How to Charge $546 for Six Liters of Saltwater

[Zach]

How to Charge $546 for Six Liters of Saltwater

http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html?pagewanted=all&_r=0

The New York Times
August 25, 2013

By NINA BERNSTEIN

It is one of the most common components of emergency medicine: an intravenous bag of sterile saltwater.

Luckily for anyone who has ever needed an IV bag to replenish lost fluids or to receive medication, it is also one of the least expensive. The average manufacturer’s price, according to government data, has fluctuated in recent years from 44 cents to $1.

Yet there is nothing either cheap or simple about its ultimate cost, as I learned when I tried to trace the commercial path of IV bags from the factory to the veins of more than 100 patients struck by a May 2012 outbreak of food poisoning in upstate New York.

Some of the patients’ bills would later include markups of 100 to 200 times the manufacturer’s price, not counting separate charges for “IV administration.” And on other bills, a bundled charge for “IV therapy” was almost 1,000 times the official cost of the solution.

It is no secret that medical care in the United States is overpriced. But as the tale of the humble IV bag shows all too clearly, it is secrecy that helps keep prices high: hidden in the underbrush of transactions among multiple buyers and sellers, and in the hieroglyphics of hospital bills.

At every step from manufacturer to patient, there are confidential deals among the major players, including drug companies, purchasing organizations and distributors, and insurers. These deals so obscure prices and profits that even participants cannot say what the simplest component of care actually costs, let alone what it should cost.

And that leaves taxpayers and patients alike with an inflated bottom line and little or no way to challenge it.

A Price in Flux

In the food-poisoning case, some of the stricken were affluent, and others barely made ends meet. Some had private insurance; some were covered by government programs like Medicare and Medicaid; and some were uninsured.

In the end, those factors strongly (and sometimes perversely) affected overall charges for treatment, including how much patients were expected to pay out of pocket. But at the beginning, there was the cost of an IV bag of normal saline, one of more than a billion units used in the United States each year.

“People are shocked when they hear that a bag of saline solution costs far less than their cup of coffee in the morning,” said Deborah Spak, a spokeswoman for Baxter International, one of three global pharmaceutical companies that make nearly all the IV solutions used in the United States.

It was a rare unguarded comment. Ms. Spak — like a spokesman for Hospira, another giant in the field — later insisted that all information about saline solution prices was private.

In fact, manufacturers are required to report such prices annually to the federal government, which bases Medicare payments on the average national price plus 6 percent. The limit for one liter of normal saline (a little more than a quart) went to $1.07 this year from 46 cents in 2010, an increase manufacturers linked to the cost of raw materials, fuel and transportation. That would seem to make it the rare medical item that is cheaper in the United States than in France, where the price at a typical hospital in Paris last year was 3.62 euros, or $4.73.

Middlemen at the Fore

One-liter IV bags normally contain nine grams of salt, less than two teaspoons. Much of it comes from a major Morton Salt operation in Rittman, Ohio, which uses a subterranean salt deposit formed millions of years ago. The water is local to places like Round Lake, Ill., or Rocky Mount, N.C., where Baxter and Hospira, respectively, run their biggest automated production plants under sterility standards set by the Food and Drug Administration.

But even before the finished product is sold by the case or the truckload, the real cost of a bag of normal saline, like the true cost of medical supplies from gauze to heart implants, disappears into an opaque realm of byzantine contracts, confidential rebates and fees that would be considered illegal kickbacks in many other industries.

IV bags can function like cheap milk and eggs in a high-priced grocery store, or like the one-cent cellphone locked into an expensive service contract. They serve as loss leaders in exclusive contracts with “preferred manufacturers” that bundle together expensive drugs and basics, or throw in “free” medical equipment with costly consequences.

Few hospitals negotiate these deals themselves. Instead, they rely on two formidable sets of middlemen: a few giant group-purchasing organizations that negotiate high-volume contracts, and a few giant distributors that buy and store medical supplies and deliver them to hospitals.

Proponents of this system say it saves hospitals billions in economies of scale. Critics say the middlemen not only take their cut, but they have a strong interest in keeping most prices high and competition minimal.

