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Could be Geriatrics and Palliative Care... Just a thought.
Best specialty for the future?
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Union representative.
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Depends, if you're just starting out, it'll depend on how the models of payment change in the next ten years. It also depends what happens to the private insurance industry, whether we move toward a single payer or not.
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Lokhar, you seem to be a fairly coherent arguer for the pro side od this health-care bill. I have real problems trying to understand exactly what the benefit is aside from expanded access for the currently "uninsured" (I use quotes because a majority are either illegal immigrants, eligible for medicaid but do not sign up, or 20-30 year old "invincibles"). I posted this elsewhere, but I really just do not see how anyone sane thinks this can be realistically funded.
This bill is purely about expanding access to care. There is very little that bends the cost curve down. Adding more people that don't care what that MRI on their R knee costs, when the real reason they have knee pain is because they are 5'6" and 275, will only exacerbate the problem.
The only provision I see that decreases cost is the excise tax or "Cadillac plan" tax, and Obama/Pelosi neutered that. All the savings I see on this plan relies on cutting reimbursement by fiat (continuing sgr cuts to doctors), or fiction. This fiction relies on "bundling" to decrease costs in part, and Medicare advisory boards deciding what to reimburse. Bundling is something anyone who has ever negotiated with a hospital or insurance company should dread. Basically it just is code for pay hospitals only for surgeries, and make anesthesiologists beg for the scraps. You will either see decreased payments to anesthesia groups, required to provide more services, be straight hospital employees, and or, elimination of subsidies. Just wait till you start getting all the "hospitalists calls at 3am to do their lp for menigitis pts, or place alines for their urosepsis pts.
Can anyone honestly believe preventative care will save money as this bill proposes? Sure, it may save lives, and be an overall benefit to society, but this bill assumes it will save MONEY. That sounds great and seems to "make sense", but we as clinicians are taught that any hypothesis has to be tested. This one is tough, to test admittedly, but every test I can find, including the feb 14, 2008 nejm article clearly shows preventative doctor care costs money in general. If you believe doctors can make people, quit smoking, eat less and excercise more, I have a bridge in New York to sell you.
Most of the uninsured added to this bill also go to expanded Medicaid coverage, for which states that are already broke must pay. The federal government pays for the early years of this Medicaid by collecting taxes for a few years before they extend the coverage. But once the federal government begins to decease payments to the states in the mid to later part of this decade, in order to make the cost look less than it really is for the cbo, where are the broke states going to come up with this money? Ca. You say stimulus bill??
Can anyone who supports this bill explain to me where these cost savings are going to come? And please do not insult our intelligence with that talk point waste/fraud/abuse nonsense. Do not say "preventative care" unless you come with a better source than the nejm. Do not say decreased er uses for primary care by the uninsured, unless you can explain why er visits are not decreased in the universal coverage land of Massachusetts.
This bill is purely about expanding access to care. There is very little that bends the cost curve down. Adding more people that don't care what that MRI on their R knee costs, when the real reason they have knee pain is because they are 5'6" and 275, will only exacerbate the problem.
The only provision I see that decreases cost is the excise tax or "Cadillac plan" tax, and Obama/Pelosi neutered that. All the savings I see on this plan relies on cutting reimbursement by fiat (continuing sgr cuts to doctors), or fiction. This fiction relies on "bundling" to decrease costs in part, and Medicare advisory boards deciding what to reimburse. Bundling is something anyone who has ever negotiated with a hospital or insurance company should dread. Basically it just is code for pay hospitals only for surgeries, and make anesthesiologists beg for the scraps. You will either see decreased payments to anesthesia groups, required to provide more services, be straight hospital employees, and or, elimination of subsidies. Just wait till you start getting all the "hospitalists calls at 3am to do their lp for menigitis pts, or place alines for their urosepsis pts.
