How Hospital Monopolies Extract their Pound of Flesh

by James A. Bacon

The average cost of family coverage in a private health insurance plan in Virginia ran more than $26,300 in 2017, according to data from the Commonwealth Fund. That number includes the employer share of the insurance premiums, the employee’s share, and out-of-pocket costs. If you want to understand why middle-class standards of living are eroding in the United States, this is a big reason why. If you want to improve middle-class standards of living, then you need to also understand why the cost of medical insurance is so bloody expensive.

There are lots of scapegoats in this story. Big Pharma and the high cost of prescription drugs is a favorite villain. The insane red tape associated with administering health plans is another. But one of the biggest drivers of higher health costs gets very little attention: the amalgamation of hospitals into vertically integrated health care systems that enjoy monopoly power in the so-called medical “marketplace.”

This post puts into writing many of the key points I made in the webinar presentation found in my previous post. Healthcare in Northern Virginia is dominated by the Inova Health System, in western Virginia by the Carilion Clinic, and in Hampton Roads by Sentara. (The market in Richmond is divided between Virginia Commonwealth University, Bon Secours, and HCA.) In this post, I’ll focus on Hampton Roads to illustrate the dynamics at work in all healthcare markets.

As seen in the pie chart above, compiled from Virginia Health Information financial numbers, Sentara dominates Hampton Roads with 51% market share. Other major players include Riverside Health Systems, with 17% market share, and Bon Secours with 15%. There are a couple of independent hospitals, but they don’t shape the market.

 

The pie chart actually understates Sentara’s dominance. First, most of Sentara’s operations are concentrated in south of the James River, where it controls 62% of the hospital market. Second, these revenue numbers don’t take into account that Sentara also owns its own health plan as well as the Sentara Medical Group employing 567 physicians at last count.

Sentara, a nonprofit enterprise, is phenomenally profitable. Based on 2018 data, Sentara hospitals in Hampton Roads generated $2.5 billion in net patient revenue (after insurance “discounts” are taken out) and almost $240 million in profits — a profit margin of 9.6%. A rule of thumb in the hospital industry is that a financially healthy hospital needs to generate 3.0% to meet the needs of its community.

How does Sentara generate so much profit? One way is using the Certificate of Public Need (COPN) to block competition in its core market. Jim Sherlock has documented on this blog how the politics of COPN work. Here’s the end result: There are only two unaffiliated ambulatory surgery centers in south Hampton Roads, a metropolitan area of roughly 1.1 million people.

What does that mean in practice? Virginia Health Information provides some tantalizing clues by comparing the statewide average cost for certain types of outpatient surgery in ambulatory surgery centers, physicians offices, and outpatient hospital settings. Here are the numbers for colonoscopies:

You can see that physicians and ambulatory surgery centers charge roughly the same for the procedure. Physicians don’t have a “facilities” charge, but they do jack up their charges for physicians, nurses and anesthesiologists, so they are competitive with ambulatory surgery centers. But look at how much hospital outpatients charge compared to ambulatory surgery centers. Focus on the orange blocks, which represent facilities charges. Hospital outpatient facilities charge a $1,130 premium. To be sure, that’s a statewide average. We don’t know if the differential in Sentara territory is bigger, smaller or the same. But it’s not unreasonable to think that the premium is on the same order of magnitude.

Here are the statewide numbers for rotator cuff surgery. Outpatient hospital premium: more than $5,400.

And the numbers for tonsillectomies. Outpatient hospital premium: nearly $2,600.

When hospitals use COPN to eliminate competition from free-standing ambulatory surgery centers, patients have few choices. Some get procedures done in physicians’ offices (if the physicians are set up to conduct the procedure). Many go to hospital-owned outpatient facilities that bill some 50% more for the same procedure.

That, my friends, is what monopoly healthcare profits look like.

Sadlyl, there is no way for consumers to fight back. The fact is, even though colonoscopies, rotator cuff surgeries and tonsillectomies are discretionary in terms of time and place, there is no price transparency. Patients can’t comparison shop based on price even if they were inclined to do so (which, given the nature of the third-party payer system they rarely are). Needless to say, hospitals have resisted any and all efforts to create price transparency.

