Hi-I'm Rick Ungar, columnist at Forbes.com on healthcare policy and polltics...ask me anything!

When a person uses charity care at a local hospital, does the hospital cover the entire cost, or does the government pay some of what is owed?

Typically, there is some portion of this type of care that is picked up either by local, state or the federal government - but not enough to keep hospitals from experiencing serious financial trouble as a result of unpaid care. The real 'payers' of unpaid care in hospitals are those of us who purchase health insurance as the hospitals boost their charges for services to include their loses from charity care and it is passed along to the rest of us.

Whose healthcare plan do you think would be the best choice for the average middle/low middle class American? Why? Honestly.

That's extremely hard to answer because not everyone is in the same circumstance, even if they are in similar financial circumstances. I think people should assess their own potential for falling seriously ill. If you have a father and a grandfather who each had heart problems, don't kid yourself into imagining that it cannot happen to you. If this is case, you may want to buy a plan with a lower deductible. In my case, I come from a perfectly awful gene pool so there was always a strong possibility that, no matter how well I took care of myself, I might face problems-which I did. Figure out what is going to give you and your family the best protection and assign the appropriate priority.

Thank you for your response. I have a good healthcare plan through my work, but would like to give some of the families I work with good options. So that being said, which plan do you think would be better for people who have children with disabilities?

I'm afraid that this is just not something I can answer. Plans that are offered vary from region to region. What I would suggest is that you try to locate a good insurance rep and sit down with this person, review the circumstances and hear what the options are.

Do you think there is any way to make healthcare not be an issue of finances and politics? Do you think every American citizen could ever have access to healthcare?

Probably not. I most certainly do think that every American should have access to health care. Indeed, we are the only industrialized nation in the world where health care is a privilege and gun ownership is a right. In every other industrialized nation, it is exactly the reverse. But I doubt that that the politics can ever be removed as, at the heart of the question, are true ideological points of disagreement that are too attractive to politicians to avoid. As for financing, it is a problem the world over. Health care continues to get more expensive-partially for bad reasons and partially for good reasons (all the technology that keeps us alive and functional for so much longer costs a lot of money). As a result, we are going to face the financing issue for a very long time until someone can figure out a way to deliver high quality care at a price that does not suck up so much of our GDP.

Does the VA system in the US cost more or less compared to all the veteran's covered being on medicare/medicaid? That is, would the US save money if medicare and medicaid were ended with the replacement being a VA like government health care system for the needy?

Very interesting question! First, you have to acknowledge that the VA system is as close to a purely socialistic medical system as one can get. Depending on who you ask, the VA is either the greatest thing since chopped liver or an absolute disaster. I find that it varies from city to city. While I think it would be an interesting experiment to begin by moving Medicaid patients to the VA system, it would have to be done slowly and carefully so as not to overwhelm the system. Also, there would be some complications in financing as states and the federal government share the cost of Medicaid. As for Medicare, again, moving everyone over to the VA would swamp the system. This is the sort of thing that must be done carefully and slowly or some serous disasters could result. But, in theory, there is something to the idea-if the American people were ever willing to accept the idea of 100 percent government provided healthcare for so many Americans.

what do you see the role of health economics and outcomes research playing into the development of our healthcare system?

Economics always plays key role. Using outcomes as guidance is a bit more controversial. At the end of the day, it only makes sense to use outcomes to guide treatment policy. But we have to acknowledge that there will be instances where that data may not be the best answer when you are the patient and your doctor wants to try something unconventional. We need to use outcomes-but allow for exceptions so long as the exceptions are not over utilized by physicians.

Are you in favor or against more government control of the healthcare system?

I don't think there is a 'one answer fits all' to that question. There are instances where government can play a very useful role in the delivery of healthcare. Other instances where it may not be necessary. If you can get a bit more specific, I may be able to give you a more direct response.

Would a government option be useful? What areas of healthcare do you think the government can be useful in?

I do like the idea of a government option - but I would do it by extending Medicare to anyone who wants to participate. The reality is that Medicare operates at a far better efficiency than private insurance companies companies. I think we all benefit if it is opened to all ages with premiums established based on age-the younger you are, the more you pay.

What are your thoughts on appearing on FNC as a token liberal — why do you do it? I realize someone has to, but assuming you're a pretty intelligent guy, isn't cable news — especially FOX — a bit below you? As in, you're forced into insipid, meaningless discussions meant solely to entertain an ignorant demographic and 'debate' other talking heads with questionable motives, all within the 90 seconds allotted to you — no?

First, it's a lot of fun and that matters! Secondly, cable news is news these days, like it or not. As for why Fox, I simply enjoy debating more than I enjoy sitting at a table where everyone is agreeing. That's kind of boring. The art of making points on television, in small soundbites, is what it is. I admit I much prefer radio because you can wind out discussions far more effectively. But one can't dismiss the large audiences that come with TV.

A huge problem with not having health insurance is the hospital charges full price to individual cash payers. How would hospitals argue against a law that required them to charge medicare reimbursement rates for the uninsured who pay cash?

