours.
This is a possible reinsurance model PPACA replacement scheme:
US citizens and lawfully present persons of a US resident household shall be eligible for coverage as per the PPACA.
The federally subsidy eligible expenses of each eligible issued policy shall be:
1. 85% of Medicare Part A scope coverage provider payouts,
2. 80% of Medicare Part B scope coverage provider payouts, plus
3. 80% of prescription drug coverage provider payouts on a policy.
Uncle Sam shall pay a share of the federally subsidy eligible expenses of each eligible policy equal to 30%,
plus 1/6th of each policyholders’ household premium calculation percentage below 400% of FPL that is above 40%.
[The 30% is to mainly cover the costs of chronic condition people.]
A policyholders’ premium calculation percentage shall be the lesser of 100% or 25 times:
their statutorily expected household monthly income,
less claimed expenses [subject to insurer confirmation]
divided by 1/12th the annual FPL amount for the covered household size.
Extractable profit to not exceed:
1. 1% of the Medicare amount, plus $100, for each inpatient episode paid within 30 days of initial correct provider billing and within 60 days of initial provider billing,
2. 1% of the Medicare amount, plus $8, for each other provider bill paid to the contracted amount within 30 days of initial correct provider billing and within 60 days of initial provider billing,
3. $1 for each off-patent drug prescription paid for, $3 if for 90 days,
4. $5 for each patented drug prescription paid for within 30 days of the policy year, $15 if for 90 days, and
5. $20 for each recombinant drug provision paid for within 30 days of the policy year.
Administrative related and in-house care costs shall not exceed the extractable profit limit, any applicable reasonable state law limit, or any policy limit.
Insurers may, with reasonable 30-days online posted notice, raise premiums of a PPACA policy type to reasonably expect to reach the extractable profit level based on actual and reasonably forecast expenses during the calendar year, subject to a 5% monthly premium rise cap.
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