You think $26,000 a year for family coverage is bad? Until Virginia ends COPN, allows competition, and creates genuine markets with price transparency, health care costs will go only higher.

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52 responses to “How Hospital Monopolies Extract their Pound of Flesh

  1. James Wyatt Whitehead V

    The first paragraph explains why I toughed out the last 5 years of my teaching career. If I could make it to age 50 I could retire early from Loudoun County and the school board would pay the cost of health insurance for me personally. The miserly VRS pension would pay the cost of keeping my wife and daughter on the plan. It was worth it.

    • James relates the real issue with health care. It really don’t matter if a rotator cuff procedure costs $10,000 or $15,000, without insurance, most folks – even middle income, to say nothing of lower income, can afford it – at all.

      Many people stay with a job they don’t like and are afraid to pursue other opportunities – almost solely because of the fear of losing health insurance for themselves and their family.

      Yet, we continue to talk about health care “costs” as if – they could be lowered – that people could then afford them. Just not true and totally deaf to the real issues.

      People in every other developed country in the world can “afford” their health care. Yes, they may well wait longer for a rotator cuff procedures that those with insurance in this country – but how about the folks in this country that don’t have insurance? What is their wait time?

      Lots of talk about equity these days. This is an equity issue between those that have health insurance and those that don’t – even though they work full time jobs.

      • Rules of thumb… a couple of years old, so…
        Insurance companies pay on the order of 1/5 the hospital’s initial bill.
        If an uninsured patient calls the hospital ombudsman about the bill, they can often negotiate to 1/3. The contracts with the insurance companies prevent hospitals from negotiating with the uninsured to what they accept from insurance companies.
        Roughly 1/3 of all bankruptcies result from medical expenses.

        I’m not sure that 1/3 is large enough. My office was upstairs from one of Virginia’s largest bankruptcy firms. Most of the people walking into their front door were either on crutches or had an arm in a sling.

      • “Lots of talk about equity these days. This is an equity issue between those that have health insurance and those that don’t – even though they work full time jobs.”

        Jeff Bezos and Barak Obama both have more stuff than I do. I demand equity! Equity now!

        • “Jeff Bezos and Barak Obama both have more stuff than I do. I demand equity! Equity now!”

          Okay. So stop giving them tax breaks is good start.

  2. Many state attorney generals filed antitrust suits against Microsoft slightly more than two decades ago. Why doesn’t Herring file suit against the big health care providers in Virginia?

    Don’t touch our health insurance. My wife worked almost 40 years for Uncle Sam for the coverage. And I already pay extra taxes to help subsidize Obamacare. That’s enough. And why are people still coming to the United States if our health insurance system is so unfair? And, finally, cutting off illegal immigration would force increased compensation for low-income working Americans and legal residents. Maybe a crackdown would allow them better access to insurance as well.

    • A lot of people in the US that have health insurance – would not have it – if it were not for the government. That’s right. Not only does the government subsidize the cost of it by 40% but it mandates that the insurance company cover you AND cover you for the same premium as health young folks and not according to your age or health conditions.

      It’s totally government subsidized insurance and the question is – why do only some folks get it and not others?

      When Jim gives the cost at $26,300, is he including the government subsidy ?

      • Larry, you are wrong about same premiums for all ages of workers. Many businesses and government agencies do charge their employees the same rates butt this is NOT mandated by law. A company using community rating cannot charge its older employers a premium that is more than three times the amount charged to younger workers. That’s in the ACA – Obamacare. They cannot charge different rates based on gender or health conditions but they can charge more to older employees. So this great equal premium government benefit does not exist.

        And once again you miss the point about equal treatment under the tax code. The law treats everyone with employer-provided insurance the same — it’s not taxable income. There is no legal obligation beyond that. You are making a moral argument based on your beliefs. Can everyone do that based on their beliefs? How about the people who argue life begins at creation and oppose abortion? Why cannot they insist on their beliefs being followed as you seem to do for yours on health insurance?

