Why would Orange Park Medical Center in Florida charge $117,445 to place a stent into a patient's artery, while the Mayo Clinic half an hour away in Jacksonville charges less than 45 percent of that amount?

The answer, in short, is because the U.S. health care system doesn't operate according to the standards of competition that govern other industries. Hospitals often rule local fiefdoms using their own idiosyncratic price-setting conventions, and the health insurance companies that pay the bills have little incentive to wage risky wars against prominent local institutions.

The prices in the above example are drawn from a database of charges at thousands of hospitals released this month by the Centers for Medicare and Medicaid Services. Variation of that level isn't out of the ordinary among U.S. hospitals, which maintain detailed price lists called "charge masters" for thousands of services.

American hospitals are locked in a vicious cycle that results in erratically inflating charges, which increasingly bear little relation to the cost of medical care or the amount actually paid. In practice, hospitals set prices as if they have no competition at all -- something that's reflected in the Centers for Medicare and Medicaid Services data. Hospitals tend to charge as much as they are able, knowing it's nearly impossible for patients to determine what local competitors charge or what health insurers pay. The fact that the system isn't affected by typical competition metrics is a major reason why Americans often pay higher health care prices than citizens of other developed nations.

These prices got so out of whack due to perverse financial incentives, poor competition among medical providers and health insurers, evolving management strategies, inattention and simple inertia stretching back more than half a century, said Farrell Turner, a health care consultant with Warren Averett in Anniston, Ala. Turner served as chief executive officer and chief financial officer for various hospitals during a more than 30-year career in the industry.

"By differences in management styles and the way that they have gone about raising their charges, what 40 or 50 years ago may have been a 4 percent difference now could be a 25 percent difference," Turner said. "It may almost be like compound interest."

Hospitals don't have uniform practices for setting prices -- even within the same facility or chain over time -- and that leads to huge discrepancies that worsen over the years. One year, a facility may raise prices a little, another year a lot. Or, the hospital may not change prices at all for a period of time, then return to the drawing board. This happens throughout the hospital industry with little consistency, Turner said.

One hospital may base its charges on a combination of services that make up the process of treating an ailment, while another may devise specific line-item prices for each element of a procedure, Turner said. Medicare and other payers fork over a lower fee for the overall treatment provided, but patients without insurance can see very different bills depending on how the hospital that provided their care accounts for charges.

This isn't how the rest of the economy works. In most industries, prices reflect the available supply of a product or service, public demand and a shared understanding of the costs of labor, supplies and overhead. Two nearby grocery stores may charge different prices for similar items, but the discrepancy tends to reflect unique, measurable disparities in their operations -- like their ability to demand greater volume discounts from suppliers or their relative market share. For the grocery stores, the costs of basic inputs like labor and real estate tend to be comparable.

In health care, by contrast, prices are subject to factors transparent to no one. Rather, listed fees are the consequence of various management styles and a given hospital's relationship with health insurance companies.

Hospital and health insurance industry experts emphasize that the list prices on the charge masters bear little resemblance to what health insurance companies, Medicare and Medicaid actually pay. Although this is true, it elides the fact that list prices continue to play a role in the rates some commercial health insurance companies pay, and can hit poor and uninsured patients the hardest.

Although these patients represent only a sliver of those treated in America's hospitals, they can be the most vulnerable to crushing medical bills that can lead to aggressive debt collection, financial ruin and bankruptcy.

Some hospitals base charges on their costs and overhead and try to keep them around what the local norms are, said Eddie Read, an El Campo, Texas-based consultant currently working as interim chief financial officer at El Campo Memorial Hospital.

"Everybody tries to get them very similar," Read said. "We don't have any interest in being thrown on the nightly news." Read retired as vice president of finance at Driscoll Children's Hospital in Corpus Christi, Texas, last year, after more than 30 years in the industry including stints as CEO and chief financial officer.

Hospitals with higher list prices disregard what competitors do, which can contribute to their charges growing more rapidly and out of line with costs, Read said. "They never look outside and see what the real world is. It's decades and decades. It's sad but it's true." Chief financial officers typically spend about 5 percent of their time working on the charge master, he said.

Further complicating this dynamic is the fact that hospital chains and individual facilities change their approaches over time, Turner said. One management team may prefer to keep charges low, while their successors may choose to raise charges in an effort to extract higher payment rates from health insurance companies, he said.

In some cases, a hospital will set a specific revenue target and elevate prices according to what procedures are most lucrative. "In order to get a 5 percent yield, you might increase some items by 1 percent, you might increase other items by 15 percent. You can either call that gaming the system or being smart," Turner said.

President Barack Obama's administration made the charges public in the hope that hospitals with the highest charges would lower them. Despite some early signs of concession by a few facilities in Florida and Alaska, the hospital industry is reluctant to embark on the massive, complex task of reevaluating how it does business.

"You don't have all the resources in the world to spend time going back and doing all this, so what is your return going to be?" Turner said. "You're not going to get anything out of it."

Likewise, health insurance companies don't have strong incentives to push back against high hospital charges because the smart ones ignore the charge masters, said Michael Seibold, managing partner of Seibold and Associates, a health care consulting firm in Tucson, Ariz.

Instead, Seibold said, health insurance companies that have enough negotiating leverage may agree to fee increases based on what they paid the previous year, not whatever the hospital says its list prices are. "It has literally nothing to do with charges," Seibold, who was a longtime executive at Blue Cross Blue Shield of Illinois, where he was president and chief operating officer from 1998 to 2001 before leaving the company, said.

In other cases, hospitals that have greater clout in a local market will insist health insurance companies base fees on a percentage discount on charges, which tends to lead to higher payouts, Seibold said. Health insurers' clients won't tolerate excluding prominent local hospitals from their networks no matter how high their charges may be. And health insurance companies often fail to scrutinize inflation in their payment rates over time, he said.

It's a story that began during the middle of the last century. In the 1950s and 1960s, hospitals charged prices based on their costs and their desire to earn a margin on their services. Health insurance companies in those days essentially paid hospitals whatever they charged. When Medicare came into existence in 1966, the program copied this model.

Things began to change in the 1980s, as national health spending continued to rapidly rise and health insurance companies and the government forced a shift away from hospitals effectively deciding for themselves how much they'd be paid.

Private health insurance companies began to negotiate rates with hospitals and create exclusive networks of providers, which sometimes are based on a discount off the hospital's listed charges. Around the same time, Medicare began paying flat fees for sets of procedures, rather than individual line items on the bills.

"Hospitals increased their charges dramatically during that period of time," said Seibold, the former insurance executive. "They will increase their charges because the only people who pay charges are health plans that are dumb enough to pay 'discount-on-charge' contracts and people who are either uninsured or private-pay," he said.

Still, when a health insurance company opens talks with a hospital about commencing a business relationship or needs to work out payment rates for new medical services, the charges come back into play, said Chip Kahn, president and CEO of the Federation of American Hospitals, a Washington-based trade group for investor-owned chains like HCA Holdings. "The charge master is involved at the beginning point in the negotiation," he said.

From 1999 through 2010, the gap between hospitals' estimates of their costs and what they listed as prices widened substantially, according to data analyzed by the Medicare Payment Advisory Commission, an expert panel that counsels Congress. Average charges were equal to 104 percent of costs in 1999 and rose to 218 percent of costs as of three years ago, the commission reported last June.

Maureen Sullivan, chief strategy officer for the Blue Cross and Blue Shield Association in Chicago, said a new trend may help buck the old system, no matter what hospitals do about charges. Government programs and commercial insurance companies have begun linking payment rates to the quality of care patients receive, she said.