For starters, I don't think such a law would pass constitutional muster. Anyone is allowed to charge whatever they want. THe lower fees charged to Medicare and private insurance companies are the result of negotiated contracts. An effort to dictate prices (which, by the way, is what was done in Japan) would have a very difficult time getting through the Supreme Court.

There have been some questions about program efficacy, but what are your theories about why health care is so expensive in the first place? What do you think might bring down costs?

Thanks for doing this AMA!

Oddly, a major driver of healthcare costs are things that we really like. There is technology today that keeps us alive and happy that would not have been available in the past. Of course, that tech is expensive and has to be paid for. A lot of the other drivers of cost are also more complicated that people think. We can all agree that when physicians 'over test' in order to drive up the bill, this is wrong. However, when your doctor tells you that you need tests, you are not going to be concerned about the policy issue-you want every test required to discover a problem or simply tell you that you are fine. And if it is your child at issue? You will be begging for additional tests as would I. It is the very personal nature of healthcare that makes it so difficult to control costs.

It's expensive because we l want it so badly? Fear of death always builds value.

In that case, what do you think are some concrete steps government can take to determine and control costs of essential services?

That is a touchy question because when government seeks to do this, people begin screaming 'rationing'. The funny part is that the private insurance companies are already deeply involved in rationing and nobody seems to care. Gov't can control a lot of these costs through the gov't run programs like Medicare and Medicaid where it naturally has more influence. Electronic health records-the use of which has been widely expanded thanks to gov't subsidies to help doctors and hospitals convert to computer based systems- should, ultimately, lower the costs as there won't be as much doubling up on tests, etc. when a patient sees a new doctor the week after seeing another doctor who already took blood tests.

Do you see a benefit to the health care system providing more resources and incentives for healthier lifestyles to prevent the onset of many medical conditions? In a government controlled healthcare system scenario, how can programs like this be implemented without us becoming a 'Nanny State'?

It would certainly seem to make sense that fewer people will get sick if they take better care of themselves. However, you should know that there is data out there that suggests that preventative programs are not really having the impact we might have expected. In terms of programs like this being implemented by the government, tell me why when the government suggests and implements such a program it becomes 'nanny state' but when a private insurance company does the same, in the effort to improve their profits by holding down claims they must pay out, it's all good?

How much does medicare/medicaid pay for prescription drugs in a year? Would the US save money by buying all the drug companies and then releasing all their drug patents to generic manufactures? ( which would reduce the amount medicare/medicaid pays for prescription drugs )

I don't know the total costs of what is spent on drugs- but I do know that the American public would go bonkers if the government attempted to become the owner of drug companies! Many people are profoundly unhappy about the government still owning 25% of General Motors...imagine how they would feel if we became the only drug company! Seriously, this is not the best approach. As such a huge customer, wouldn't it make more sense for the CMS, which oversees Medicare and Medicaid, to use their huge bargaining power to buy the drugs at a better price?

Hi Rick-

Thanks for this awesome AMA. You're doing an incredible job answering so many questions. It's much appreciated.

My mom works at a VA hospital as an MD. She sees all kinds of really messed up stuff, as you might imagine. After Obamacare passed, she remarked offhand that it wasn't solving the real problem. I, an econ major, asked what she meant. Basically, her point was that you could expand coverage to every single person if you wanted to, but it won't actually solve the real problem. I'd always figured that the real problem was access to insurance, but she countered that it was, in fact, health. Seems obvious in retrospect. And it's a good point: access to health insurance =/= health.

My question is this: given the projected astronomical growth of health care spending and costs (and I understand that they're two separate things) over the next few decades, what is the best way to control that rise and to actually drive health care costs down?

Edit: clarification.

That's a very big question...and not one that can really be answered in this format! I might recommend my book on that subject which will hopefully be out in the next six months. Your mother is, to a large extent, correct. The best way to reduce the problems of healthcare is for people to be healthy! However, not everyone who gets seriously...and expensively...ill can do something about it. Sometimes, it just happens. What's more, we know that end-of-life care is responsible for a huge chunk of the total healthcare expenditure and that isn't going to go away- at least not until we discover the secret to immortality. Naturally, end of life care raises some very difficult questions. We can all have a point of view as to what should be an appropriate level of care when it comes to end of life- but these ideas have a funny way of changing when they are being applied to someone you love and want to keep around. As long as this is an issue, this will be a very difficult question to deal with.

Sometimes, it just happens.

Absolutely. But, I think, this is relatively rare. One of the points she makes on a regular basis is that the American diet has deteriorated in a huge way since when she was growing up. It follows that she's a huge advocate of preventative care and of what she calls "intentional eating," or what most of us, I think, would call dieting. She has a co-worker who has reversed her multiple sclerosis symptoms through maximizing her vegetable intake. Something like nine servings a day, and then cutting out lots of the crap that's in the standard american diet. (Which, appropriately, spells SAD) Do you think that this is a realistic possibility in America? I want to think it is, but part of me thinks that so many of us will just say, 'MURICA and keep eating Big Macs every day and driving SUVs and drinking Big Gulps.