        • TMT – employers are not mandated to offer health insurance but if they do – it must be guaranteed issue – i.e. any employee regardless of age or health is entitled to buy it –

          AND the premiums are community rated – which means a 50 year old pays the same as a 27 year old or someone with diabetes pays no more than someone without.

          The insurance can be offered (and priced differently) for family coverage or self-only or high option, etc… but within each one of those classes the premiums are the same. There is no medical underwriting where the premium is adjusted according to agre of medical conditions.

          It’s also not taxed – not FICA, not Federal and not State.

          and the question is why isn’t ALL health insurance operating by the same rules so that a person who works but his employer does not offer health insurance can go out into the market and get guaranteed issue, community-rated insurance that is not taxed?

          If everyone had the same opportunity – it would be a fair system.

          Instead, the government has picked winners and losers – literally by providing subsidies and benefits to one group and not others.

          We need to have a system where everyone is treated the same way on health insurance.

          • TooManyTaxes

            Larry, where did you find the statement that employers must not charge age-rated health insurance premiums? It’s plain wrong. The federal ACA and related regulations permit charging older people higher premiums so long as they are not not more than three times as much. So if ABC Company charges a 25-year-old employee $200 a month, it can charge a 64-year-old employee $600 a month.

            Why isn’t everything even? Well why does the sun rise in the east? I’d like to see the earth revolve in the opposite direction. We’d have a Mediterranean climate and California would have bad weather and earthquakes. Wanting things differently doesn’t make them. And what great principle says heath care should be the same? It isn’t and getting there would screw a lot of people, including public employees.

            As DJR says, I want to have as much stuff as Bezos and Obama. Me too.

  3. “Many people stay with a job they don’t like and are afraid to pursue other opportunities – almost solely because of the fear of losing health insurance for themselves and their family.”

    Not really. People change jobs all the time in the private sector. They move from employer to employer usually getting coverage from the next employer just like the did from the prior employer.

    The public sector, of course, is quite different. Politicians solicit contributions and demand support from public employee unions / associations by promising retirement benefits rarely found in the private sector. Mr. Whitehead’s comment illustrates this. He waited until 50 to retire so he could keep health insurance while no longer working for Loudoun County. Presumably, he’ll enjoy that benefit from age 50 until he goes on Medicare.

    I applaud Mr. Whitehead’s service to our youth and understand his decision in waiting to retire until age 50. However, it’s a sad state of affairs that he had to “tough out” the last 5 years of his employment as a teacher in order to get the retirement health benefit. Unfortunately this a constant refrain from public sector employees. Police who don’t want to be policemen stay on the force waiting to vest in their pension plan for example. Ditto for federal employees. Meanwhile, the penalty for firing a policeman or civil servant a few years ahead of vesting is so high that the bureaucracy puts up numerous hurdles to prevent firings. One example is bad police remaining on the job.

    So, why don’t governments increase the pay for government employees, institute a transferrable 401(k) and tell employees that they either need to work until Medicare or find their own solution to health insurance between retirement and Medicare? Easy answer – because politicians would have to spend money now to curry favor with public sector employees instead of making promises where the bill will only come due well down the line. And incurring costs now means raising taxes now. Bad for election chances.

    Welcome to Illinois.

    • “Not really. People change jobs all the time in the private sector. They move from employer to employer usually getting coverage from the next employer just like the did from the prior employer.”

      Yes, especially with the Obamacare elimination of preexisting condition exemption. Prior to that, I could give you examples of people who were indeed afraid they would be denied coverage in a new employer ‘s plan.

  4. No longer do all employers offer health insurance as we are more and more a service economy and more and more companies do not offer it.

    You take someone like James – who would want to find another job in the private sector that actually offers health insurance to people over 50?

    Our county school system – is “self-insured”. What does that mean? It means the premiums are directly tied to claims and if two people had expensive cancers, the premiums go up on everyone.

    Contrast that to an insurance pool that has thousands in it.

    You say portable 401K/IRA – I ask what would happen if health insurance were also portable?

    You want to put pressure on the private sector to pay fair wages? Make health insurance portable. Let people leave immediately and not wait at all, if they find a better paying job and don’t have to worry about their health insurance.