"There has been a movement away from just looking at paying for discrete services to really understanding the patient's experience and to really understanding whether we're driving better value," Sullivan said. "The discussion on how much you're paying for services is not divorced anymore from the quality and value of the services that are provided."

A 40-year-old Californian with a moderate income will pay between nothing and $219 a month for a basic health insurance plan next year under President Barack Obama's health care reform law, a state agency announced Thursday.

Covered California, the authority in charge of the state's health insurance exchange, has released details about what the health insurance market for individuals who don't get coverage at work will look like next year. In all, 13 health insurance companies will sell products on the exchange, and premiums will range from 2 percent more to 29 percent less than what comparable plans cost this year, the agency said.

California is not only the most populous state in the U.S., but it also has the highest number of uninsured residents, 7.3 million in 2011. The state is tied for the fourth-highest percentage of residents without health insurance at 20 percent, census data show. The state embraced health care reform soon after Obama signed the law in 2010 and is seen as a bellwether for whether the initiative can succeed.

The results of Covered California's negotiations with health insurance companies belie predictions of massive premium increases under the law, at least for products that offer a range of benefits similar to those currently sold to small businesses.

The average cost of a standard health insurance plan sold on the health insurance exchange will range from $304 to $321 a month in the Golden State next year, Covered California announced. Compared to existing plans with comparable benefits and factoring in available subsidies for low- and moderate-income people, prices like these represent either a small increase or a significant decrease in the monthly costs, the agency said.

"This is a home run for consumers in every region of California," Peter Lee, the executive director of Covered California, said in a press release. 'Our active negotiating will not only benefit potential enrollees to Covered California, but will benefit all Californians by making health care affordable.' California is one of just six states that will use their negotiating leverage to force lower premiums under Obamacare.

Health insurance companies and political opponents of the health care reform law repeatedly have cautioned that its benefit mandates and limitations on industry practices like excluding sick people and charging higher rates to women and older people would dramatically raise premiums.

The evidence to date is mixed. In Maryland, CareFirst BlueCross BlueShield requested that the state approve a 25 percent hike in premiums for individuals for next year. In contrast, two health insurers in Oregon actually scaled back their proposed increases after seeing what their competitors planned.

Prices could be higher for individuals who currently buy skimpier coverage than will be permitted under Obamacare in the individual market. The law mandates that insurance covers things like prescription drugs and maternity care, which will tend to increase premiums. This especially could affect younger and healthier customers.

"Californians in the individual market may pay more than they have before for the additional benefits -- even if those are benefits they may never use," the California Association of Health Plans said in a press release.

Tax credit subsidies may offset premium increases for those who earn less than four times the federal poverty level, or $25,960 for a single person this year.

Starting next year, 5.3 million Californians who don't receive health benefits from their jobs will be eligible to buy health insurance from the exchange marketplace, according to Covered California. Individuals who buy health coverage for themselves rather than get it through their employment represent just 5.6 percent of the state's current health insurance market, the California Association of Health Plans said in a press release Thursday.

California's leading health insurance companies, including Kaiser Permanente, WellPoint subsidiary Anthem Blue Cross, Health Net, and Blue Shield of California will participate in the exchange. Several large national health insurance companies including UnitedHealth Group, Aetna and Cigna, won't sell products through Covered California.

"With today’s announcement, we have proof that health reform can stimulate competition and increase value for consumers," Blue Shield of California President and Chief Executive Officer Paul Markovich said in a press release.

Among those who can purchase health insurance via Covered California, 2.6 million will qualify for financial assistance because they have incomes ranging from 133 percent of the federal poverty level, which is $15,282 for a single person this year, to four times the poverty level. Those with lower incomes will gain access to California's Medicaid program, called Medi-Cal.

Covered California estimates that 46 percent of those eligible to shop on the health insurance exchange will be Latino, 33 percent will be white, 14 percent will be Asian and 4 percent will be African-American.

Under Obama's health care law, four grades of health insurance will be available on the state-based exchanges. They are named after metals that signify the levels of coverage and premiums: Bronze, Silver, Gold and Platinum. Subsidies are based on an individual's income and pegged to the cost of a Silver plan. People younger than 30 can opt for a bare-bones "catastrophic" plan, but cannot receive subsidies to offset its cost.

In practice, that means a 40-year-old Californian can choose among a variety of levels of coverage at a range in price. This table from Covered California illustrates the average amount a consumer will pay, displayed in black, and the value of what the government will pay to insurers, in green.

One of the most important, and least certain, goals of health care reform is to attract younger and healthier people into the health insurance market. This segment of the population would pay premiums into the system but have fewer medical costs, and they are needed to balance the high health care costs of older, sicker people. This is particularly important, since Obamacare forbids health insurance companies from rejecting people with preexisting conditions and restricts how much older customers can be charged.

Unsubsidized catastrophic health insurance will cost an average of $136 to $168 a month for a 21-year-old next year, according to Covered California. That same customer could elect for a Bronze plan that, depending on her income, would cost between nothing and $185, or a Silver plan with monthly premiums that range from $44 to $230.

Read Covered California's report on 2014 health insurance premiums:

Iowa Gov. Terry Branstad is poised to become the ninth Republican governor to support expanding Medicaid under President Barack Obama's health care reform law, the Dubuque Telegraph Herald reported Wednesday.

Branstad struck a deal with Republicans and Democrats in Iowa's divided Legislature Tuesday that caused him to reverse his prior opposition to adding more people to the joint federal-state health care program for the poor and people with disabilities, the Telegraph Herald reported, citing Iowa Senate President Pam Jochum (D).

Obama and the congressional Democrats who authored the health care reform law intended a major Medicaid expansion to provide coverage to millions of poor Americans, mostly working-age adults without children. But the Supreme Court ruling that upheld Obamacare last year also granted states the right to opt out of the expansion. With enrollment for next year beginning on Oct. 1, 2013, only about half of states appear likely to take up the expansion, meaning millions will continue to go without health benefits.

The health care reform law authorizes states to expand Medicaid to anyone whose income is below 133 percent of the poverty level, which is $15,282 for a single person this year. People who don't get health benefits from their jobs and earn between the poverty level, or $11,490 in 2013, and four times that amount can qualify for tax credits to offset the cost of private insurance.

The federal government will pay the full cost of expanding Medicaid from 2014 through 2016. That share will decline over several years until it reaches 90 percent in 2022 and beyond. The federal government currently pays an average of 57 percent of the costs for people on Medicaid. States don't face a deadline to decide on the expansion.

The Iowa proposal would offer the poorest residents Medicaid coverage while using federal Medicaid dollars to subsidize private insurance for people who earn between 101 percent and 133 percent of poverty, according to the Telegraph Herald.

Branstad strongly came out against the Medicaid expansion after the 2012 Supreme Court ruling, telling The Huffington Post last June, "We're opposed to it and we're not going to have any part of it."

In recent days, Iowa news outlets began reporting that Branstad had softened his resistance to the Medicaid expansion and indicated he could support a plan that protected the state from hypothetical cuts in federal Medicaid spending. Branstad and the Iowa House had devised a smaller Medicaid expansion that wouldn't have tapped full federal funding, but the state Senate voted it down it this month. Iowa officials were considering extending the legislative session to deal with the Medicaid issue.

Branstad's concerns about the Medicaid expansion are addressed in the deal with lawmakers, Tim Albrecht, a spokesman, told the Telegraph Herald. "This is a modernization of Medicaid and will serve both patients and taxpayers at a superior level," he said, according to the newspaper.

Republican governors, including John Kasich of Ohio and Rick Scott of Florida, have considered similar approaches, but have failed to win support from their Republican-controlled legislatures. The majority-Republican Legislature in Arkansas, however, joined with Democratic Gov. Mike Beebe last month to back a privatized version of the Medicaid expansion.