I guess the question is: do you think a change of culture when it comes to health/food is necessary to control healthcare spending in the future, or can we do so simply with gov't regulations of the insurance industry?

Actually, I don't agree that this is relatively rare. While acute conditions like diabetes can be avoided by better health habits, I don't know that there is much we can do, as individuals, to avoid many cancers. sure, we can avoid smoking and lower our risk of lung cancer, but I experienced a blood cancer and I haven't a clue what I did to myself to bring that on. And while there may some situations where, as in the case of your mom's friend, she held off her multiple sclerosis symptoms by increasing vegetables, the key to that sentence is 'she held of her symptoms'. Sadly, the MS is still there and will become more expensive as it progresses. All that said, of course I am supportive of people eating right and exercising and I do believe it will make a difference. However, I really don't think it will mean the end of disease.

Have any of these titles and roles helped to get you laid?

Ha! I've been married a long time and when I was single, I didn't have any good tiles or roles!

How much credit should Wal-Mart get for reducing the cost of prescription drugs in the US? I have been taking warfarin and a statin. Totally awesome that a month's supply of each costs about $4 for each at Wal-Mart.

I would say quite a bit! But it takes a Wal-Mart to be able to use pharmaceuticals as a 'loss-leader'. They aren't making much if any money on your $4 prescription - but they are bringing you into the store where you will, presumably, spend more money on other things.

Does Romney have any good ideas for HC reform? Very odd that he is not proposing any specific policy changes.

If he does, he certainly isn't sharing them! I don't think we will know what his ideas really are until we are (a) faced with a Romney presidency should that occur and (b) the Senate flips thereby allowing the repeal of Obamacare. On the other hand, if we credit Governor Romney with what has taken place in Massachusetts, I would say he had some very good ideas- he's just turned his back on them for political benefit. Romney is not alone in pushing this 'repeal and replace' narrative...without bothering to tell us what is going to be the replacement. This has been the GOP meme for a few years now and we still have no idea what they have in mind. I think we all know why...they have nothing in mind.

Do you see much difference between for-profit and nonprofit(but not nonrevenue) healthcare as given by providers or administered by payors?

Interesting question. I think we increasingly see that even non-profits are under stress when it comes to maintaining their financial viability. And when that happens, they begin to make coverage decisions and choices that become controversial. That said, there is certainly more room for the non-profits to do a better job when the 2-4 percent profit (the norm for the for-profits) requirement is taken off their shoulders.

Is that reflected in the very few nonprofit insurers as well?

I think it is.

Why did President Obama push the exchanges to not take effect until 2014? That portion of the ACA likely effects costs more than other provisions in the bill and opens up access for millions.

The answer depends on how cynical one wants to be. Opponents of the President argue he did it so the horrors of the exchanges would not be known until after the election. Those who actually understand it, know that it takes a lot of time to organize and launch an exchange. Indeed, even states that got started early are pushing hard to make the deadline.You can't turn around this large of a ship overnight!

A lot of the industry talk, particularly around Medicaid and Medicare, revolves around payment and service delivery reform. Things like pay-for-performance, bundled payments, all the way to the implementation of the ACOs, and other similar types of innovations. All of them are generally trying to move away from a strict fee-for-service payment system.

So: Do you think any of them will actually be successful in driving down long term trends, or actually producing absolute savings to the system? Or is it all just sound and fury?

Thanks for doing this, I really enjoy your perspectives.

Good question. The honest answer is nobody really knows. This is what is so often missed about Obamacare. Most of the efforts to cut costs come by way of experimental programs because they are things we haven't done before. It would, therefore, be helpful if people would settle down and see what works and what doesn't. The early results on the ACOs are somewhat promising, but they have a long way to go before we see if they result in a serious reduction in costs.

I agree with you that it's all kind of indeterminate and experimental - but I'm kind of interested in your opinion. Are there innovations out there that you feel have a lot of potential? If you had to bet on it, what would you wager on?

Or is it all so murky that nothing stands out as something that might really be effective?

Thanks again, I appreciate your thoughtful replies all over this thread!

I do think there is real potential in some of the things that are being tried. I think that electronic health records that are being installed have great potential to save a bunch of money. I also think the ACO concept could end up paying real dividends. There is further reason to believe that moving away from the pay-per-peformance model will incentivize far more efficiency in healthcare delivery. But, we'll have to wait and see how it pans out. We already know that the use of electronic health records has given rise to some fraud and misuse by emergency rooms who are using it to boost the claimed level of service and, thereby getting paid more. Once we work out the bugs of those who misuse the technology, hopefully, we'll see it begin to save money.

If cannabis is proven to cure, treat and elevate MANY illnesses, can save lives and kill none, why is it still a schedule 1 drug and not used in the medical field when before the war on drugs was used in many medicines. US department of health even states it kills cancer cells.