The top three group-purchasing organizations now handle contracts for more than half of all institutional medical supplies sold in the United States, including the IVs used in the food-poisoning case, which were bought and taken by truck to regional warehouses by big distributors.

These contracts proved to be another black box. Debbie Mitchell, a spokeswoman for Cardinal Health, one of the three largest distributors, said she could not discuss costs or prices under “disclosure rules relative to our investor relations.”

Distributors match different confidential prices for the same product with each hospital’s contract, she said, and sell information on the buyers back to manufacturers.

A huge Cardinal distribution center is in Montgomery, N.Y. — only 30 miles, as it happens, from the landscaped grounds of the Buddhist monastery in Carmel, N.Y., where many of the food-poisoning victims fell ill on Mother’s Day 2012.

Among them were families on 10 tour buses that had left Chinatown in Manhattan that morning to watch dragon dances at the monastery. After eating lunch from food stalls there, some traveled on to the designer outlet stores at Woodbury Commons, about 30 miles away, before falling sick.

The symptoms were vicious. “Within two hours of eating that rice that I had bought, I was lying on the ground barely conscious,” said Dr. Elizabeth Frost, 73, an anesthesiologist from Purchase in Westchester County who was visiting the monastery gardens with two friends. “I can’t believe no one died.”

About 100 people were taken to hospitals in the region by ambulance; five were admitted and the rest released the same day. The New York State Department of Health later found the cause was a common bacterium, Staphylococcus aureus, from improperly cooked or stored food sold in the stalls.

Mysterious Charges

The sick entered a health care ecosystem under strain, swept by consolidation and past efforts at cost containment.

For more than a decade, hospitals in the Hudson Valley, like those across the country, have scrambled for mergers and alliances to offset economic pressures from all sides. The five hospitals where most of the victims were treated are all part of merged entities jockeying for bargaining power and market share — or worrying that other players will leave them struggling to survive.

The Affordable Care Act encourages these developments as it drives toward a reimbursement system that strives to keep people out of hospitals through more coordinated, cost-efficient care paid on the basis of results, not services. But the billing mysteries in the food poisoning case show how easily cost-cutting can turn into cost-shifting.

A Chinese-American toddler from Brooklyn and her 56-year-old grandmother, treated and released within hours from the emergency room at St. Luke’s Cornwall Hospital, ran up charges of more than $4,000 and were billed for $1,400 — the hospital’s rate for the uninsured, even though the family is covered by a health maintenance organization under Medicaid, the federal-state program for poor people.

The charges included “IV therapy,” billed at $787 for the adult and $393 for the child, which suggests that the difference in the amount of saline infused, typically less than a liter, could alone account for several hundred dollars.

Tricia O’Malley, a spokeswoman for the hospital, would not disclose the price it pays per IV bag or break down the therapy charge, which she called the hospital’s “private pay rate,” or the sticker price charged to people without insurance. She said she could not explain why patients covered by Medicaid were billed at all.

Eventually the head of the family, an electrician’s helper who speaks little English, complained to HealthFirst, the Medicaid H.M.O. It paid $119 to settle the grandmother’s $2,168 bill, without specifying how much of the payment was for the IV. It paid $66.50 to the doctor, who had billed $606.

At White Plains Hospital, a patient with private insurance from Aetna was charged $91 for one unit of Hospira IV that cost the hospital 86 cents, according to a hospital spokeswoman, Eliza O’Neill.

Ms. O’Neill defended the markup as “consistent with industry standards.” She said it reflected “not only the cost of the solution but a variety of related services and processes,” like procurement, biomedical handling and storage, apparently not included in a charge of $127 for administering the IV and $893 for emergency-room services.

The patient, a financial services professional in her 50s, ended up paying $100 for her visit. “Honestly, I don’t understand the system at all,” said the woman, who shared the information on the condition that she not be named.

Dr. Frost, the anesthesiologist, spent three days in the same hospital and owed only $8, thanks to insurance coverage by United HealthCare. Still, she was baffled by the charges: $6,844, including $546 for six liters of saline that cost the hospital $5.16.