Can anyone honestly believe preventative care will save money as this bill proposes? Sure, it may save lives, and be an overall benefit to society, but this bill assumes it will save MONEY. That sounds great and seems to "make sense", but we as clinicians are taught that any hypothesis has to be tested. This one is tough, to test admittedly, but every test I can find, including the feb 14, 2008 nejm article clearly shows preventative doctor care costs money in general. If you believe doctors can make people, quit smoking, eat less and excercise more, I have a bridge in New York to sell you.
Most of the uninsured added to this bill also go to expanded Medicaid coverage, for which states that are already broke must pay. The federal government pays for the early years of this Medicaid by collecting taxes for a few years before they extend the coverage. But once the federal government begins to decease payments to the states in the mid to later part of this decade, in order to make the cost look less than it really is for the cbo, where are the broke states going to come up with this money? Ca. You say stimulus bill??
Can anyone who supports this bill explain to me where these cost savings are going to come? And please do not insult our intelligence with that talk point waste/fraud/abuse nonsense. Do not say "preventative care" unless you come with a better source than the nejm. Do not say decreased er uses for primary care by the uninsured, unless you can explain why er visits are not decreased in the universal coverage land of Massachusetts.
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While you use " " around uninsured, I can use " " around the word "insured". That is because "insured" individuals, many are at risk of losing that insurance, being denied insurance ever again, random and unexplained rate increases, etc. etc. I'm sure you probably heard the arguments, and this bill is also designed to look out for those that are insured. It also increases funding and reimbursements for Medicaid so if those 10+ million or so actually did apply for medicaid, their would be funds for them, and allow some of those 20-30yr old invicibles to stay on their parents plans so they are covered...
Mostly agree. But then, if they did try to "ration" care, that would be another (oh wait, it already is) talking point of opponents. Comparative Effectiveness Research, evidence based medicine, and, yes, Tort reform need to take place, and while Tort reform wasn't in this bill, instead of spending all this time and energy on grandstanding/campaigning on repealing the bill, Republicans (and Dems alike) should try to address these issues
The excise tax doesn't decrease costs... it just increases funding. Same with the increased Medicare tax. Decreased costs could come from A) Decreased Medicare Advantage Plans, since they cost more and provide worse care, B) negotiation of drug costs to Medicare Part D (did they end up including this? C) Buying over state lines (claimed to be in it.. but is it actually?)... probably a few more things in there
Yeah, over the long run I believe preventative measures cost more money. Mammograms to catch breast cancer earlier not only cost money for mammograms, but because all the women are now living 20, 30, 40 years longer, their strain on the medical system is much more over the length of their life. But, is it cheaper year to year ($500,000 over 40 years vs $100,000 over 2 years...)? But, if price was the only factor, then no one with cancer should get treatment, anyone with an MI should just be allowed (or even forced to) die, because they will cost the system money. There needs to be some balance between costs and providing the best healthcare, so attacking the bill because it provides for preventative healthcare, even if that isn't a price saver, shouldn't be right...
No time to comment on rest of post...
D
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Primary care and preventive care aren't one and the same.
All "prevention" isn't about expensive screening tests like colonoscopy and mammography. The best thing from a cost standpoint that we can prevent is chronic disease. That's the thing that's likely to bankrupt the system, not cancer. The best way to do this is good primary care.
All "prevention" isn't about expensive screening tests like colonoscopy and mammography. The best thing from a cost standpoint that we can prevent is chronic disease. That's the thing that's likely to bankrupt the system, not cancer. The best way to do this is good primary care.
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Well, it looks like we have some agreement here, so I will enjoy this discusssion. You are correct, there are also some admirable benefits for the currently insured, and I should have included that. I was too vague with access. While I like all these provisions, I can see the plausibility that some conspiracy theorists have espoused that the reason all these things happened is an attempt to bankrupt the private insurance market to ensure the government steps in with a single payer. Why do I say that, because the way I currently understand the bill, most healthy people have a purely financial incentive to just pay the relatively small no insurance tax, deposit the savings on insurance premiums into say a short-term tax exempt bond fund/multiyear CD, and just go without insurance. Then if they get sick, they just buy insurance because they can not be denied from having pre-existing conditions. That appears to be the optimum financial solution based on a game-theory like way of analyzing the propostion. Now, I am not saying all people will not get insurance, just that the incentives appear distorted.