The chief executives of 28 states and the District of Columbia favor the Medicaid expansion, while about a dozen Republican governors remain opposed, according to an analysis by the Henry J. Kaiser Family Foundation. A handful of governors, including Scott and Missouri's Jay Nixon (D), have seen their Medicaid expansion plans die in their state legislatures.

Employers are concerned about increased health benefit costs arising from President Barack Obama's health care reform law but almost none intends to drop coverage for full-time workers next year, according to survey results released Thursday.

The health care law's requirement that companies with at least 50 employees provide affordable health benefits is the chief reason most firms expect their spending on health insurance to rise in 2014, according to a poll conducted by the International Foundation of Employee Benefit Plans, an organization of human resources professionals. Nevertheless, more than two-thirds of companies definitely plan to offer health benefits to full-time workers, and just 0.5 percent said they definitely will discontinue coverage. More than 90 percent of companies surveyed currently offer health benefits to full-time workers.

The health care reform law heavily relies on private companies continuing to be the most common source of health care coverage and aims to stem the ongoing decline in employer-sponsored health insurance. Obamacare seeks to build on the estimated 159 million people currently receiving job-based health insurance by mandating that larger employers offer coverage to workers or face penalties starting at $2,000 per employee.

Major disruption of current health benefits or large numbers of workers losing their employer-sponsored benefits and shifting into the law's government-run health insurance exchanges could further undermine weak public support for Obama's signature domestic policy achievement.

Based on the findings of the survey, these negative outcomes won't be seen in the near future, despite protestations from Republicans and some business owners that Obamacare would force many companies to cancel job-based health insurance. Fewer than 3 percent of companies surveyed reported they were at least somewhat unlikely to continue coverage of full-time employees.

Since Obama signed the Affordable Care Act into law in March 2010, numerous surveys of employers have produced similar findings. As the law's provisions to expand health coverage to millions of people begin to take effect in 2014, employers are more likely to have concrete strategies in place to adapt to the changing health insurance marketplace, which includes new rules on what health plans must cover and what share of the premiums employers must pay. More than nine in 10 companies are past the "wait and see" stage of planning, and 52 percent have begun to institute changes in their benefits, according to the survey.

Employers expect to keep providing health care coverage despite their conviction that the health care reform law boosts their employee benefit costs. The survey shows that 88 percent of companies already have seen spending increase because of provisions like the requirement that young adults can remain covered on their parents' plans until they turn 26. Additional rules that come online next year will further raise spending, employers reported.

Businesses could opt to discontinue health benefits, or to encourage some of their employees to forego them and direct workers to shop for their own health insurance on the exchange marketplaces that will begin selling coverage for 2014 on Oct. 1. Workers who earn up to 400 percent of the federal poverty level, which is $45,960 for a single person this year, will be eligible for tax credits to defray the cost of insurance if they don't get it at work. Those whose income is below 133 percent of that line, or $15,282 for an individual in 2013, may qualify for Medicaid coverage in states that expand the program under Obamacare.

Few companies are eyeing this alternative, however, the survey shows. Seventy-seven percent of the firms polled definitely won't eliminate health benefits and lead their employees to obtain their own coverage via the exchanges, and less than 1 percent definitely will, according to the poll. Likewise, 71 percent of companies definitely won't push a portion of their workforces into the exchanges and less than 1 percent definitely will. Among those who do discontinue health benefits, more than two-thirds are at least somewhat likely to boost pay in trade.

The health care reform law's "pay or play" requirement that companies either offer qualifying benefit plans or pay financial penalties, however, will affect hiring and the hours available to part-time workers, the survey shows. Almost 20 percent of companies with fewer than 50 employees has or will curtail adding staff to avoid triggering the so-called employer responsibility clause of the law. The same percentage has or plans to keep some workers below the 30-hour threshold that designates them as full-time.

The health plans offered by the vast majority of these businesses already meet Obamacare standards for affordability -- 74 percent -- and for quality of coverage -- 81 percent -- the survey shows. Still, some companies have taken steps to contain health insurance costs or to increase the burden on workers, and others intend to pursue such strategies in future years, according to the survey. Furthering ongoing trends that pre-date health care reform, employers are making changes to health benefits, such as making workers pay a larger share of premiums or increasing deductibles.

Read the full International Foundation of Employee Benefit Plans report below:

WASHINGTON -- The Senate on Wednesday confirmed former hospital executive, Virginia government official and nurse Marilyn Tavenner to be administrator of the Centers for Medicare and Medicaid Services, a vast agency responsible for those named programs and major parts of President Barack Obama's health care overhaul.

On a 91-7 vote, the Senate ended a more-than-six-year stretch, dating back to the George W. Bush administration, during which the agency lacked a confirmed leader. The Senate had declined to vote on Tavenner's nomination during Obama's first term and failed to vote on Obama's prior nominee, Donald Berwick, or Bush's nominee Kerry Weems.

The Centers for Medicare and Medicaid Services already provides health care benefits to more than 100 million Americans and has a budget rivaling the Pentagon's. The agency's role is growing as the Obama administration implements the health care reform law, which will reduce the number of uninsured Americans by an estimated 25 million by 2023. As head of the agency, Tavenner is charged with carrying out key elements of Obamacare, including its expansion of Medicaid.

Tavenner has helmed the Medicare and Medicaid agency in an acting capacity since December 2011, when Obama first nominated her for the job. The president renominated her this February. Berwick left the post in 2011 because stiff resistance from Republican senators blocked his path to confirmation after he had served in an acting capacity for more than a year. Likewise, Weems was acting administrator for almost a year and a half.

The last confirmed administrator of the Centers for Medicare and Medicaid Services was Mark McClellan, who resigned in October 2006. Since then, partisan politics and Senate obstruction through filibuster threats have been to blame for the absence of a fully empowered chief -- a departure from the experience of previous administrations.

Tavenner's nomination languished for nearly a year and a half despite her qualifications. Berwick is a pediatrician and the founder of the Institute for Healthcare Improvement, a nonprofit that advises medical providers on improving quality and reducing costs, but he came under Republican fire over his support for the United Kingdom's government-run health system, among other issues. Weems was a budget expert and an employee of the Department of Health and Human Services for more than 20 years.

The Senate Finance Committee advanced Tavenner's nomination last month. She cleared her final hurdle when Sen. Tom Harkin (D-Iowa) lifted a hold on her confirmation tied to his objections to the White House diverting funds for preventive medicine to implementation of Obamacare.

All seven votes against Tavenner came from Republicans, including Senate Minority Leader Mitch McConnell (Ky.).

The high and wildly varying prices for hospital services revealed by President Barack Obama's administration last week likely aren't going away any time soon because the antiquated system that generates them is intricately threaded throughout the health care system, according to industry representatives.

The Obama administration revealed more than 160,000 charges for inpatient procedures at more than 3,300 U.S. hospitals Tuesday. With the data disclosure, the administration was aiming to increase public pressure on hospitals, especially those with much higher prices than nearby competitors, to bring down charges to prices more in line with local norms. The primary beneficiaries of such a change would be the roughly 49 million Americans who are uninsured, as they are virtually the only people who can be asked to pay outright what the hospital is charging.

Hospital trade associations acknowledged that the dysfunctional character of the price lists, called charge masters, harms patients without health insurance. But they also sought to downplay the negatives of the price disparities released by the Centers for Medicare and Medicaid Services, saying that few patients actually see those charges on their bills. Hospital industry sources also highlighted the magnitude of the effort that would be required to devise a new system for establishing list prices for their services.