You got me. I say legalize it!

Upvoted for taking your time here. Thoughts on the ICD-10 delay?

Yeah...political pressure by medical interest groups seeking to delay as it will have a negative impact on their earnings. They also are, as usual, slow to make these administrative changes and are always seeking delay.

Bit of a hypothetical question this one. . .

As a Scandinavian I'm sort of grown and bred with the idea of universal healthcare and I'm rather fond of my own system, but do you believe that the USofA could ever implement such a widescale system?

What would be the greatest challenges in attempting such a feat? Would it be delegating and allocating resources to build up such an infrastructure and system in such a large country on a federal level or is it the cultural opposition for a change of such magnitude?

I think that it is inevitable that we will get to a single-payer system as it will be the only possible solution. The biggest problem standing in the way is the lack of belief on the part of business that this will cost them less than the health care benefits they currently provide to their employees. I think that business can be shown how the tax they would pay in support of a single-payer system would cost them less than what they currently pay for health care benefits. However, it is very hard to convince them that the tax won't creep up over time and end up costing them more. If business can be convinced, we will see single-payer sooner rather than later. I also think we are approaching the time when the private, for profit health insurance business model is going to fail. When they go away because they can no longer earn a profit, government will be the only 'bank' large enough to take over the health insurance system.

Thanks for answering! Here's a followup:

Would such a system "kill" the insurance companies or would they manage to be strengthen by federal support? Is it in the interest of the federal government to keep these private companies going or they would they rather remodel and build a new system under federal organization?

I think any government offered system likely hurts the private system as they are unlikely to be able to compete and earn a profit. This is why a federally operated system will not arrive until the insurance companies can no longer make a profit even without government competition-something that we are getting very close to.

Who scored more points on the Mitt Romney tax return thing and why?

Remains to be seen. I think it was weird for him to release what he did and in the way he did it as it is now only going to restart a discussion that had faded away.

The timing of it did feel flat. I would have like to seen the release timed with a demand of Obama's college transcripts. Also the past 10 year of tax returns would have felt more transparent.

I think the demand for Obama's college transcripts has been done to death...as were the demands for Pres. Bush's college transcripts which were also never released.

Thanks for your time Mr Ungar Its great to talk politics with someone who is credible. Unless you are also the Rick Ungar that was an Executive Producer for "X-Men" the animated series I have no more questions.

As it happens, I am the same Rick Ungar who was Ep of the X-Men!

I respect your political opinions on all these matters.

However, as a man who is just about 30 years old, I'm sure you'll understand when I say:

"You're the Rick Ungar who was EP of that awesome 90's X-MEN and you decided to lead off an AMA with your Forbes stuff?"

I don't want to piss on your parade, but what are the odds we might be able to get a separate AMA from that angle later if there is a demand for it?

I'm afraid that I'm not getting your point. Are you asking if you could get an AMA on how someone who was an animation producer ends up a columnist at Forbes and an expert on health care policy???

Do hospitals have to provide charity care? If so, is it a state or national regulation? I live in NJ and I doubt a new hospital has been built in this state in decades. Are there states in the US with low regulation of what services hospitals must provide? Have those states seen an increase in hospitals operating within their borders in recent years?

Emergency rooms are obligated, under a federal law signed into being by President Reagan, to take everyone who comes into the emergency room and give them the necessary amount of care to stabilize their condition.

See, that is crap. If the government wants any person to be able to go to the emergency room it should pay for it itself.

It would be interesting to know if fewer hospitals have been opened since that law was passed compared to prior.

By the way- what you are raising is precisely why Obamacare seeks to get everyone insured.

No. Hospitals continue to open. So, you think that people who are shot on the street but can't afford the $20,000 it takes to save them in the ER should be left to die if they don't have the money? And how do we ask someone if they can afford treatment when they are brought in unconscious? Do we, as a people, believe in letting people die because they can't afford the needed care? I hope not.

This is a really complicated issue.

One that costs the government an awful lot of money every year, just on the homeless alone.

http://www.reportingonhealth.org/resources/lessons/million-dollar-homeless-patient

That isn't the source I was looking for, but it works.

Not so complicated for me. Not sure I would care to live in a society that allows people to die because they don't have the money needed to save their life. That's just not who we are and, hopefully, it is never who we will become.

What do you know about the MLR bill that is going on at the moment?

It is an effort to protect insurance agents who sell health insurance policies. Right now, they are not excluded in the definition of the medical loss ratio meaning that insurance companies are going to want to get rid of independent agents because it might take them over the percentage the insurers are allowed under the MLR before going into the penalty. The House has passed a bill to allow these independent agents to be excluded, thus protecting their business interests. We will see what the Senate does. The reason they were excluded is that they become somewhat unnecessary once the exchanges are set up and customers can go directly to the exchange to purchase health insurance, no longer needing the independent agents.

What do you think of the strategies used against smoking in countries like New Zealand and Australia. Do you think the US will eventually follow the same path?