    This is the problem with Conservatives and health care. They want to identify “bad guys” to focus on – like the big hospitals or big pharma , or COPN – but they have zero ideas for true portable and affordable health care. They even want to kill Obamacare… and leave thousands without the only insurance they can get.

    Health care is not about COPN and “vertically integrated” companies… that’s a distraction from the realities that we just will not deal with – and that’s millions of people who do not have insurance at all even though they are full time workers.

    • For once, I agree with you. Sort of. I’d really prefer to see teachers (for example) get paid more now so they can save up for their post-retirement, Medicare health insurance. Barring that simple approach … It shouldn’t take 25 years of service and reaching the age of 50 to vest in life insurance benefits between retirement and Medicare. Teachers should vest 4% per year for each of the 25 years at which time they would be fully vested. If you leave after 5 years you are 20% vested and the school system will pay 20% of either your insurance or your medical bills.

    • “Health care is not about COPN and “vertically integrated” companies… that’s a distraction from the realities that we just will not deal with – and that’s millions of people who do not have insurance at all even though they are full time workers.”

      More Gregorian chanting from the hymnal of the left. Take another look at the multiple charts Jim included in his post. Stare at hem until you understand them. YOUR Democrat Party is perpetuating laws and policies that make healthcare more expensive for everybody. Everybody. Stifling competition so that Virginia’s BigHealth special interests can make more money is hardly a distraction.

      And … you want to know something interesting? Sky blue Maryland has plenty of ambulatory care facilities. Of course, sky blue Maryland also has limits on campaign contributions.

      The real distraction is you and your many flawed arguments. Unlimited campaign contributions create anti-competitive comfort zones for the special interests in BigHealth who want protection from competition from our state government. This leads to higher prices for everybody which raises insurance premiums. These higher premiums would have to be bourne by citizens whether we kept the current health insurance system or not.

      The Democrat majority in our state government is stealing from you Larry. They are stealing from you and giving that money to the fat cats in Virginia’s BigHealth industry.

      New Gregorian chant for you …

      Clown Show clowns robbing us bl-i-i-i-nd
      Democrats don’t care a whit
      Clown Show clowns robbing us bl-i-i-i-nd
      Democrats don’t care a whit

      • Why do you blame the Democrats in Virginia? The Republicans were in power for for more than 20 years. They could have repealed COPN. There have been multiple Republican Attorneys General. They could have brought anti-trust suits. Yes, the special interests are influential. But both parties have been attentive to their interests.

        • Ditto. This one isn’t partisan at all that I’ve seen.

          • Are you reading Sherlocks tomes?

          • It’s not a question of partisanship. It’s a question of whether the new Democrat majority will do anything about it. For all of their carping about how Republicans are the vassals of big corporate special interests Virginia’s Democrats are just as bad. The only difference between the Democrats’ Senate Majority leader (Dominion Dick Saslaw) and his Republican predecessor (Tommy “Ashley Madison” Norment) is that Saslaw is a more aggressive and shameless panderer.

        • I blame the Democrats because they are in power. They are in a position to change Virginia’s systemic corruption and they won’t – even when one of their own (Chap Petersen) puts forth sensible legislation. I blame the Democrats because their Speaker of the Senate is the worst offender of them all, worse than any Republican.

          And when Republicans screw up … I blame them too …

          https://www.baconsrebellion.com/wp/goodbye-and-good-riddance-to-goodlatte/

        • Dick – I went to many meetings in Fairfax County where Democratic office holders and wannabes said “Things are bad under the Republicans. Put us in office and we’ll change these things.” The Ds have jumped on energy and climate. Why not heath care costs?

          Or is it like redistricting. They hammered the issue for years and now are trying to defeat the nonpartisan redistricting amendment.

          • Of course that’s true. Most of Virginia’s Democrats are liars and con artists, just like most of Virginia’s Republicans. But the Democrats are in power now and their defenders need to explain why they should be held harmless from pandering to special interests. Like you, I listened to 20 years of claptrap from liberals about how the structural corruption in Virginia was the fault of Republicans and would only be eliminated with a Democrat majority. Well, we have that majority – where are the campaign finance and disclosure reforms?