“It’s just absolutely absurd.” she said. “That’s saltwater.”

Last fall, I appealed to the New York State Department of Health for help in mapping the charges for rehydrating patients in the food poisoning episode. Deploying software normally used to detect Medicaid fraud, a team compiled a chart of what Medicaid and Medicare were billed in six of the cases.

But the department has yet to release the chart. It is under indefinite review, Bill Schwarz, a department spokesman, said, “to ensure confidential information is not compromised.”

# # #

[Bill Peckham]

Interesting article - great angle on a sort of routine food poisoning event. What a nutty system. The question unanswered is what should it cost? The thing that stands out though is that they describe this as a cost shift, but who in this story is underpaying? Is the $120 Medicaid paid (with $65 more going to the doc) so low? That seems pretty reasonable, maybe too low but so low that it justifies the other charges? No way. What exactly are the over payments suppose to be getting us?

[Quickfeet]

To be fair, you aren't really just paying for a bag of salt water. You are paying for the building, the utility bills, nurses, doctors, malpractice insurance, building insurance, custodial staff, billing depart, financial depart, management, lawn care, and whatever else they have to pay for whether you're there or not.

In retail some things get lots of markup while some things have little to no markup. A business for example might have 80% margin on luggage but have 1% on video game systems. A company (can't give the name) that I used employee me, only made 1 cent profit out every dollar spent by the customer. So, is a t-shirt that was made in china for a dollar worth 20? Well the company only made 20 cents off the deal.

I also am aware that despite all of what I said, I know people are getting rich off all this now matter what. Guaranteed

[Rerun]

No matter how many articles we read or documentaries we see on this subject, someone is always surprised when they write a news story.  No one pays any attention until they get S I C K then it is breaking news.  Hey, America!  We are getting screwed. 

Then no one does anything about it.

         

[NDXUFan]

Interesting article - great angle on a sort of routine food poisoning event. What a nutty system. The question unanswered is what should it cost? The thing that stands out though is that they describe this as a cost shift, but who in this story is underpaying? Is the $120 Medicaid paid (with $65 more going to the doc) so low? That seems pretty reasonable, maybe too low but so low that it justifies the other charges? No way. What exactly are the over payments suppose to be getting us?

Bill, you are sharp enough to figure out what we are getting, NOTHING!!!!

[Bill Peckham]

Interesting article - great angle on a sort of routine food poisoning event. What a nutty system. The question unanswered is what should it cost? The thing that stands out though is that they describe this as a cost shift, but who in this story is underpaying? Is the $120 Medicaid paid (with $65 more going to the doc) so low? That seems pretty reasonable, maybe too low but so low that it justifies the other charges? No way. What exactly are the over payments suppose to be getting us?

Bill, you are sharp enough to figure out what we are getting, NOTHING!!!!

Actually we're getting a medical system that allows 100 people to be poisoned, scattered around Upstate NY and all live to tell the tale. The issue is with the people in the article saying this is due to cost shifts, that these people may have overpaid based on the actual value of the service but that makes up for those who underpay, well who underpaid? Everyone in the article paid to a degree, some much more than others, who isn't paying their way that this money is suppose to be supporting?

[Bill Peckham]

Bill, you are sharp

Mark, have you read the site rules yet? I haven't seen an introductory post from you.

[Rerun]

                       

Yes please go introduce yourself.

Rerun, Moderator

[Hemodoc]

To be fair, you aren't really just paying for a bag of salt water. You are paying for the building, the utility bills, nurses, doctors, malpractice insurance, building insurance, custodial staff, billing depart, financial depart, management, lawn care, and whatever else they have to pay for whether you're there or not.

In retail some things get lots of markup while some things have little to no markup. A business for example might have 80% margin on luggage but have 1% on video game systems. A company (can't give the name) that I used employee me, only made 1 cent profit out every dollar spent by the customer. So, is a t-shirt that was made in china for a dollar worth 20? Well the company only made 20 cents off the deal.

I also am aware that despite all of what I said, I know people are getting rich off all this now matter what. Guaranteed

Actually, you are mainly paying for the unfunded federal mandates where the costs are shifted from those not able to pay to those that can through health insurance. That is also one of the reasons health insurance itself costs so much.