I don't know what those strategies are. Tell us!

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Thanks for that. I think participating in the comments section is critical as it is what separates writing on-line to writing in print. And, to be honest, I'm convinced that my willingness to spend the time I do in responding to comments is largely responsible for the success of my column.

When did we get to the point where we rely on our employer to be in our healthcare decisions? I think this used to be a benefit that employers would offer to keep employees, and now its expected that they provide health care? Seems kind of strange looking back on it.

What happened to the private pay system of insurance? My mom and dad back in the 70's had to pay insurance each month on each of the members of the family? How did this disappear?

Individual insurance has not disappeared. And employer based health insurance has been prevalent since WWII. In fact, we have seen a decline in the employer health benefit over the past decade rather than an increase.

But the cost went up really dramatically. My dad runs his own 1 man business and for him and mom it is $660 a month, with no health conditions and a huge deductible.

Thanks for the info!

Costs have gone up for all insurance policies - more so in individual policies because there is no 'pool' as there is in a group policy. You'll find that the larger the pool (ie. the more employees), the lower the premium costs because the amortization opportunities are better.

It seems to me that there is a shocking conflict of interest in our system, where doctors are allowed to make decisions that put money directly in their own pockets -- ie ordering tests from labs they have ownership stakes in, ordering drugs from companies that pay them as consultants (essentially a kickback), doing studies on companies that pay them, etc.

As much crap as people give lawyers, they would be disbarred (at least here in Oregon) for doing something like that.

Would you support conflict of interest rules to ban this? Do you think it would make a difference in health care costs?

Interesting question. I think we trust doctors to do the right thing as they are dealing with our lives. That said, they don't always behave as we would like. That said, any one physician who may be taking money from a drug company is not going to have much of an impact on that drug company's bottom line. But we should require that they disclose to patients when they are taking money from a drug company.

are you related to stu? best poker player to ever live?

Not related!!! But, yes, he probably is the greatest poker player of all time!

1:Given your personal present circumstances, if you could live in any country in the world, using country's quality of healthcare/healthcare delivery regime as your only criterium, where would you live and why?

2:Disregarding your personal present circumstances (ie having a good health insurance plan and being well-off enough to pay for any additional costs: same question.

1. If I'm going purely by health care, I think I'd choose France, Australia or Taiwan. I think they each have a very intelligent system that is combined with good doctors.
2. Probably the same answer I guess.

Is it cheaper to keep a man alive than let him die?

depends on the man, doesn't it?

Do you think the policies in the ACA will one day evolve into a single payer system? If so, how long do you think it will take?

I have written that the MLR provisions of the ACA might prove to be the greatest step forward in the direction of single payer. I suspect that the health insurers are going to find it very difficult to maintain their slim profit margins (they make a ton of money but on very slim margins) with the restrictions of the MLR-something that is good for consumers but problematic for insurance companies. We are already seeing health insurance companies moving into other businesses as they know the inevitable result. How long will it take? That's not something I could know. We'll see.

How did you go from working with Marvel to writing about healthcare system? Was it a gradual process?

Long story. I got interested in health care policy in 1997 through a personal experience. I spent many years studying it (while still at Marvel) and finally reached a point where policy became more interesting to me than cartoons. When the passion for something overtakes something else you are doing, it's time to move on and do what interests you. That's what I did.

From all the figures I see the US system is by far the most expensive/inefficient healthcare system in the world. Why does this not get more traction?

I think most of us know this. Anyone who doesn't simply isn't paying attention.

This may be a bit late but I hope you do answer. What is your take on tort reform and should it have been put in the ACA?

It's a bit of a misdirection. While I do think that the states can organize their medical malpractice procedures better so as to root out nuisance lawsuits before they get to a courtroom, it is worth pointing out that these lawsuits represent just 2 percent of the total expenditure in health care. Further, 33 states have already placed caps on 'pain and suffering' damages which is where the big money has always come from in malpractice cases. Indeed, in some of our largest states, it can be hard to find a lawyer to represent a plaintiff in a malpractice case because these are usually contingency cases for the lawyer and the big money just isn't there any longer. We do have to have a legal avenue for redress for people who are truly the victims of medical malpractice. Some tweaks are needed in the system-but it is not the huge issue that some like to make it out to be.

When and how much do your parent companies, advertisers and bosses influence your content?

Absolutely zero. I've never heard from an advertiser. I've been yelled at by my employer a few times when I wrote something they thought was outside my beat, but they've never asked me to change what I wrote. In all these years, there was but one time that asked me to take a story down. They felt it was outside my beat, was highly inflammatory, etc. I disagreed with them then and disagree with them to this day, but, hey, maybe they were right. One time out of the thousands of pieces I've written is a pretty good record so I have no complaints.

Here is what I need to know. Drug companies,health insurance companies, doctors,hospitals, and pharmacies all say they make a paltry 1-7% profit margin. WHERE DOES ALL THE MONEY GO? We spend hundreds of BILLIONS a year but everyone acts like they are all but starving to death.

