Just how many men (and women) should be in the room when state leaders try to negotiate a budget, or anything else?

For years, we New Yorkers have been complaining about Albany’s “three men in a room” custom, which brings together the governor, Assembly speaker and Senate leader into a back room to negotiate deals out of the public eye. The sense has been that these three make all the decisions in secret, and legislators and the public have nothing to say about it.

Even before Gov. Eliot Spitzer took office, leaders began making small changes in this practice, occasionally gathering for public leaders’ meetings covered by the press. Spitzer has taken the changes a step further, inviting the leaders of the minority parties in each house and a few other legislators to take part.

The result was a session on May 16 described by reporters present as full of sniping, fingerpointing, grandstanding, taunting and giggling. At one point, Spitzer felt it necessary to assert his authority by saying, “This is my room and we’re going to play by my rules.”

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An article published in the current issue of Health Affairs reports on pricing for self-pay patients, one of the only parts of the health care business that is largely “unregulated.” The author, Gerald Anderson, reports that people who pay their own hospital bills get charged more for care than those whose bills are paid by insurance companies or have Medicare or Medicaid coverage.

That’s not a surprise, of course. We’re accustomed to bulk discounts and buying clubs—the “membership has its privileges” sort of thing. Yet the magnitude of the difference should capture your attention: on average, patients without public or private insurance pay three times the Medicare-allowable cost. Anderson doesn’t report the average for New York but in New Jersey self-pay patients are charged a whopping 4.56 times the Medicare-allowable cost. Pennsylvania is right behind with a charge-to-cost ratio of 4.33. California, Alabama and Nevada round out the rest of the top five. At the other end of the scale Wyoming and Maryland hospitals charge self-pay patients 1.85 times and 1.23 times the Medicare-allowable cost. Note: Let me suggest that “cost” is in the eye of the beholder (or, at least, the beholder’s accountant). I don’t claim here that the Medicare number is the right way to define cost—hospitals don’t think so—but I do want to call attention to the discrepancy.

The article isn’t describing a new problem, but it is getting worse. In 1984 the average ratio was 1.35.

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