"I can promise you that if you got into the weeds here, you would immediately discover that it ain't as easy as it sounds," said Chip Kahn, the president and CEO of the Federation of American Hospitals, a Washington-based trade group that represents investor-owned chains including HCA Holdings and Tenet Healthcare.

"If someone decided tomorrow to do it, everybody could do it. But I'm telling you, it would cost billions of dollars -- probably small billions, not big billions -- because it's not a minor task," Kahn said.

Reducing the charges or making other changes could require hospitals to renegotiate on payment rates with health insurance companies, for example, Kahn said. He added that federal law requires there to be a uniform charge list within each hospital, even though health insurers and government programs don't pay those prices.

The irrationality of the status quo is plain to see in the hospital charges database made public by the Medicare agency. A preliminary analysis by The Huffington Post uncovered instances when the price for a procedure at the costliest hospital was 10 times higher than the charge at the least expensive facility in the area, for example.

Rich Umbdenstock, president and CEO of the American Hospital Association, didn't attempt to defend these disparities in a statement issued after HuffPost, The New York Times and the Washington Post first reported on the Medicare database.

"There are many parts of the health care delivery and financing systems that urgently need updating, and the matter of 'charges' is among those at the top of the list," Umbdenstock said in the statement. "The complex and bewildering interplay among 'charges,' 'rates,' 'bills' and 'payments' across dozens of payers, public and private, does not serve any stakeholder well, including hospitals."

In America's uniquely peculiar health care system, hospitals create and update these price lists based on their projections of the cost to treat patients combined with their estimates of what share of their overhead should be included. Hospitals also factor in other considerations, such as what additional revenue they require to finance other activities, like medical education.

Only a sliver of the population is likely to ever receive a bill based on these charges. Medicare and Medicaid set payments to medical providers under law, and those payouts are typically are a small fraction of the prices on hospitals' charge masters. Private health insurance companies also tend to pay significantly less than list prices by negotiating rates with hospitals, often based on a discount off the charge master or a percentage above the Medicare rate.

Although hospitals often provide discounts to patients without health insurance who lack the means to pay for the care they receive, those discounts are based on the prices on the charge master -- and can remain high.

"This is not a system designed for retail purchasing. This is a system designed for health care coverage and public program coverage," Kahn said. "Unfortunately, you frequently design your business for 90 to 95 percent of your customers, and what we're talking about are the customers that just don't fit in that system very well."

In response to Medicare going public with hospital charge data, ​Providence Health & Services, a chain based in Anchorage, Alaska, will review its price lists and consider making changes, Alaska Public Media reported Thursday. But the rest of the industry isn't likely rushing to follow suit.

The rollout of Obama's health care reform law, which imposes cuts in Medicare payment rates and other changes on the hospital industry, is another reason to think twice before reworking the ways hospitals calculate charges, Kahn said.

"We need to get into that and see what effect it has before we stand on our heads to go too far with more changes," Kahn said. "The system right now is like at the cracking point with a lot of different things."

At the same time, Obama's efforts to extend health insurance coverage to millions more people via his health care reform law -- which the American Hospital Association and the Federation of American Hospitals endorsed -- should mitigate the problems facing the uninsured because of hospital charges, Kahn said. The law also strengthens rules requiring hospitals to offer discounts to indigent patients, he said.

"We need to find a way to help those other people, and hopefully the requirements for discounts and other things in health reform will help them," Kahn said. "I'm hoping we'll get enough coverage that it'll make that problem so small."

When a patient arrives at Bayonne Hospital Center in New Jersey requiring treatment for the respiratory ailment known as COPD, or chronic obstructive pulmonary disease, she faces an official price tag of $99,690.

Less than 30 miles away in the Bronx, N.Y., the Lincoln Medical and Mental Health Center charges only $7,044 for the same treatment, according to a massive federal database of national health care costs made public on Wednesday.

Americans have long become accustomed to bewilderment and anxiety when confronting health care bills. The new database underscores why, revealing the perplexing assortment of prices for medical care, with the details of bills seemingly untethered to any graspable principle.

Even within the same metropolitan area, hospitals charge prices that differ by staggering degrees for the same procedures. People without health insurance pay vastly higher costs for care when less expensive options are often available nearby. Virtually everyone who seeks health care winds up paying inflated prices in one form or another as these stark disparities in price sow inefficiencies throughout the market.

While this basic picture has emerged as the consensus reality among health care experts, their evidence has been primarily anecdotal. Hospitals have protected their price lists -- documents known as charge masters -- as closely guarded secrets.

Their prices are secret no more.

The database released on Wednesday by the federal Centers for Medicare and Medicaid Services lays out for the first time and in voluminous detail how much the vast majority of American hospitals charge for the 100 most common inpatient procedures billed to Medicare. The database -- which covers claims filed within fiscal year 2011 -- spans 163,065 individual charges recorded at 3,337 hospitals located in 306 metropolitan areas.

The Obama administration shared the data in advance with The Huffington Post, The New York Times and The Washington Post. What emerges through a preliminary analysis is a snapshot of an incoherent system in which prices for critical medical services vary seemingly at random -- from state to state, region to region and hospital to hospital.

These price differences impose a uniquely punishing burden on the estimated 49 million Americans who have no health insurance, experts say. They are the only ones who see on their bill the dollar amounts listed on these official price lists. Yet these same prices effectively shape what nearly everyone pays for health care, because they determine how much private health insurance companies must surrender in reimbursement for services. That in turn influences the size of the premiums that insurance companies charge their customers.

Obama administration officials declined to characterize the causes of these gaping disparities in price, leaving unclear whether they reflect some form of malevolence -- profiteering by some institutions or price-rigging -- or rather more nebulous factors, such as varying estimates about the underlying costs of providing services.

[Click here to search the database.]

Administration officials said they offered up the data with hopes that its release would administer a market corrective, forcing hospitals to take greater heed of competitors while arming ordinary people with information they could use to seek a better deal. The data could also spur health insurance companies to negotiate with hospitals to seek lower prices.

"Our purpose for posting this information is to shine a much stronger light on these practices," said Jonathan Blum, director of the Center for Medicare. "What drives some hospitals to have significantly higher charges than their geographic peers? I don't think anyone here has come up with a good economic argument."

The very fact that prices are now public may bring change, he added. "Hopefully, it will cause hospitals themselves to take a hard look at their charge-master practices and to ask hard questions of themselves as an industry why there is so much variation," he said.

Within the nation’s largest metropolitan area, the New York City area, a joint replacement runs anywhere between $15,000 and $155,000. At two hospitals in the Los Angeles area, the cost of the same treatment for pneumonia varies by $100,000, according to the database.

Public access to this data on hospital charges pulls back the curtain on one of the most troubling characteristics of the American health care system: Medical providers set their prices in ways that seem arbitrary, with little oversight and practically no market incentive to reduce them, because almost no one actually pays the official rates.

The data lands as unexpected health care bills continue to be a leading cause of financial ruin for American families. Uninsured and low-income people are often subject to aggressive debt collection by hospitals and their agents when their illnesses result in bills they cannot pay.

Even among people of means, skepticism about American health care is common and with reasons based in data: Americans typically pay higher prices for health care than people in other countries, without gaining higher-quality care or superior health.

The new trove of billing data seems certain to amplify calls for a solution to rising medical costs -- not only for ordinary people, but for the economy as a whole. Health care spending continues to grow faster than the economy, though the rate of increase has slowed in recent years, prompting hopes that a fix may be materializing.

In 1999, average charges billed to Medicare were equal to 104 percent of the cost to provide medical care, according to a report issued last June by the Medicare Payment Advisory Commission, an expert panel that counsels Congress. By 2010, the ratio had more than doubled to 218 percent.