I don't think doctors and pharmacies have made this claim. As for health insurers, it is true. They operate on about a 4 percent profit margin. Where does the money go? They have to pay for the actual health care which, as you may have heard, is pretty expensive.

What do you see as the best and worst case big-picture scenarios (in terms of costs, coverage, etc) for how the full implementation of the ACA might play out over the next few years? Are there any specific provisions/ measures that you think could have interesting or unpredictable ramifications (electronic records, for example)?

Worst case- it has no impact at all. Best case- many more people insured with some of the programs designed to bend the cost curve start to work and show results. Had it been up to me, I would have included a Medicare for all option so, that would have been an interesting ramification!

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I don't think there will, at the end of the day, be many companies who elect to pay the penalty rather than continue to provide coverage to their employees. Remember that this only applies to companies with more than 50 employees.

Thank you very much for this AMA!

Over lunch last week a friend of mine explained why he is deciding to vote against his economic and moral self-interest by voting for Romney in November. As a student of political science and history i was naturally curious as to why anyone would do this. He threw out some run of the mill talking points but really focused on the ACA as his main source of grief with the administration. He called the bill too secretive, too long, too expensive etc. He wanted to know why we couldnt simply piecemeal the parts that we agreed on into a bill and go from there. I didnt have a concrete answer for him that was satisfactory off the top of my head.

1. I assume that the bill cannot be gradually put together as each part is critical to the frame work and how we pay for the overall reform 2. Begining to reform such a complex and vital part of our econmy requires a large first step not a series of weak measures. 3. it is better to look at the bill and the issue as evolving rather than something that is completly set in stone and unchangeable.

I am wondering if this is an accurate assesment of why the ACA needed to be as large as it was and how to explain that there is complexity in changing an entrenched system?

I'm always somewhat baffled by people being turned off to this law because of the page count. Reforming healthcare is a pretty complex thing to do and, unfortunately, isn't going to happen in a ten page deal memo! You are right that approaching this piecemeal would likely not have accomplished much. As it is, the ACA really takes a very small step towards the reform that is required but it is a start- and really only a start. You are absolutely right that this will evolve as we see what works and what does not.

How do government regulations of the health insurance business pass constitutional muster? Effectively, am I as a consumer prohibited from buying HI from someone with the assets to pay for my health care costs? To illustrate, a 30 yo person has a wealthy neighbor. They sign a contract that says the 30 yo will pay $400 per month to the wealthy neighbor in exchange for payment of medical bills between $2K and $500K. Would such a private contract be illegal in the US?

This is not really a federal constitutional question - it is a state issue. Your neighbor is free to sell you that policy so long as he or she has been licensed by the state in which you live. To be so licensed, the policy offered is going to have to contain the minimum benefits legislated by your state. The state will also have to determine that your neighbor has the financial ability to pay off should you make a claim. So, from a constitutional perspective, you are free to enter into that arrangement with your neighbor- but, from a state regulatory perspective, if your neighbor sells you that contract without dealing with the state, your neighbor is going to be in trouble!

Why isn't anybody talking about deflation?

I don't know. What do you want to talk about?

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I don't spend a lot of time in the newsroom as my role is as an op/ed writer. The culture, however, is terrific. The mere fact that the 'capitalist tool' would be so welcoming to someone like me says a great deal about the magazine.

I've heard polls that suggest the majority of journalists are liberal, as well as standard Fox News propaganda saying everyone but them is biased. Would you agree based on your personal experience with journalists, and if so, why do you think that occurs?

You know, I'm really not sure. When you consider that I work at Fox and Forbes, two very conservative media players, I am mostly exposed to conservative journalists. What I never understand is how Fox accuses the 'mainstream media' of liberal bias when Fox is, itself, a huge part of the mainstream media!

The US federal government already pays out enough in healh care reimbursement to cover everybody at the rates that other countries pay. How can we ratchet things down so that we can basically get everybody covered for that amount?

How much of our medical costs are for billing and dealing with insurance overhead?

What are we getting that say someone from Germany isn't getting?

As a personal note, the last time I was in the ER, the bill was $8000, which was knocked down to $1000 by the insurance company. With all of the tests they did on me, I think they lost money on me. When the insurance companies negotiate the prices, do they pay some sort of retainer to the hospital? Ie we will pay you $10,000,000 but you write off 80% of the bill?

What do you think of the Sherpaa plan available in New York?

I"m unaware of any insurance program that pays a flat rate in exchange for larger write offs. Insurance companies do negotiate far better rates than what is charged on 'rate card', ie. full retail.

Where do you think you get the moral right to force people into paying into a government-run health care program?

Exactly where is anyone being forced to pay into a government run health care program? There is only one government run program and that would be the Veterans' Administration-and nobody is forced to participate. Indeed, there is an alternate program, Tri-Care, which would allow a vet to go outside that system. Medicare is a federal payor program- but the caregivers are decidedly from the private sector. Last I checked, there are no hospitals or doctors that work for Medicare. Medicare is also voluntary, except for Part A for which there is no premium charged. And you can drop out-but its a bitch to get back in when you come to your senses. Medicaid is also a state/federal combined payor program - nobody has to join. So, what is this government run health care program you are being forced to pay into?