At my lead medical center in CA, Kaiser Panorama City is right in the middle of gang banger territory. They have "free" health care at the county hospital not far away, but they prefer to go to Kaiser that gives them better care. Kaiser on their part MUST treat until they are stable enough for transfer. In the case of these gang bangers, they often drop off a friend after he is shot or stabbed. The ER costs alone are speak nothing of the incredible strain for ICU and surgical care of which Kaiser gets NOTHING in recompense. Many of these thugs give aliases so you don't really even know for sure who they are treating.

So, why does saline cost so much? Unfunded federal mandates are a big part of that cost inflation. Even so, hospitals all across the US are closing down due to not being able to sustain their facilities and meet pay rolls.

[Bill Peckham]

To be fair, you aren't really just paying for a bag of salt water. You are paying for the building, the utility bills, nurses, doctors, malpractice insurance, building insurance, custodial staff, billing depart, financial depart, management, lawn care, and whatever else they have to pay for whether you're there or not.

In retail some things get lots of markup while some things have little to no markup. A business for example might have 80% margin on luggage but have 1% on video game systems. A company (can't give the name) that I used employee me, only made 1 cent profit out every dollar spent by the customer. So, is a t-shirt that was made in china for a dollar worth 20? Well the company only made 20 cents off the deal.

I also am aware that despite all of what I said, I know people are getting rich off all this now matter what. Guaranteed

Actually, you are mainly paying for the unfunded federal mandates where the costs are shifted from those not able to pay to those that can through health insurance. That is also one of the reasons health insurance itself costs so much.

At my lead medical center in CA, Kaiser Panorama City is right in the middle of gang banger territory. They have "free" health care at the county hospital not far away, but they prefer to go to Kaiser that gives them better care. Kaiser on their part MUST treat until they are stable enough for transfer. In the case of these gang bangers, they often drop off a friend after he is shot or stabbed. The ER costs alone are speak nothing of the incredible strain for ICU and surgical care of which Kaiser gets NOTHING in recompense. Many of these thugs give aliases so you don't really even know for sure who they are treating.

So, why does saline cost so much? Unfunded federal mandates are a big part of that cost inflation. Even so, hospitals all across the US are closing down due to not being able to sustain their facilities and meet pay rolls.

huh, interesting. If only we could mandate that people have their own insurance, think of all the money it would save the system.

[Hemodoc]

Yes, you mean insurance that they can't afford? You mean getting employers to take the IRS fine instead of expensive health insurance. You mean a law that forces people into part time work WITHOUT any benefits. You mean a law that forces employers to drop family and spouses from health coverage as several large companies have done in the last couple of weeks. Yes, that is a great law Bill.

[rocker]

Actually, you are mainly paying for the unfunded federal mandates where the costs are shifted from those not able to pay to those that can through health insurance. That is also one of the reasons health insurance itself costs so much.

Nonsense.  Probably the largest expense in all of this is profit.  Many large "non-profit" hospital chains take in 20-50% more than they spend every year.  That's how you get the huge executive salaries, and hospital areas that have virtually turned into cities of high-rises.  They have to keep spending and spending. I live near a middling-size city, and it has at least three hospital areas covering many blocks.  Not to mention their many outlying hospitals in surrounding areas.  You know, I could really do without that $30 million lobby renovation you were bragging about.  How about putting that money into actual care?

And of course, they aren't giving any of that money back in taxes.  In fact, I have a line item on my property taxes, roughly 8-10% of my taxes.  It is a payment that is just handed to the large, very profitable hospital in my town.  For what?  It's not like I get a discount there.

You've really got to stand in awe of their lobbyists.  "Here, how about you make everyone just give us money for nothing?"  "OK!"

And as the article points out, since there's nothing resembling an open market in healthcare, that profit is taken at every level of the system - from manufacturers to distributors to salespeople.