  5. Despite all the sidetracking in these comments – excellent post Jim. Our “bought and paid for” General Assembly clearly wants to reward their benefactors in BigHealth. COPN is the perfect vehicle for The Imperial Clown Show in Richmond to do this. Stifle competition while turning a blind eye to the jaw dropping monopolization of healthcare region by region in Virginia. Democrats own all three state wide offices and majorities in the House of Delegates and the Senate. They own this travesty.

    For all their caterwauling about Citizens United and how Republicans lick the boots of special interests it’s been enlightening to see what the new Democrat controlled state government has done about this in Virginia. Nothing. Not a damn thing. As usual, Chap Petersen has fought the lonely fight against unlimited campaign contributions. As usual, the plantation elite (this time from the Democrat Party) has beaten down Sen. Petersen’s reforms.

    If it weren’t for double standards the Democrats in Virginia would have no standards at all. Their majority leader in the Senate, Dominion Dick Saslaw, is the poster child for pandering to special interests. Yet there is nothing but eerie silence from the left as the Democrat majority controlling the state government does nothing but support the worst of the special interest boot lickers inside their own party. Shame!

  6. A primer… well, it’s funny (haha, and not as in ‘this fish tastes funny’)

  7. I become more and more persuaded that the libertarians have it right, we should just pay for health care like we pay for everything else, picking and choosing and using our own money. Just reviewed some Medicare claims and it authorized $35 for a series of X-rays and $15 for the radiologist to read it. What do I gain by having the third party in the middle of that? Clearly the providers were willing to take that piddling amount– absent the Medicare system it might have been cheaper still.

    If there is “insurance” it should truly be for the extraordinary expenses. What we have now is insane and most “reforms” just double down on dumb. The whole structure puts the patient last.

    • BigHealth will have a hissy fit but technology is advancing fast enough to replace many health care professionals. I’m surprise that a human had to read those X-Rays of yours.

      https://scitechdaily.com/artificial-intelligence-identifies-prostate-cancer-with-near-perfect-accuracy/

      Next up – replacing teachers with AI.

      • Maybe he didn’t….maybe he just owns the analysis program. How would I ever know that in this set up? 🙂 At my last physical my GP did an ECG, and the auto “analysis” had a dire prognosis. I showed it to my cardiologist, who laughed and tore it up and told me I’m fine. The real joke? I PAID BOTH (or Medicare did, without blinking….)

        • You shouldn’t even need to see your GP. Your vitals should be checked by a local nurse and the results stored “in the cloud”. Your GP ought to review those results and conduct a video visit. And if GPs in Murfeesboro, TN charge less than GPs in Henrico County (or Richmond) then you should have the option of your insurance paying for the Murfeesboro GP or you making up the difference out of your own pocket to talk to a GP in the Richmond area.

          If eighth grade algebra can be taught remotely then the state of Virginia only needs one eighth grade algebra teacher. The kiddies can connect with part time online tutors for help with their algebra assignments between lectures from the state’s one algebra teacher. Local libraries (which have long outlived their usefulness) can become community tutoring centers for children without access to adequate technical capabilities.

          Of course, if eight grade algebra can’t be taught remotely … then the schools should be reopened or this school year canceled and all teachers furloughed without pay.

          • re: ” You shouldn’t even need to see your GP. Your vitals should be checked by a local nurse and the results stored “in the cloud”. Your GP ought to review those results and conduct a video visit. ”

            Totally agree – and if you want more – pay out of pocket.

            “And if GPs in Murfeesboro, TN charge less than GPs in Henrico County (or Richmond) then you should have the option of your insurance paying for the Murfeesboro GP or you making up the difference out of your own pocket to talk to a GP in the Richmond area.”

            this is more interesting and not really addressed in BR.

            Whether it’s Medicare or Obamacare or other – costs do vary by zip code. When you sign up for Obamacare – it asks for zip code – and the difference in cost is amazing…

            So WHY should Medical costs vary so much if the standards for Doctors and Hospitals is the same – what makes one doctor or hospital cost more than another?