Additionally, this medicaid funding, that is only for a few years of the bill from my understanding. Then the states have to take over. Also, medicaid reimbursement only increases to medicare levels (=/-10% according to some sources, I do not have a firm understanding on how this will play out yet) for primary care and general surgery from my understanding of the bill.
My main concern with the bill is not that anything in it is horrible (although those independent medicare boards and incentives to form ACQs could be horrible in practice), it is just that they enacted a major entititlement expansion in a field with exponentially acelerating costs, yet really did next to nothing to control those costs.
You and I both know that care NEEDs to be rationed. Who does the rationing is the concern. I do not thing the government should be the sole one doing so, I think HSAs and buying across state lines with refundible vouchers are the rational way to go, but the problem with that is most consumers are not rational, or else we would not see the rampant credit card debt we already do. So basically, I do not have a firm solution here. I know what should work in theory, but I am also pretty sure most people would screw it up.
This in theory should decrease costs by shifting more people from low or no deductible/co-pay plans to ones where people actually have to pay something for care. It is a more skin in the game provision I agree with. So I disagree that this will not decrease costs. You are correct that it would have no effect on costs, and just increase funding, if corporations chose to keep the cadallac plans and just pay the excise tax, but I believe most corporations will just change health plans to avoid the tax.
I agree with you here, but my problem is that this bill relies on cost savings from preventative care to get to the second decade CBO estimates it makes. I believe these estimates are flawed from a cost standpoint.
Basically, this is a huge deficit increaser.
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It isn't much more than expanded access to the currently uninsured and protections for people who already have insurance (no lifetime or annual caps, children can stay on longer, etc).
Correct.
Correct.
It doesn't bend the cost curve. It expands access. I would be happy to answer questions about the bill. Whether the United States should expand coverage is more of a philosophical question, and one that you and I can disagree on. That is a separate issue though. If the purpose of this bill is to expand coverage, it succeeds. If it is to bend the cost curve down, it really doesn't do much about that.
There is nothing in this bill that would directly lead to lower reimbursements. I mean Medicare may or may not lower their reimbursements, but aside from certain imaging services, there is nothing in this bill that would force them to decrease or increase the costs.
If they decreased the reimbursement, that might bend the cost curve down (again, not saying decreasing the reimbursement is a good thing, merely that it saves money). But it really has nothing to do with the bill. That would just be medicare being medicare.
The bill doesn't propose that it saves money (CBO did not say that it would). Again, the bill is about expanded access and almost the whole bill is dedicated to that aspect. The bill makes no comment on preventative care saving money - merely that preventative care is important and that it should be free to those with insurance.
It won't. I'm apologize if I implied that it would. The things that actually might result in cost savings were taken out of the bill due to political pressure.
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Looks like we agree on the facts then Loktar. You are right, whether you agree with this bill basically boils down to whether you think it is more important to decrease costs, or expand access. I think it is incredibly foolish and naive to expand access to a very broken system before you control costs. I believe that regardless of our countries financial situation, and the fact that we have a precarious economic condition with HUGE deficits only makes me more astounded that someone rationally thought this would be a good time to expand access. If someone on the contrary takes a John Paul Jones approach of "damn the torpedoes, full speed ahead" on expanding access, regardless of the cost, then there is not much I can say to that person to get them to change their minds. I bet they like their credit card debt as well, but that is another issue entirely.
In addition, I believe a lot of the mandates in this bill such as the minimum coverage levels deemed acceptable, and the requirement for policies to include things like obstetrical care, substance abuse, and mental health services will serve to only increase the cost of premiums. This may be a sinister plot by progressive to lead to a single payer system. Or it may be foolishness, who knows.