Probably the second-largest expense in the system is the enormous cost of private insurance.  Hospitals employ armies - armies - of people whose sole job is to make sure that the billing complies with every niggling jot and tittle demanded by private insurers - because every private insurer has a completely different process.  And every claim they can deny for some reason goes straight to their bottom line.  A paid claim is a failure for the insurance company.

hospitals all across the US are closing down due to not being able to sustain their facilities and meet pay rolls.

Statistics on that?

[Bill Peckham]

Yes, you mean insurance that they can't afford?

You're right there should be subsidies otherwise it wouldn't be fair! Maybe they should provide subsidies on a sliding scale or something. All the way up to a pretty high level of income, even people making 350% of the federal poverty level ought to get some help.

You mean getting employers to take the IRS fine instead of expensive health insurance.

It's a free country. Employers aren't forced to provide health insurance but maybe there should be fine if they don't since their employees will instead be getting their health insurance elsewhere and be eligible for the subsidies we both think are a good idea.

You mean a law that forces people into part time work WITHOUT any benefits.

People are going to be forced to work part time? By who? How? Or are you saying that there will be fewer full time jobs, and people who want full time jobs will only be able to find part time jobs because of Obamacare? There is a job crisis that is ongoing in this country, you can see it in this chart, but in general despite the ongoing constriction in Public sector job growth the overall employment rate is improving. Individuals need to have health insurance, it's a public good, it is the law of the land, you said that the current system of allowing people to be uninsured - those dang gang members, driving up everyone's health care costs - adds huge expense to the system. So it makes sense that we mandate that everyone carry health insurance, and we should specify what that insurance covers and how it is priced so that people with preexisting conditions can buy coverage at the community rate and the coverage will support the standard of care we have come to expect we need to spell out what health insurance should cover to be called comprehensive health insurance.

All that seems to me to be the ante for having a functioning economy in the 21st century. On top of that you need to have an economy that provides gainful employment for your citizens. The solution is more full time jobs with health benefits not more full time jobs without health benefits.

You mean a law that forces employers to drop family and spouses from health coverage as several large companies have done in the last couple of weeks.

The law forced employers to eliminate coverage for spouses who have other sources of coverage? Forced how? By who? How is this different from the way companies scaled back the value of health benefits in the past? How is what's happening today - some companies adding benefits, some scaling back - different from what's happened in the past?

Yes, that is a great law Bill.

You're right! A law that requires health insurance to provide coverage so that if needed it will fund medical care that meets community standards and a law that requires that comprehensive health insurance be made available to people at a community rate regardless of preexisting conditions or gender. And just to be politically astute we should limit the premium penalty as people age, and we should let kids stay on their parent's insurance until they're older ... say 26? Now that we've defined what we mean by comprehensive health insurance, and set up a system of subsidies, the law should require that everyone carry their own health insurance. Peter, I think this could improve the situation compared to how it was say in 2010. Nice work!

[Hemodoc]

Bill, how are you going to increase employment when companies such as Delta announce that ObamaCare will cost them more than $100,000,000 in the next year alone. Yes, we all agree that we should have better coverage and more employment, but Obama and his "fiscal" policies and the ACA will not accomplish either. So it is not the goals that we disagree upon, but the socialistic approach employed by this administration.

[rocker]

Bill, how are you going to increase employment when companies such as Delta announce that ObamaCare will cost them more than $100,000,000 in the next year alone. Yes, we all agree that we should have better coverage and more employment, but Obama and his "fiscal" policies and the ACA will not accomplish either. So it is not the goals that we disagree upon, but the socialistic approach employed by this administration.

I swear that you kids these days use "socialism" as a synonym for "ikky".

Please tell me your working definition of "socialism", and explain what is socialist about the ACA.

[Hemodoc]

Bill, how are you going to increase employment when companies such as Delta announce that ObamaCare will cost them more than $100,000,000 in the next year alone. Yes, we all agree that we should have better coverage and more employment, but Obama and his "fiscal" policies and the ACA will not accomplish either. So it is not the goals that we disagree upon, but the socialistic approach employed by this administration.

I swear that you kids these days use "socialism" as a synonym for "ikky".

Please tell me your working definition of "socialism", and explain what is socialist about the ACA.

I agree, you are correct, socialism is "icky." Spot on.