The Centers for Medicare and Medicaid Services long has had access to hospital charges via the cost reports facilities must submit to the agency, said Blum, the Obama administration official. Before now, few had given a thought to making the data public. His agency's actions were inspired in part by a sweeping Time magazine article on hospital charges by author Steven Brill published in March, Blum said.

The newly released data covers facilities that were collectively responsible for 90 percent of inpatient claims to Medicare while excluding certain institutions, such as children's hospitals and cancer centers.

The Huffington Post reviewed the two dozen types of services billed to Medicare at least 100,000 times in fiscal 2011 in 13 metropolitan areas spanning the U.S. The locations varied in population from less than 1 million to the largest three metro areas: New York; Los Angeles; Chicago; Portland, Ore.; Austin, Texas; Jacksonville, Fla.; Richmond, Va.; Birmingham, Ala.; Tucson, Ariz.; Honolulu; Madison, Wis.; Provo, Utah; and Chattanooga, Tenn.

How is it possible that two hospitals in close proximity would set prices as differently as Bayonne Hospital Center in New Jersey and the Lincoln Medical and Mental Health Center in New York? It's partly a relic of how hospitals used to operate and partly reflects their strategies to maximize revenues in ways that don't have a direct connection to the cost of the care they provide any individual patient.

"The charge masters are totally irrational," Robert Laszewski, a former health insurance company executive who consults for health care companies as president of Alexandria, Va.-based Health Policy and Strategy Associates, wrote in an email to The Huffington Post.

Hospitals used to base prices on health care costs and on the need for profit that would, among other things, enable them to make investments in their facilities, Laszewski explained. "They became the baseline from which the hospitals started," he wrote. But over time, hospitals raised charges in anticipation of negotiating discounts with private health insurance companies while maintaining their revenue streams, he said.

Prices have continued growing over decades to the point where there is no plausible justification for them, according to Laszewski: "Over the years, the charge masters have become more and more disconnected from reality."

The charges are the prices hospitals establish themselves for the services they provide. Although Medicare and Medicaid don't base their payment rates on these figures, private health insurance companies typically do, which means they usually pay more for the same health care than the government does. That translates into higher premiums for people with insurance. And uninsured people are expected to pay the full list price or a discount from that number, which tends to mean they pay more than anyone else.

When a hospital doesn't get paid as much as it wants from one source, it tries to make up the difference in other ways, such as billing so-called self-pay patients -- almost always the uninsured -- for the full list price of a service, said Robert Huckman, a health care expert at Harvard Business School. Even when hospitals agree to huge discounts for patients who can't pay the bill, those discounts are taken from inflated prices much higher than those the government or private insurance companies pay, he said.

"The charge master is complete nonsense that really doesn't matter -- unless you are an uninsured person and you're getting these huge bills driving you toward bankruptcy," Laszewski wrote. "The biggest irony of the U.S. health care system is that only the uninsured -- often people who don't have a lot of money -- are the only ones the hospital expects to pay these incredibly inflated list prices!"

Hospitals also inflate charges to raise money for things that aren't related to treatments, said former Sen. David Durenberger (R-Minn.), who is senior health policy fellow at the University of St. Thomas in Minneapolis.

"The biggest factor by far, in my experience, is what are you trying to cross-subsidize," he said. Hospitals will increase charges to finance things like technology upgrades and education and research and to compensate for their operational efficiencies, Durenberger said.

Myriad reasons legitimately explain how a health care service may be priced much differently from area to area, including labor costs and other local economic circumstances. But such factors fail to explain price discrepancies among hospitals in close proximity, Huckman said. "There's no doubt that the variation in charges is significantly larger than the variation in the underlying costs for these hospitals," he said.

The new Medicare database is replete with examples of inexplicably high prices and wide variations between hospitals in the same geographic area. The peculiar disorganization of the American health care system is evident by looking at just a few instances.

In the New York metro area, Bayonne Hospital Center -- part of a chain called CarePoint Healthcare -- charges the highest prices for several types of procedures, including COPD treatment, among the regional hospitals reviewed by HuffPost. Its price for that treatment runs four times the average in the New York area, according to the database. Medicare -- the government health care program for older people and people with disabilities -- paid an average of $6,826 for these same treatments within the New York area -- or less than 7 percent of Bayonne Hospital Center's charge.

Major joint replacement surgery at the hospital comes in at $155,769, which is almost three times the local average and more than nine times the price at Lincoln Medical and Mental Health Center in the Bronx. Medicare paid an average $18,944 in that area.

Garfield Medical Center in Monterey Park, Calif., outside Los Angeles, charges $241,654 to take care of a patient undergoing renal failure with major complications, which is almost 10 times the price at Beverly Hospital about 5 miles away in Montebello and more than three times the regional average.

And Birmingham's Brookwood Medical Center has the highest charges in 14 of the 24 Medicare billing categories in area facilities HuffPost reviewed, including a $156,958 price for simple pneumonia and inflammation of the lung. That's almost 12 times what the same treatment costs at Russell Hospital about an hour away in Alexander City, Ala., and about four times the local average.

Loyola Gottlieb Memorial Hospital in Melrose Park, Ill., outside Chicago, charged the highest prices for 16 of the 24 procedures reviewed by HuffPost. For kidney failure, Loyola Gottlieb charged $97,926, more than twice average cost of 59 hospitals in the Chicago area. The price is more than five times what John H. Stroger Jr. Hospital, 12 miles to the east, charges.

Those numbers reflect data from fiscal year 2011, and an official from Loyola University Health System, which runs the Gottlieb Memorial Hospital, said the hospital has reduced charges by an average 25 percent since then. "Loyola University Health System closely monitors charges and conducts reviews regularly to ensure that the health system is competitive in the Chicago market," said Chief Financial Officer Jay Sial, in a written statement.

The other hospitals named in this article did not respond to or declined requests for comment.

The public availability of hospital charges is unlikely to bring swift and radical change to pricing or spare uninsured patients from exorbitant bills, said Huckman, the Harvard health care expert. Still, he added, it’s a good start.

"It would be hard for a hospital -- unless there's a justified reason -- to be able to preserve a large margin over what its otherwise equal competitors charge," Huckman said. "If someone knows the amount that even the most advantaged payer reimburses a hospital for a particular service and they can take that in with their own bill, I think that gives a pretty powerful opportunity for that customer to interact with the organization and say, 'Why is my number so different?'"

Jay Boice, Aaron Bycoffe and Andrei Scheinkman contributed to this report.

Amid all the political posturing over the Medicaid expansion that's part of President Barack Obama's health care reform plan, it can be easy to lose sight of what's at stake here for a vulnerable portion of the U.S. population.

Because the Supreme Court ruled that states could opt out of the Medicaid expansion that could start next year, millions of poor, uninsured adults will remain without access to health coverage and regular medical care.

The Republican governors of more than a dozen states, including Rick Perry in Texas, are adamantly opposed to the Medicaid expansion. And although the chief executives of 27 states and the District of Columbia support broadening the program, GOP legislators in a number of states are obstructing those plans.

These are the consequences of this situation, as broken down by Caroline Pearson, a director at the Washington-based consulting firm Avalere Health, on Twitter Friday:

In other words, Pearson explained in an email to the Huffington Post, a nationwide Medicaid expansion would have provided health coverage to 10.7 million people. If 26 states refuse to expand the program for next year -- which increasingly appears likely -- 5.3 million fewer people will join the program. A portion of those people, estimated by Avalere health to be 1.9 million, would be able to get subsidized private health insurance instead.