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The medical home approach seems to be working in many instances. This is something that is so young, we have to continue to see if it will produce the benefits we are hoping for-I think it will.

I understand journalists become aware of many things which they aren't able to report.

Are you aware of any recent fiction which you believe was written to cover a true story? What is the most "realistic" fiction you've read?

Is there anything interesting that you've learned that, for whatever reason, you couldn't publish, but might be able to comment on here?

Is there anything interesting that the reporting world takes for granted, but the public may be completely unaware of? Anything we would benefit from knowing?

And last, how do you feel about the internal perceptions of more traditional journalism versus modern times? Is there a rift between the older generation and the new? Are we seeing traditional reporting die off?

Hmmm...there are rooms into which I am invited where the understanding is that I will not report on what I hear. If I did report on it, I wouldn't be invited! Still, it is worth being there as it informs the background and makes me smarter when it comes to covering things I can report on...which is pretty much everything. Certainly there are differences in traditional journalism versus modern in the sense that the internet has made it possible for everyone to be an op/ed writer. Still, I think the best still rise to the top and the amateurs don't really reach much of an audience.

What are your thoughts on New York City's ban on over sized beverages? Do you think it's a first step towards more regulations promoting healthier lifestyles, or just an over reaching political outlier?

I think it is just symbolic. If I really want to drink that much soda at the movies, I'll just order up two sodas. But I kind of like what it says.

My insurance Ppo seems to be playing hardball and recently dropped all the hospitals and doctors I use, I have to get a surgery for my son much sooner to get the good in network rate.

Are insurance companies trying to make up their profit loss by stiffing doctors and hospitals that you know of?

I'm not sure i would define it as 'stiffing doctors and hospitals'. However, we are definitely seeing insurance companies dropping docs and hospitals they think are too expensive. And when is a hospital or doc too expensive? When they are the best doctors and hospitals. What we are seeing is an effort by insurance companies to push beneficiaries towards what is cheaper rather than what is best. Not a good thing!

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1. We have to wait and see how the ACO concept works out. There are some examples, such as the Mayo Clinic approach, where things have one reasonable well. However, it is far too soon to know if this is going to make a dent in the cost problems or not.

2. Ha! Actually, my personal and professional relationships at Fox are excellent. My liberal friends never understand it, but I have to say that some of the people over at Fox are some of the nicest people I know. Really. I learned long ago not to pick my friends by their politics or I would miss out on some interesting people. I also always accept that, if they are informed (not always the case) they are as likely to be right as I am. Keeping one's mind open to other approaches and solutions make you a lot smarter.

How do you feel about how this Socialized Healthcare bill worked out?

I know the US Healthcare system was in a pretty lousy state (for a number of reasons) and that American politicians have been talking about Healthcare reform for an awful long time. I'm personally glad something was done, however I'm really not thrilled about the end product.

How do you feel about this corporate Health Insurance mandate as opposed to a single payer system?

If a state has considered allowing non-profit health insurers, would this be something to jump on as a constituent? Is it time to start writing state lawmakers?

Kind of weird that, in one sentence, you call it a 'socialized healthcare' bill and then, two lines later, call it a 'corporate health insurance mandate'. You do realize that these are diametrically opposed concepts? The reality is that there is absolutely nothing socialized about the ACA. It is far more as you describe in your second description- a corporate health insurance mandate. You have to legislate in realities. America is, apparently, not ready for a single-payer health care system and, even if they are, the Republicans in Congress were not going to go for it. To pursue legislation that has no chance of passing is a fool's errand. I think the ACA could have been better and stronger in some areas, but you have to start with what you can pass.

My first name is Forbes. What are the chances I could apply for a job as a Music Columnist on the website at some point?

Well, if your name is Forbes Forbes, maybe your chances are good! Seriously, I have no idea. Are you publishing music pieces anywhere at this time?

Why do so few pundits and other so-called health care experts understand that major factors inflating health care costs are 1) pricing that is severely restricted by the coding required by third party payors, 2) the administrative overhead created by third party reimbursement, and 3) the lack of consumer stake in the cost of health care?

I think experts do understand these issues. I know I've written a great deal about the impact of coding just as I've written about administrative overhead of private insurance running at 13-15 percent while Medicare runs at about 3%. I think that the 'lack of consumer stake' is often a misguided argument. Consumers know they have a stake in the cost. They know it because they see their health insurance premiums go up each and every year. But it ain't like buying a TV set. You don't go shopping for the best deal when looking for a cardio surgeon to open your chest and fix your heart. You don't look for off-label brands that cost less when it comes to the chemotherapy you need. You don't decide to delay a purchase until the prices come down like you might with a new iPhone 5. It simply is not the same.