Definition, well how about a description, European style socialism is what Obama is putting into place. Universal health care has been a goal of the left for decades. Thank you for calling me a kid, but that doesn't really apply my friend.

[rocker]

Definition, well how about a description

Right, no definition.

European style socialism is what Obama is putting into place. Universal health care has been a goal of the left for decades. Thank you for calling me a kid, but that doesn't really apply my friend.

Don't forget, Obama also breathes oxygen and eats food - just like European Socialists.

[Hemodoc]

Definition, well how about a description

Right, no definition.

European style socialism is what Obama is putting into place. Universal health care has been a goal of the left for decades. Thank you for calling me a kid, but that doesn't really apply my friend.

Don't forget, Obama also breathes oxygen and eats food - just like European Socialists.

Well, you give your definition my friend, as if anyone can define completely a political system without someone making an objection. Nevertheless, not much sense debating what socialism is or isn't with you. If you don't understand Obama's goals at this point, not much sense in that conversation either. In any case, have a great day.

[Bill Peckham]

Well, you give your definition my friend, as if anyone can define completely a political system without someone making an objection. Nevertheless, not much sense debating what socialism is or isn't with you. If you don't understand Obama's goals at this point, not much sense in that conversation either. In any case, have a great day.

The VA is an example of a socialistic delivery of healthcare. Docs are paid by the VA, the VA owns the hospitals, etc.  Obamacare is nothing like that, at all. The law requires people to carry comprehensive health insurance. It doesn't produce or supply health insurance, much less health care.

Peter you like to ascribe motivations to Obama, but that is all you are doing, ascribing motives based on your political biases. The law is what it is. It does what it does. There is no need to consider the motives of people who support or oppose the ACA to understand what it does.

[Hemodoc]

Bill,

I am not sure what point you are trying to make. If you are defending socialized medicine, the VA is NOT an example of success at all.

http://www.usatoday.com/story/opinion/2013/08/21/va-veterans-disability-claims-backlog-editorials-debates/2683167/

In short, public funded healthcare is essentially socialized medicine for a short definition. The motives of the ACA is indeed to move the entire system to a single payer public sector health system. The fines to employers are only a fraction of the cost of providing health care so the incentives under the ACA is to move more and more people into the exchanges with subsidies. Over a matter of a few years, the ACA will completely destroy the employer based health provisions. At some point, the call will be to move to a single payer system. Motives, yes, Harry Reid is speaking plainly that that is the goal.

http://www.forbes.com/sites/theapothecary/2013/08/10/sen-harry-reid-obamacare-absolutely-a-step-toward-a-single-payer-system/

[Bill Peckham]

Bill,

I am not sure what point you are trying to make. If you are defending socialized medicine, the VA is NOT an example of success at all.

http://www.usatoday.com/story/opinion/2013/08/21/va-veterans-disability-claims-backlog-editorials-debates/2683167/

In short, public funded healthcare is essentially socialized medicine for a short definition. The motives of the ACA is indeed to move the entire system to a single payer public sector health system. The fines to employers are only a fraction of the cost of providing health care so the incentives under the ACA is to move more and more people into the exchanges with subsidies. Over a matter of a few years, the ACA will completely destroy the employer based health provisions. At some point, the call will be to move to a single payer system. Motives, yes, Harry Reid is speaking plainly that that is the goal.

http://www.forbes.com/sites/theapothecary/2013/08/10/sen-harry-reid-obamacare-absolutely-a-step-toward-a-single-payer-system/

Then you admit that the ACA isn't socialism since it doesn't publically fund health care. You know Peter, you talk in circles a lot, you have a habit of self refuting.

My point, which seems pretty clear, is that words have defined meanings, socialism has a defined meaning: collective or governmental ownership and administration of the means of production. In the case of healthcare it would mean the ownership and administration of hospitals and clinics, just like the VA. The ACA doesn't do anything of the sort. I didn't pass any judgement on the quality of the VA but I'd note that the link you googled up a is a non sequitur and has no bearing on the quality of healthcare provided by the VA, only that a lot people are clamoring for access and the VA takes a long time to fulfill its gatekeeper role.