That leaves 3.4 million poor people uninsured because politicians in their home states decided to reject full federal funding for the expansion from 2014 through 2016 and at least 90 percent in perpetuity.

Avalere Health created a handy map with its assessments on what states are likely to do about the Medicaid expansion.

(One can quibble with a few of Avalere Health's guesses. New York, which has one of the nation's most generous Medicaid programs, seems like an obvious candidate for an expansion and the big federal money it brings, for example. And while Republican Tennessee Gov. Bill Haslam concocted a Medicaid expansion plan, he declined to actually introduce it to the state legislature.)

Looking at the map, it's clear that the distribution of those who could've gotten Medicaid benefits won't be equal across the country. The states that won't expand Medicaid are concentrated in the south, for one thing. What's more, those states include some of those with the highest rates of uninsurance.

Texas has the highest uninsured rate in the U.S., with 24 percent of the population -- that's 6.1 million people -- uninsured in 2011, according to census data. Florida, with 3.8 million uninsured, and Lousiana, with 906,000, each have 20 percent of their residents without health insurance, tying them for fourth-worst with with South Carolina, Georgia, and California. Among those state, only California plans to expand Medicaid.

The polling firm Gallup, whose figures are slightly different from the census, starkly illustrates the sad reality in this map (h/t the Atlantic Cities):

President Barack Obama has a problem.

Many Americans aren't sure whether his health care reform law is even on the books; those people most likely to gain health coverage from Obamacare know the least about it; and Americans who do have health insurance are worried the law will blow up the health care system.

During a news conference Tuesday, Obama sought to assuage the fears of the bulk of Americans who have health insurance already and to tamp down anxiety that his administration won't be ready when people start lining up to obtain health coverage under the law this fall. His remarks reflected how much work is left to be done.

"The main message that I want to give to the American people here is, despite all the hue and cry and sky-is-falling predictions about this stuff, if you've already got health insurance, then that part of Obamacare that affects you, it's pretty much already in place and that's about 85 percent of the country," Obama said.

Even so, the law remains unpopular, according to survey results issued Tuesday by the Henry J. Kaiser Family Foundation. Just 35 percent of those polled have a favorable view of the health care reform law, the lowest share since October 2011, while 40 percent have an unfavorable opinion. Another 24 percent weren't sure or wouldn't answer, the highest share since April 2010.

While it's true that provisions of the law are in place for people who currently have coverage, such as one that enables young adults to remain on their parents' health plans until they turn 26, Obama and his team have to be ready come Oct. 1, when the rest of Americans can begin shopping for 2014 health benefits on the law's health insurance exchanges.

It will be a major challenge to get the word out that new health plans will be available and subject to minimum benefit standards and rules prohibiting health insurance companies from, among other things, refusing to cover people with pre-existing conditions. Also challenging are the technical and bureaucratic efforts needed to establish those exchanges, online marketplaces where consumers can research coverage options and determine whether they qualify for Medicaid benefits or subsidies for private health insurance. On Tuesday, Obama acknowledged there will be "glitches and bumps" along the way.

"What is left to be implemented is those provisions to help the 10 to 15 percent of the American public that is unlucky enough that they don't have health insurance," Obama said. "And, by the way, some of you who health insurance right now, at some point you may lose your health insurance and if you've got a pre-existing condition, this structure will make sure that you are not left vulnerable."

Educating the public about how to sign up for health coverage through the exchanges won't be easy. More than three years after Obama signed the reforms into law, 42 percent of respondents to the Kaiser Family Foundation survey falsely believed Congress had repealed it, that the Supreme had overturned it, or didn't know one way or the other.

The Kaiser Family Foundation also confirmed previous polling that showed people who are uninsured and those with low incomes -- the primary intended beneficiaries of Obamacare's coverage expansion and financial assistance -- are the worst informed about the law.

A Kaiser Family Foundation survey issued last month revealed that the most popular parts of the law, like tax credit subsidies for health insurance, are the least well-known, while the least popular, the individual mandate that nearly everyone obtain health coverage, is the best known.

The April Kaiser Family Foundation survey also found that conversations with friends and family are the most common sources people cited when asked where they got information about health care reform, followed by news organizations.

With viewpoints entrenched on the law and misconceptions -- such as the "death panel" myth -- persistent, the findings suggest yet another obstacle for the administration, health care reform supporters and health insurance companies to overcome when Obamacare's big promotional push begins this summer.

Conservative Republican governors Jan Brewer of Arizona, Rick Scott of Florida and John Kasich of Ohio are battling with their own party members over their efforts to accept a huge influx of federal dollars and provide health coverage to poor people. So far, the governors are losing.

Republican governors in eight states made waves when they embraced an expansion of Medicaid, a core component of President Barack Obama’s health care reform law. However, GOP legislators have been cool to the plans -- saying they're unaffordable, despite unprecedented federal funding.

This Republican infighting threatens to deny millions of people access to medical care and the financial security that comes with health care coverage. The standoff also imperils the prospects that Obama's sweeping overhaul will fulfill one of its most important promises: that low-income adults largely shut out of today's health insurance market because of cost will gain access to health benefits.

"Florida lawmakers have just an incredible opportunity in the palm of their hands to provide health coverage to a million working Floridians, and it would not cost Florida anything for the first three years," said Leah Barber-Heinz, the advocacy director for the Florida Community Health Access Information Network. "We are surprised there is even still a debate going on."

Under Obama's health care law, the federal government will pay the full cost of opening Medicaid to anyone who earns up to 133 percent of the federal poverty level, which is $15,282 for a single person this year, from 2014 through 2016. Over time, that share will decline until it reaches 90 percent in 2022 and future years. That compares to the average 57 percent of the costs the federal government pays states for people currently on Medicaid. States don't face a deadline to decide on the expansion.

The Medicaid expansion was supposed to take effect nationwide, but the Supreme Court disrupted Congress' plan last June when it ruled states could decline to broaden the program, which the federal and state governments jointly run and finance.

More than a dozen Republican governors, including Rick Perry of Texas and Bobby Jindal of Louisiana, oppose the Medicaid expansion. The chief executives of 26 states and the District of Columbia support the expansion, but legislatures with Republican majorities have effectively killed their plans in a number of states, including Michigan, Missouri and Montana. To date, the only GOP-led legislatures to approve expansions are in Arkansas and North Dakota.

Republican state lawmakers hostile to Obamacare aren't persuaded by their GOP governors -- and are under pressure from tea party-affiliated groups like Americans For Prosperity, which campaigned last year against Republican and Democratic candidates it viewed as pro-Obamacare.

"It's been extremely difficult for people who were at one time on the record opposed to the Affordable Care Act to be able to support this," Barber-Heinz said.

Arizona state Rep. John Kavanagh (R) confirmed that Medicaid is just one front in the war against Obama's health care law. “This is clearly an extension of Obamacare,” said Kavanagh, the House Appropriations Committee chairman. “We don’t believe in this mass takeover by government of the health care industry.”

And while the standoff between Republicans continues, 21-year-old Victoria Lofters of Ft. Lauderdale, Fla., and others like her, can do little but wait.

Lofters is an uninsured student at Broward College who works three jobs and is trying to pay down the more than $20,000 in medical debt she owes from ongoing treatment for ovarian cysts and a bout with gastritis. Doctors have warned the cysts could progress into cancer or burst. But her condition is going largely untreated because she can't afford the medical care.

"Me and many other of my peers fall into this category," said Lofters, who earned about $13,000 in 2012 and estimates she's visited hospital emergency departments for health care more than 40 times over the past year.

In 2011, 3.8 million Floridians, or 20 percent of residents, had no health insurance, giving the state one of the highest rates of uninsured people in the nation, according to census data. A Medicaid expansion would cover 1.3 million people, the Urban Institute and the Henry J. Kaiser Family Foundation estimated last year.