I hear from Conservatives that the Affordable care act will raise our deficit, and from liberals that it lowers it. Can you explain which is true?

The truth is that we don't know. You can see estimates that make both arguments- but they are estimates and estimates are notoriously wrong. If people are acting with their heads instead of pursuing their political interests, you start by doing 'something'. Then, you watch and see what happens. If something is costing too much and delivering too little, loose it. If something is working better than anticipated, bulk up on it. What happens with this law has a lot to do with how much longer we will continue to use it as a political football rather than the starting point for getting a grip on the healthcare system.

Medical student here: Do you see a significant shift in the imbalance in reimbursements from subspecialists to primary care thanks to the new bill?

Without a question. The new bill gives primary care docs a raise while specialists have been seeing declines for awhile now. But there is a long way to go. There is no question that we are facing a true shortage in primary care docs and we need greater incentives to entice new doctors to go into this line of work.

When I consider the prospect of a US-government run healthcare system, I look to education as an example of a horrible failure. More and more people are opting for private schools for their children.

Q: Do you view education as a reasonable analog for what healthcare could become? If so, how would you avoid the same pitfalls?

Btw, thank you for doing this AMA and rolling with the punches. Love your responses to some of the less-civil comments. I'll even let the typo in the original post slide... *politics ;-)

I'm not sure why you are so ready to blame educational failures on the federal government. Whlle the feds do try and improve the educational system (with varying success to be sure), at the end of the day, education remains an issue that is primarily controlled at the local and state issue. As for the federal government in health care, I don't know that our eventual system will necessarily be run by the federal government. There is a strong case to be made for universal care administered on the state basis. Of course, you could ask the very same question-are the states capable of pulling this off given their records of success in other programs? We'll see.

Why is/was the argument "we've already got universal insurance through emergency rooms" not more prominent?

You sound like Governor Romney. It is not more prominent because it is a truly bad argument. For startes, nobody would disagree that ER care is the most expensive and, therefore, the most inefficient way to provide care. Secondly, while the law requires an ER to get a patient to the point of stability, what happens to that patient when it turns out that she needs a by-pass surgery in a non emergency setting. Or a patient is found to have cancer when in the ER and needs chemotherapy? That treatment is not provided by the ER.

My husband and I make about 80k a year combined. We have two very small kids. I purchase blue cross blue shield through the state. Our premiums and deductibles keep going up like crazy. Do you think this is because of Obama care? I don't know what to make of it.

It is most certainly not because of Obamacare. The Kaiser Institute-which everyone can agree is non-partisan, put the amount of premium increases last year attributable to Obamacare at about 1.5 percent. This is not the key driver of premium increases to be sure- rising health care costs are the driver. If- and I acknowledge that it is still an 'if'-Obamacare manages to get a grip on spiraling costs, it will have done far more to reduce these costs than increase them.

Hi Rick, do you think medicare will increase the benefits age to 68 instead of 65 as the average life expectancy increases? Also, do you believe American healthcare should focus more on comfort of living for geriatrics rather than forcing a 90yr old to have a feeding tube? Thanks for doing an AMA!

I don't think we'll see a rise in the Medicare age as there is a significant 'down side' to it. Like all insurance pools, Medicare needs a percentage of its beneficiaries to be 'healthy' to offset those who are sick. By taking out the youngest participants, you are likely taking out those who are more likely to be healthy but still paying a premium for the program. This would skew the program in the wrong direction. As for forcing a 90 year old to have a feeding tube, I don't think anyone would agree with someone being forced to do anything. But it is not that simple. When that 90 year old is that sick, odds are that he or she is not in a position to make those decisions which often leaves it to family members to do this. Families want their loved ones to live and don't want to be responsible for making a decision that might end the life of that loved one. Thus-the feeding tube. The solution to this, in part, was the provision originally in the ACA bill, that would have allowed everyone to see their doctor for free when they reach Medicare age for the purpose of discussing what they want when they get into the position you reference. That provision was included by a Republican. And yet, Sarah Palin and her death panel pitched resulted in this provision being removed. A hollow political victory for the right-wing politicians and a true loss for senior citizens and their families.

How did you get your job? Did you have to apply with an interview or write articles that were judged? Or some other technique

I got to Forbes via an on-line magazine called True/Slant that was operated by Lewis D'Vorkin. Lewis went on to become Chief Product Officer at Forbes and invited me to the site to write.

I am a free enterpriser myself. But I have a slight different view on growth driven economics. Your specialty is health(care) but I find the approach to health or housing is completely the same, everyone wants to earn more so they can afford something. Don't you think people earning less would actually make things including healthcare affordable. I try to address this is my new book Object Oriented Development in Africa, what is the point of people earning a million dollars when that can only buy them a pint of milk. Why did people afford more for less in the US in the 50s and 60s?

I don't get the occupy movement neither? I think we have left too much in the hands of economists than they deserve and this is harming capitalism, what do you think?

I don't see healthcare and housing as the same at all.