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The costs of the 340B program exist of course.  They are initially imposed on insurance companies and pharmaceutical manufacturers.  But, the costs are not confined to just these industries.  The costs created by the 340B program are ultimately integrated into the overall health care system and are manifested through rising insurance premiums, declining insurance coverage, declining innovation and productivity (especially for pharmaceutical drugs), and higher medical costs in unrelated segments of the health care system.  Perhaps more troubling, the added noise created by the 340B cost shifting worsens the overall functionality of the U.S. health care system

Premium prices are influenced by many factors, including what insurers guess their costs will be, a region’s labor costs and how much hospitals and other facilities charge. Competition between insurers is also a significant factor.

While some of the lowest cost plans are in the “bronze” tier of coverage, such plans generally have higher annual deductibles and co-payments than a silver plan.  Also, the silver plans reduce some costs for subsidy-eligible consumers, which could reduce their exposure to big bills if they fell seriously ill.

“Although premiums are generally the first and last thing discussed when comparing plans, out-of-pocket costs may be an equally or even more important consideration, particularly for those with significant health care needs.”

"Look at any of the long-term projections for the federal budget or for state budgets," said Alan Weil, executive director of the National Academy for State Health Policy. "If we don't bring down health care costs, we're either going to be paying a whole lot more in taxes or we're going to stop spending money on other things we care about."

"It has to end eventually," said Larry Levitt, senior vice president of the Kaiser Family Foundation, "because we can't have an economy driven entirely by health care."

The number of people enrolled in health savings accounts (HSA) has more than tripled in the last six years from 4.5 million people in January 2007 to 15.5 million in January 2013, according to America's Health Insurance Plans, a trade association that represents health insurers.

In the future, Cohen said he expects to see several options used more widely to lower costs, such as rewards for low cholesterol or keeping diabetes under control, incentives to join gyms and benefits for participating in healthy lifestyle programs.

The data also shows that businesses could save money while providing their employees with more choices, he said. Some of those choices, such as closed-network programs or single primary-care physician-based programs, have been avoided in the past because the common wisdom is that people don't like being limited by what doctors they may see.

Under the Affordable Care Act, health care providers may be rewarded if they demonstrate better health outcomes at lower costs.

“In the old world, doctors and hospitals were paid more if they did more,” Kannaday said. In the new model, doctors and hospitals that demonstrate they are providing quality care at a lower cost are rewarded financially, she said.

decline in charity care and bad debt with more patients

All health plans offered on a state exchange must provide comprehensive coverage that includes doctors’ visits, lab work, hospital stays, emergency room services, maternity care, prescriptions, mental health services and children’s dental and vision care.

Policies with the most generous benefits will be “platinum” plans; they will have the highest monthly premiums but fewer out-of-pocket costs and lower deductibles. The “gold” and “silver” plans will be somewhat less generous, while those in the “bronze” category will have the cheapest premiums but may require high out-of-pocket costs and deductibles.

Be aware that the plans may have narrow provider networks — your favorite doctor or the hospital down the street may not be a participant. You’ll need to check to see if a certain provider is in the network, advised Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reform.

For employees, perhaps the most telling red flag from the study is that their employers may be saving money not by making them healthy but rather by shifting healthcare costs onto them. "Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees — those from lower socioeconomic strata with the most health risks — bearing higher costs that in effect subsidize their healthier colleagues," wrote the authors.

The relatively small share of PDP enrollees who switched plans at some point between 2006 and 2010 were more likely than those who did not switch to end up in a plan that lowered their premiums.  Nearly half (46 percent) of enrollees who switched plans saw their premiums fall by at least 5 percent the following year, compared to 8 percent of those who did not switch plans.  But those who switched plans were only slightly more likely than those who did not switch to face lower out-of-pocket costs for drugs during the year

"Fifteen years ago, pricing was not as important…[but] when the co-pay is coming out of a patient's pocket, they more often want to know what they're paying," said Moshir Jacob, medical director at the Toledo Clinic. The Ohio practice advertises that it offers lower prices than area hospita

Others doubt there has been a structural change. "We haven't done anything in the past three or four years that fundamentally altered the health-care system," said Gerard Anderson of Johns Hopkins University, who was the lead author of the "It's the Prices, Stupid" paper a decade ago. "And everything in Obamacare that tried to control cost was watered down."

The system now offers members a choice: Have your procedure at one of 51 hospitals that agreed to limit what they charge, or have the surgery elsewhere and pay any expenses above $30,000 out of pocket.

making unionized workers less competitive and potentially causing unionized employers to drop the plans that cover more than 20 million people.

To offset the expected rising costs of these "multiemployer" plans, several union groups want their lower-paid members to be able to remain on the plans wh

"will shatter not only our hard-earned health benefits, but destroy the foundation of the 40 hour work week that is the backbone of the American middle class," the union officials wrote.

We were told that insurers would develop narrow networks excluding high-cost providers, and squeeze providers to give lower rates,” Mr. Holahan told me. “But smaller insurers will probably not get a good network at good prices.”