Just because you don't like socialism and you don't like the ACA does not make the ACA socialistic.

[Hemodoc]

The ACA doesn't fund health care! Are you serious Bill?

Just because it doesn't fund 100% of health care does not in any sense diminish the expansion the public sector health care nor the new subsidies on the exchanges nor shunting more from the private sector into the government sponsored exchanges.

In addition, you are overlooking the massive takeover and of the ENTIRE health care system which is NOW controlled by the government. If you cannot understand the socialistic nature of the entire ACA, there is little point in further discussion.

In addition, it is getting tiresome to read your absurd and false insults against me in almost all of your responses. Bill, if you wish to discuss politics, you have stated on many occasion you enjoy that so let's talk politics if you wish. I have not ventured into trading insults against you in response to yours simply because I still respect your friendship and your contributions mentoring me in blogging and introducing me to those in dialysis advocacy.

[rocker]

The ACA doesn't fund health care! Are you serious Bill?

Just because it doesn't fund 100% of health care does not in any sense diminish the expansion the public sector health care nor the new subsidies on the exchanges nor shunting more from the private sector into the government sponsored exchanges.

You don't seem to realize that your "government sponsored exchanges" consist entirely of private companies.  There is no (zip zilch nada) government agency that one can purchase insurance from.

More's the pity.

In addition, you are overlooking the massive takeover and of the ENTIRE health care system which is NOW controlled by the government. If you cannot understand the socialistic nature of the entire ACA, there is little point in further discussion.

On this I must agree.  As long as you keep repeating hysterical falsehoods like "the government has taken over healthcare!!!1111", there is no point in discussing, as you are entirely detached from reality.

[Hemodoc]

Sorry Rocker, it appears you don't understand what socialism really is which is probably not surprising since most folks don't understand the concept of socialism. Marx understood socialism quit well. He states it is an intermediate stage between capitalism and communism where collectivist philosophies prevail as the underlying hallmark of the economy and government control over all of these elements.

Thus, back to your question defining socialism, the issue why you cannot precisely define socialism or whether a given system is "socialistic" is simply because it is a transitional state that is not static. That is why Bill, Obama's motives do matter and why Harry Reid's statement that the goal is a single payer system are entirely relevant to this discussion.

Rocker, simply because the government does not yet own the bricks for all of the health care facilities does not in the least prevent you from understanding how the ACA is moving from a capitistic/individualistic system to a collectivist/government controlled system. The exchanges are paving the way for a single payer system in that all of the private insurers are dictated to on coverage details in large part eliminating competition between the different insurance companies. Competition as you must be aware is one of the hallmarks of capitalism.

In addition, you are ignoring the impact of ACO's on the current fee for practice, i.e., private practice that has put the final nail in the coffin eliminating this last vestige of capitalism in American medical practice. And yes, it is the ACA that brings this into place:


The Patient Protection and Affordable Care Act (ACA) authorizes the use of Accountable Care
Organizations (ACOs) to improve the safety and quality of care and reduce health care costs in
Medicare. The ACO program – a voluntary program – began on January 1, 2012. This is not a
demonstration project or pilot, it creates a new entity, an ACO that can directly contract with
Medicare. 

http://www.acponline.org/advocacy/where_we_stand/assets/aco.pdf

So Rocker, please don't fall into place with Bill's insults by adding your own against me in your commentaries when in fact you are simply demonstrating your own ignorance of what socialism truly is or isn't and how the ACA is indeed a very socialistic law. If you wish to discuss politics, go for it. If you wish to insult me with your insinuations that I am ignorant, you may be taking on more than you wish my friend.

[Icare]

We lived an hour from the Canadian boarder for 50 years and I can tell you government health care SUCKS! We got to talk to people who came to the states for cancer treatments and payed out of pocket because they were on a one year waiting list in Canada.. When you here about doctors leaving their practices it not a joke or a threat. Malpractice with all the law suites are what drives up cost! Trust me within the next ten years dialysis patients will be seen as a cancer to the health care system. The people that will be making the laws have seen us kill unborn babies by the millions, So who to hell will care about a million kidney patients? Wake up America!!