"I'm busting my you-know-what to make it happen for myself, and I'm still barely making it," said Lofters, who said she's one of the first women in her family to enroll in college and hopes to earn a Ph.D. in occupational therapy. "I'm trying to become a productive citizen."

Lofters worries her plans for the future will be derailed by poor health or the burden of medical debt. "What if one day, I'm just so sick I can't do anything? What if I can't go to school, what if I can't work? What would I do? It brings tears to my eyes because I don't want to be that way."

In addition to financing health care coverage for uninsured poor residents, Obamacare's Medicaid money would flow through states' hospitals, let employers off the hook for providing health benefits, allow state and local governments to cut back on programs that would become redundant, and enable states' residents to see some of their federal tax dollars go to their neighbors.

"Any time Washington wants to give us money, it is my opinion and the opinion of others that they're giving our money back to us that's owed to us. It disappoints me that my colleagues and others don't get that," said Florida state Rep. Mike Fasano. Fasano is the leading House Republican pushing for an expansion supported by Scott but opposed by Florida House Speaker Will Weatherford (R) and other leaders. Weatherford, 33, is viewed as a likely statewide candidate in 2018 in a state where the tea party seized control of the 2010 GOP primaries.

A coalition of Florida Senate Republicans and Democrats wants to approve a form of expansion that would use the Medicaid dollars to purchase private health insurance, similar to the plans adopted in Arkansas and sought by Kasich in Ohio. Arizona's Medicaid program already provides coverage through private health plans.

Arkansas' Republican-led legislature adopted Gov. Mike Beebe's (D) proposal with more than three-quarters of the vote this month. Kasich hopes the approval could spur action in Ohio, where legislators have blocked his similar plan so far, said Greg Moody, the director of the Ohio Office of Health Transformation.

Like other Republicans, Kasich opposed Obamacare. But he sees the expansion as an opportunity to reform Ohio's Medicaid program and is seeking a privatized option to appeal to Republican legislators, Moody said.

"It was a constant kind of careful negotiation to try to understand what our very conservative House, particularly, would find more appealing than the Medicaid-only option, but at the same time be in a range that the federal government would ultimately approve," Moody said.

In Ohio, 1.5 million people, or 14 percent, had no health insurance in 2011, census figures show. According to the Urban Institute and the Kaiser Family Foundation, expanding Medicaid would extend coverage to 684,000 people.

Kasich helped assemble a broad coalition to support his Medicaid plan, including business leaders, hospitals and health care providers, and activist organizations usually more affiliated with Democrats, Moody said. Similar interest groups have backed the Medicaid expansion elsewhere.

But not enough GOP legislators are swayed by their arguments so far, Moody said. "It's been a bit of a roller coaster."

In Arizona, the Republican resistance to Brewer’s plan has led her to an unusual alliance with House Minority Leader Chad Campbell (D), her longtime nemesis, and Democrats make up the base of Brewer's support on Medicaid. Campbell is confident the plan could pass via an alliance of Democrats and moderate Republicans, but GOP lawmakers dispute that claim.

The conservative Republicans who control the Arizona Legislature have revolted against Brewer. Kavanagh said Medicaid funding isn't sustainable and fears devastating economic consequences from federal spending -- while acknowledging the immediate benefits a Medicaid expansion could create for his state. “It brings in money to Arizona, but at what cost?” he said.

Campbell dismissed Republican objections about spending. “For all the arguments I hear about the federal government not being able to afford it, I don’t see them rejecting federal money for highways or border security,” Campbell said. “They are willing to throw away health care for people and can cost this state thousands of jobs.”

The uninsured rate in Arizona was 18 percent, and 1.2 million residents lacked health insurance in 2011, according to census data. The Obamacare Medicaid expansion would provide benefits to 238,000 people, according to the Urban Institute and Kaiser Family Foundation project.

The stalemate between Brewer and GOP lawmakers has consumed the Capitol, but she won't give up until the Legislature delivers a plan, said Matt Benson, her spokesman. "She’s patient," he said.

More than 40 percent of U.S. residents went without health insurance or had coverage that didn't protect them against high medical costs last year, survey results released Friday reveal.

Thirty percent of people in the U.S., or 55 million, were uninsured for at least part of the year prior to the survey, which was conducted from April to August 2012 for the Commonwealth Fund, a New York-based research organization. Another 30 million people, or 16 percent of the population, were "underinsured," meaning their health plans offered too little coverage and exposed them to high out-of-pocket costs, the survey found.

People earning up to four times the federal poverty level, which is $11,490 for an individual this year, were the most likely to be uninsured or underinsured. The lower the income, the more common uninsurance or underinsurance was, according to the survey:

Lower-income and uninsured people reported the most problems accessing medical care they needed because of cost:

And said they faced financial hardships as a consequence of having little or no health insurance coverage protecting them from high expenses, leading in some cases to debts, exhausted savings and damaged credit ratings:

President Barack Obama's health care law offers financial assistance for health insurance to low- and middle-income people earning up to 400 percent of the federal poverty level, which is $45,960 this year for a single person.

Sara Collins, the vice president for affordable health insurance at the Commonwealth Foundation, said Obamacare could mitigate some of the consequences of an expensive health care market.

"Of the 55 million adults in the survey who were uninsured during the year in 2012, more than half have incomes that would make them eligible for coverage under the law's Medicaid expansion if they are legal residents," she said during a conference call with reporters Thursday. "And more than one-third have incomes that would make them eligible for subsidized private plans sold through insurance marketplaces."

The impact of the health care law's Medicaid expansion will be blunted, however, by Republican governors and Republican-led state legislatures that are refusing to broaden the joint federal-state program to more poor people.

And while subsidies for private insurance, in the form of tax credits, will be available, they may not be large enough to offset premium hikes for some people, which health insurance companies say are partially the result of Obamcare's benefit guarantees.

The largest health insurance company in Maryland wants the state to okay its plan to raise premiums on individuals by an average of 25 percent next year -- and it's partly blaming new Obamacare rules.

CareFirst BlueCross BlueShield submitted a proposal to Maryland regulators Wednesday that would take effect in 2014 for people who buy their own health insurance, rather than obtain it from their jobs, The Washington Post reported. Older customers may see lower rates next year while younger people would see the largest increases under CareFirst's rate-hike request, in part because of the new law, according to the company.

New benefits and mandates from President Barack Obama's 2010 health care reform law kick in next year, providing guaranteed coverage for people with pre-existing conditions, protections against older people and women being charged higher rates and requirements that a minimum set of benefits, including maternity care and prescription drugs, be covered.

“The biggest driver of the increase is opening up the market to all comers ... The premiums reflect that,” CareFirst CEO Chet Burrell told The Washington Post.

Health insurance companies have cautioned that with these new benefits will come new costs, especially if older and sicker people who are shut out of today's market flood the Obamacare health insurance exchanges seeking coverage and younger, healthier people stay away because of higher premiums.

The health care reform law, however, also provides subsidies for the purchase of health insurance to anyone who earns between the federal poverty level, which is $11,490 for a single person this year, and four times that amount. People at the lowest end of that income scale also will qualify for additional subsidies to offset their out-of-pocket costs.

These subsides, in the form of tax credits, are crucial to making health insurance plans more affordable. They are especially key for younger, healthier people with fewer medical needs and less incentive to obtain coverage beyond the obligation to comply with the law's individual mandate that nearly every legal U.S. resident be covered starting next year.

Young people and those in working families are the most likely to qualify for health insurance tax credits, according to a recent analysis by Families USA, a liberal health care reform advocacy organization.

