As Donald Trump was fighting with Congress over the shutdown and funding for a border wall, his administration implemented a new rule that could be a game-changer for health care.
Starting this month, hospitals must publicly reveal the contents of their master price lists — called “chargemasters” — online. These are the prices that most patients never notice because their insurers negotiate them down or they appear buried as line items on hospital bills. What has long been shrouded in darkness is now being thrown into the light.
For the moment, these lists won’t seem very useful to the average patient — and they have been criticized for that reason. They are often hundreds of pages long, filled with medical codes and abbreviations. Each document is an overwhelming compendium listing a rack rate for every little item a hospital dispenses and every service it performs: A blood test for anemia. The price of lying in the operating suite and recovery room (billed in 15-minute intervals). The scalpel. The drill bit. The bag of IV salt water. The Tylenol pill. No item is too small to be bar coded and charged.
But don’t dismiss the lists as useless. Think of them as raw material to be mined for billing transparency and patient rights. For years, these prices have been a tightly guarded industrial secret. When advocates have tried to wrest them free, hospitals have argued that they are proprietary information. And, hospitals claim, these rates are irrelevant, since — after insurers whittle them down — no one actually pays them.
Of course, the argument is false, and our wallets know it.
First of all, hospitals routinely go after patients without insurance or whose insurer is not in their network. When Wanda Wickizer had a brain hemorrhage in 2013, a Virginia hospital billed her $286,000 after a 20 percent “uninsured” discount on a hospital bill of $357,000 — the list price, according to chargemaster charges. Medicare would have paid less than $100,000 for her treatment.
Second, those list prices form the starting point for negotiations, allowing hospitals and insurers to take credit for beneficence, when there is none.
I recently received an insurance statement for blood tests that were priced at $788.04; my insurer negotiated a “discount” of $725.35, for an agreed upon price of $62.69 “to help save you money.” My insurer’s price was around 8 percent of the charge. Since my 10 percent co-payment amounted to $6.27, my insurer happily informed me, “you saved 99 percent.”
.. Just as airlines have been shown to exaggerate flight times so they can boast about on-time arrivals, hospitals set prices crazy high so they can tout their generous discounts (while insurers tout their negotiating prowess).
Only Trump’s flamboyant awfulness stands in the way of his party’s power grab.
Donald Trump, it turns out, may have been the best thing that could have happened to American democracy.
No, I haven’t lost my mind. Individual-1 is clearly a wannabe dictator who has contempt for the rule of law, not to mention being corrupt and probably in the pocket of foreign powers. But he’s also lazy, undisciplined, self-absorbed and inept. And since the threat to democracy is much broader and deeper than one man, we’re actually fortunate that the forces menacing America have such a ludicrous person as their public face.
.. If you want to understand what’s happening to our country, the book you really need to read is “How Democracies Die,” by Steven Levitsky and Daniel Ziblatt. As the authors — professors of government at Harvard — point out, in recent decades a number of nominally democratic nations have become de facto authoritarian, one-party states. Yet none of them have had classic military coups, with tanks in the street.
.. What we’ve seen instead are coups of a subtler form:
- takeovers or intimidation of the news media,
- rigged elections that disenfranchise opposing voters,
- new rules of the game that give the ruling party overwhelming control even if it loses the popular vote,
- corrupted courts.
.. The classic example is Hungary, where Fidesz, the white nationalist governing party, has effectively
- taken over the bulk of the media;
- destroyed the independence of the judiciary;
- rigged voting to enfranchise supporters and disenfranchise opponents;
- gerrymandered electoral districts in its favor; and
- altered the rules so that a minority in the popular vote translates into a supermajority in the legislature.
Does a lot of this sound familiar? It should. You see, Republicans have been adopting similar tactics — not at the federal level (yet), but in states they control... the states, which Justice Louis Brandeis famously pronounced the laboratories of democracy, “are in danger of becoming laboratories of authoritarianism as those in power rewrite electoral rules, redraw constituencies and even rescind voting rights to ensure that they do not lose.”
.. Thus, voter purges and deliberate restriction of minority access to the polls have become standard practice in much of America. Would Brian Kemp, the governor-elect of Georgia — who oversaw his own election as secretary of state — have won without these tactics? Almost certainly not.
.. you get a lot less reassured if you look at what happened at the state level, where votes often weren’t reflected in terms of control of state legislatures.
Let’s talk, in particular, about what’s happening in Wisconsin.
.. Having lost every statewide office in Wisconsin last month, Republicans are using the lame-duck legislative session to drastically curtail these offices’ power, effectively keeping rule over the state in the hands of the G.O.P.-controlled Legislature.
.. What has gotten less emphasis is the fact that G.O.P. legislative control is also undemocratic. Last month Democratic candidates received 54 percent of the votes in State Assembly elections — but they ended up with only 37 percent of the seats.
.. In other words, Wisconsin is turning into Hungary on the Great Lakes, a state that may hold elections, but where elections don’t matter, because the ruling party retains control no matter what voters do.
.. As far as I can tell, not a single prominent Republican in Washington has condemned
- the power grab in Wisconsin,
- the similar grab in Michigan, or even
- what looks like outright electoral fraud in North Carolina.
.. Elected Republicans don’t just increasingly share the values of white nationalist parties like Fidesz or Poland’s Law and Justice; they also share those parties’ contempt for democracy. The G.O.P. is an authoritarian party in waiting.
.. Which is why we should be grateful for Trump. If he weren’t so flamboyantly awful, Democrats might have won the House popular vote by only 4 or 5 points, not 8.6 points.
.. And in that case, Republicans might have maintained control — and we’d be well along the path to permanent one-party rule.
Instead, we’re heading for a period of divided government, in which the opposition party has both the power to block legislation and, perhaps even more important, the ability to conduct investigations backed by subpoena power into Trump administration malfeasance.
.. But this may be no more than a respite. For whatever may happen to Donald Trump, his party has turned its back on democracy. And that should terrify you.
.. The fact is that the G.O.P., as currently constituted, is willing to do whatever it takes to seize and hold power. And as long as that remains true, and Republicans remain politically competitive, we will be one election away from losing democracy in America.