    • “I become more and more persuaded that the libertarians have it right, we should just pay for health care like we pay for everything else,…”

      Like airline tickets?

  8. re: ” I’ve become more and more persuaded that the libertarians have it right, we should just pay for health care like we pay for everything else, picking and choosing and using our own money”

    Reality check Haner – no insurance company would want you – at any price you could afford. The government saves your bacon on this.

    re: gregorian chants and other miasma

    All the talk about COPN and big bad hospitals is a distraction.

    It does not matter if a procedures costs 10K or 20K if you don’t have insurance to start with.

    And the government picks winners and losers by mandating coverage for those who get employer-provided and Medicare.

    If it were not for Medicare – how many seniors would be broke or just die for lack of medical care?

    what’s the truth? No Medicare equals lots of dead or broke seniors.

    Why are people “entitled” to Medicare in the first place? What did you do to deserve it?

    • No idea what I did. Oh, voted for the idiots who promised it to me, I guess. And paid FICA taxes in for 40 something years….you mean that? Just give me my contributions back and cut me loose….bet I do just fine. Give me a real market where I can shop and negotiate, and I’ll do great.

      Like most soft-hearted (and headed) liberals, you think average folks are too stupid manage their own affairs, decide what they really need. But if they could keep the money they didn’t spend, you watch how much more attention they pay…..how prices would fall.

      • “…bet I do just fine…”. Uh yep, there are still free clinics.

        Better divorce the wife and separate the property. Wouldn’t do to let the hospital and doctors grab any of her half.

        The good news is she’s statistically the only one that needs LTC insurance. Men usually don’t make the 180-day deductible anyway.

  9. Not that I am a big defender of the hospital oligopolies, but there is an important element of this picture left out. Hospitals are required to treat patients that can’t pay, the charity cases. Ambulatory surgery centers are not. Hospitals need to have equipment and specialists available to treat a wide array of conditions, some of which may present themselves only occasionally. Ambulatory surgical centers can specialize on one or two procedures. There are colonoscopy mills, for example. Hospitals are expected to be able to house and treat patients for relatively inexpensive conditions, such as routine child birth. Ambulatory surgical centers can focus on relatively expensive procedures.

    There is a lot to criticize regarding medical costs in the United States. However, it is a complex subject and focusing on comparing costs between ambulatory surgical centers and hospitals is an oversimplification.

    • If ambulatory centers also had to treat charity cases – I’d agree to reductions/repeal of COPN but you don’t hear the COPN critics offering that.

      Also – Medicare REQUIRES people over 65 to have procedures like colonoscopies done in hospitals..

      • You’re right. Charity care patients are left to die in the streets of Maryland. You can barely drive down the Beltway by Silver Spring without running over a few corpses.

        You and the other Clown Show defenders all have some form of political nearsightedness where you can’t see what’s happening in the other 49 states.

        Virginia’s state government is hopelessly corrupt and the new Democrat majority isn’t going to do a thing about it.

        • so you actually have lower medical prices in Maryland?

          And the hospitals make less profit because of the free-market ambulatory?

          Why doesn’t Bacon point that out? You might need to do a post and show him how…

          now don’t be a snowflake…

        • How do the Maryland hospital prices for colonoscopies, rotator cuff surgery, and tonsillectomies compare with those of Virginia hospitals? If they are significantly lower, I will agree with your point.

          • ditto…

            and once more – without insurance, it will cost thousands of dollars and many folks will not be able to afford it – whether it’s 15K or 5K or even less.

      • Oh, I didn’t know about the Medicare requirement.

        • that’s what I got told…….

        • DJ would prefer the self-administered form.

          You will receive an endoscope and a blank CD in the mail and use it with your laptop to examine your alementary and laryngeal passages**, saving the video to the CD, and return posting to your doctor.

          ** order dependent, please be sure to follow the directions.

    • Funny how Maryland has vastly more ambulatory surgery centers than Virginia while their hospitals still treat patients who can’t pay.

      Don’t fool yourself. The Virginia COPN approach is a reward for BigHealth political contributors. Just like Virginia’s lack of charter schools. Virginia has 9 charter schools. Maryland has 50. Tennessee has 100. California has 1,234.
      In Virginia it’s very hard to start a charter school. Why? So that the BigEd political contributors face minimal competition.