Health insurance premiums also are tied to the rising costs of medical care, although growth in those costs has slowed in recent years. Health insurance rate hikes aren't a new phenomenon. From 2005 to 2012, the average increase in premiums for policies sold via online vendor eHealth Inc. rose 32 percent for individuals and 27 percent for family coverage, the company reported in November.

Maryland, under staunch Obamacare supporter Gov. Martin O'Malley (D), is one of 31 states with the authority to approve or reject health insurance rate increases and will negotiate with CareFirst to bring down next year's premiums, The Washington Post reported. CareFirst covers 70 percent of state residents who purchase their own health insurance policies, according to the newspaper. CareFirst's rate-hike proposal is significantly larger than the 4.3 percent increase sought by Kaiser Permanente, according to the newspaper.

Two other states, Vermont and Rhode Island, recently disclosed proposed health insurance premium increases for next year that are smaller than CareFirst's request in Maryland. In Vermont, where state law already offers some of the guarantees included in Obama's health care reforms, the proposed increases are minor, according to Kaiser Health News. Rhode Island insurers asked for an average 18 percent increase, the Wall Street Journal reported.

Aetna and other major health insurance companies are advising brokers and customers about how to extend their current policies, which don't have to meet the new Obamacare standards, before the end of the year. This strategy would enable consumers to retain the plans they have now, which may be less comprehensive and thus less expensive.

Patients injured in last week's bombings near the finish line at the Boston Marathon are poised to get a little help from their health insurance companies and the hospitals that treated them.

Blue Cross Blue Shield of Massachusetts, Tufts Health Plan and Harvard Pilgrim Health Care won't charge marathon bombing victims co-payments or other out-of-pocket costs related to their hospital care, the Boston Globe reports.

The health insurance companies also are making arrangements to ensure that patients have access to ongoing medical services, including mental health counseling, when they leave the hospital, according to the newspaper.

Boston medical facilities like Massachusetts General Hospital, Brigham and Women's Hospital and Tufts Medical Center, which took in some of the more than 280 injured marathon participants and spectators, also may waive some charges, the Boston Globe reports.

Massachusetts General Hospital is holding off on billing any patients and has experienced good cooperation from the health insurance companies covering the patients who do have benefits, spokeswoman Sally Mason Beomer told The Huffington Post Tuesday.

Under Massachusetts' unique health care system , 96 percent of state residents had some form of health insurance to protect them from extreme health care costs as of 2011. Massachusetts also has a safety net program for uninsured or under-insured people who receive care in the state, whether they are residents or not.

Health insurance and safety net benefits may not cover all of the future expenses for follow-up treatment, rehabilitation and other needs that some bombing victims may incur, however.

Donations are flowing into the One Boston Fund -- which has raised more than $20 million so far -- and other initiatives set up to benefit the bombing victims and their families, including personal pleas from people injured in the explosions.

The victims of the Boston Marathon bombing have endured pain and injury but they may be spared further insult in the form of huge medical bills, thanks to Massachusetts' unique health care system.

Owing to a 2006 health care reform law enacted by then-Gov. Mitt Romney (R), just 4 percent of Massachusetts residents were uninsured in 2011, according to census data. And many of those bombing victims who lack health insurance, including those visiting Boston from out of state, may qualify for financial assistance from a "Romneycare" safety-net program.

"When I was watching the events and hearing from my colleagues what was happening at the hospitals I said, 'Well, thank God we have near-universal coverage in Massachusetts' because those people almost certainly would be covered," said JudyAnn Bigby, who was secretary of the Massachusetts Executive Office of Health and Human Services under Gov. Deval Patrick (D) from 2007 to 2012.

Boston's emergency services and its hospitals have been praised for the speed and effectiveness of the medical response to the bombing last Monday. More than 280 injured marathon participants and spectators passed through the doors of Boston hospitals and clinics over the last week, but none have died beyond the first three fatalities and just two victims remained in critical condition as of Monday.

But all that medical care costs money. Trauma care, surgery, hospital services, recovery and rehabilitation charges can quickly mount. Compared to other states with higher rates of uninsured people and weaker safety nets, the Massachusetts health care system is built to minimize the likelihood that huge debts will follow major injuries and illnesses.

Massachusetts enforces an individual mandate that nearly every state resident obtain some form of health coverage, and it also provides subsidized coverage via Medicaid or private health insurance to low- and middle-income people who don't receive health benefits at work. This system served as a model for President Barack Obama's health care reform law, known as the Affordable Care Act.

In addition to providing for health insurance coverage, Massachusetts runs a program called Health Safety Net. This benefit allows patients who have no health insurance or inadequate coverage to apply to have the state pay their hospital bills, even if they aren't residents, Bigby said. Generally, the only people who qualify are those who make up to 400 percent of the federal poverty level, which is $45,690 for a single person this year -- but exceptions are made for severe illness and injuries, according to Bigby. The Health Safety Net benefit is largely financed by assessments on hospitals and health insurance companies.

Federal law requires hospitals to accept and stabilize everyone in need of emergency medical care regardless of their ability to pay. In Massachusetts, however, broader insurance coverage and a safety net program for uninsured people's hospital bills not only alleviates some worry about high costs, but also diminishes the chances a patient will be sent out of the hospital as soon as they are out of mortal danger, Bigby said.

"In some of those places, people would be seen and stabilized and hospitals would try to ship them somewhere else, to a public hospital or somewhere where people without insurance generally are sent," Bigby said.

Yet, given the extensive nature of some patients' injuries, including lost limbs, there will be ongoing medical and rehabilitative costs that may not be covered by health insurance or by the Massachusetts safety net program. "The breadth of coverage could leave some people with some uncovered expenses given the severity of some of the potential injuries," Bigby said. The Health Safety Net Program is limited to hospital costs.

Patients' costs will vary, Bigby said, depending on the care they receive and the level of coverage their health insurance plans provide. In Massachusetts, some less expensive insurance requires patients to cover 20 percent of their hospital bills and pay deductibles as high as $5,000, she said.

That's one reason why some bombing victims are raising money online and why Gov. Patrick and Boston Mayor Tom Menino (D) have backed the creation of the One Boston Fund. The fund will benefit those injured in the blasts and the families of the three killed at the marathon site and the police officer killed in Cambridge Thursday. Massachusetts and the federal government also have crime victims' compensation funds available.

Additionally, hospitals have charity care programs that can waive some charges, said Tim Gens, general counsel for the Burlington-based Massachusetts Hospital Association. "Massachusetts has a very strong and extensive safety net," Gens said.

At Beth Israel Deaconess Medical Center in Boston, which treated victims as well as the two bombing suspects, billing questions will wait until a later date, spokesman Jerry Berger wrote in e-mails to The Huffington Post. "We just aren't focusing on that yet. It's a question that will be addressed when everyone is discharged," Berger wrote. "We have been focusing on providing care."

The most severely injured bombing victims likely will suffer lifelong health problems or disabilities as a result of their injuries, and Massachusetts law guarantees residents of the state will remain insured, said Donald Berwick, a former acting administrator of the U.S. Centers for Medicare and Medicaid Services under Obama and a possible 2014 gubernatorial candidate in Massachusetts.

In other states, those would qualify as pre-existing conditions that would enable health insurance companies to refuse future coverage for the victims, he said. That will change when the health insurance market reforms under Obama's health care reform law are enforced next year, Berwick noted.

"Massachusetts is the only state, until the Affordable Care Act comes into effect, in which they have to issue insurance," he said.

CORRECTION: A previous version of this story misstated Boston Mayor Tom Menino's political affiliation. He is in fact a Democrat.