      These situations have nothing to do with complexity or even liberal vs conservative perspective. They revolve around a corrupt state government legislating and regulating to support their unlimited contribution paying benefactors.

      • If they actually deliver lower prices and better academic results……..

        right?

      • Does Maryland allow VOUCHER schools? Does Maryland require Charter schools to report academic performance?

        I’d support both Charter and Voucher schools in Virginia IF they:

        1. – accept any/all demographics like public schools do
        2. – test and report academic performance like public schools do

        and locate those schools in neighborhoods with disadvantaged kids.

        to add info here:

        Voucher Schools by state:

        United States1 15

        Alabama No
        Alaska No
        Arizona No
        Arkansas Yes
        California No
        Colorado No
        Connecticut No
        Delaware No
        District of Columbia Yes
        Florida Yes
        Georgia Yes
        Hawaii No
        Idaho No
        Illinois No
        Indiana Yes
        Iowa No
        Kansas No
        Kentucky No
        Louisiana Yes
        School Choice Program for Certain Students with Exceptionalities
        Maine Yes
        Maryland Yes
        Massachusetts No
        Michigan No
        Minnesota No
        Mississippi Yes
        Mississippi Speech-Language Therapy Scholarship for Students
        with Speech-Language Impairments;
        Mississippi Dyslexia Therapy Scholarship for Students with
        Dyslexia
        Missouri No
        Montana No
        Nebraska No
        Nevada No
        New Hampshire No
        New Jersey No
        New Mexico No
        New York No
        North Carolina Yes
        Special Education Scholarships for Children with Disabilities
        North Dakota No
        Ohio Yes
        Cleveland Scholarship Program;
        EdChoice Expansion Program;
        Educational Choice Scholarship Program;
        Jon Peterson Special Needs Scholarship Program
        Oklahoma Yes
        Oregon No
        Pennsylvania No
        Rhode Island No
        South Carolina No
        South Dakota No
        Tennessee No
        Texas No
        Utah Yes
        Vermont Yes
        Virginia No
        Washington No
        West Virginia No
        Wisconsin Yes
        Racine Parental Private School Choice Program;
        Special Needs Scholarship Program;
        Wisconsin Parental Choice Program
        Wyoming No

  10. The other issue here is that for the folks that DO have insurance, none of this has much to do with the insured.

    I’m not yet convinced of the COPN and vertical integration issue and here’s why:

    One of the biggest insurers is Medicare. And Medicare sets the reimbursement rate and other insurance follows along. They use Medicare reimbursement as a benchmark.

    So who does this really affect? Not the middle class who have insurance, right?

    So what’s this really about?

  11. Mr. Whitehead
    Locally, the employer’s contribution to retiree health insurance is pegged to the teacher’s years of service in the district. Teachers from surrounding districts were taking jobs in the district as they approached retirement to take advantage of the full employer contribution being offered. Thus, the school board took action to require 20 years of service in the district to qualify for this benefit. My friend in the in the classroom next door did decide to retire early so as to get the full employer contribution while it was still available. Unfortunately, retirees have seen large increases in deductibles and co-pays and do lose the insurance when they become eligible for Medicare.

  12. James Wyatt Whitehead V

    Mr. Banford I am actually thankful in a way for Loudoun County Public School Board. Many school districts in Virginia will not pay one cent of your health care insurance upon retirement. That is a partial reason for so many teachers to hang on until age 65 and then enroll into Medicare. I was very fortunate to be old enough to be grandfathered in. Teachers that have just signed their contracts with LCPS for the first time do not get such an important benefit. I really am thankful. If I had to hang on another 15 years I might be taken away by those two fellows wearing white suits and carrying a straight jacket.

  13. By definition most health insurance is not insurance…
    Insurance, fire, auto, health, etc. DOES Not cover Pre Existing conditions…
    I’m surprised all you “smart” technocrats don’t know that…
    as for COPN, we’ll that is just government interfering in the free market picking winners and losers….
    And the big Losers are us Consumers!!!

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