However, a single payer is something I am strongly against. Why? Because history has shown us that if a single payer is anything like medicare, then government will screw the "rich doctors" as much as they can. Currently some specialties that can effectively refuse to see medicare patients if medicare's rates are too low get reimbursed fairly well. However, if you look at the specialties where in effect the doctors really can not refuse medicare, then you see what the government does with monopoly power. This is the power they would have with a single payer. My specialty gets medicare rates 66% lower than what private payers pay. I know some of this is inflated rates to private payers, but most is just flat WAY under cost rates from medicare. So I have no trust of the government to be "fair" with its monopoly power with a single payer. No doctor in my opinion should.
In addition, I believe a lot of the mandates in this bill such as the minimum coverage levels deemed acceptable, and the requirement for policies to include things like obstetrical care, substance abuse, and mental health services will serve to only increase the cost of premiums. This may be a sinister plot by progressive to lead to a single payer system. Or it may be foolishness, who knows.
However, a single payer is something I am strongly against. Why? Because history has shown us that if a single payer is anything like medicare, then government will screw the "rich doctors" as much as they can. Currently some specialties that can effectively refuse to see medicare patients if medicare's rates are too low get reimbursed fairly well. However, if you look at the specialties where in effect the doctors really can not refuse medicare, then you see what the government does with monopoly power. This is the power they would have with a single payer. My specialty gets medicare rates 66% lower than what private payers pay. I know some of this is inflated rates to private payers, but most is just flat WAY under cost rates from medicare. So I have no trust of the government to be "fair" with its monopoly power with a single payer. No doctor in my opinion should.
I absolutely agree with the bolded statement. I like the idea of expanding coverage to everyone as well but do we even have the money to be doing it right now? The point is we don't have the luxury. We don't have the money. We should have took a conservative approach to see what changes would prove to cut costs first. We didn't cut costs but we spent a whole lot more of money we don't have. It is just more money we will either borrow or print. This is extremely dangerous and I'm amazed that the majority in America is completely blinded. Costs are the #1 issue right now with our economy the way it is. We don't have any money to expand coverage, but we keep pretending like we do. I am growing terrified of our government. We have a very fragile economy right now. An inflationary environment is going to devastate this nation.
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If you believe the CBO then this bill will be paid for... it is paid for by increased Taxes and Fees primarily, and some slight cuts in expenses, but it is suppose to be paid for. Whether or not we should be adding new taxes in the economic climate as it is can be up for debate, but major chunks of the taxes are aimed at individuals making over 200K who are not necessarily feeling the pain or crunch of the economic problems... We are also dealing with opposing economic theories, and that deficit spending is an effective means of restoring the economy, and since healthcare is 1/6th of the economy, i'd say increasing its infrastructure could fall into line with deficit spending. That 1 trillion dollars being infused into the system has to be spent somewhere...
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Yes, and I think that is a valid view to hold. However, I think that politically we're at a point where any real effort to control costs would be shot down by the opposing party under shouts of rationing and wanting to kill grandma. Really, if you look at when we spend most money, the vast majority is in the last year of life when there is very little chance of the person making a recovery.
Things like that are a huge resource drain. I know many physicians want tort reform, and I personally feel that it's unfair to physicians what is happening now. Just like I find covering the expansion of care to the uninsured a moral issue, I find tort reform a moral issue as well. There should be tort reform because it is morally the right thing to do, but overall it doesn't really decrease the cost of healthcare all that much (look at states with caps and other tort reform). Anyway, I am totally in favor of implementing cost controls, but I think we're unfortunately going to be waiting for a day that never comes if we do that. Neither party is really going to favor something like that, because frankly, it is political suicide.
This is obviously my opinion, but we're on our way to bankruptcy with healthcare anyway, and if we're going to be damned, I'd rather be damned on the right side. This bill costs $100bn a year, which is not all that much compared to the $2.5 trillion healthcare economy. I know $100bn sounds like a lot, but our defense budget is $700bn. To me, the lives saved due to expanded care is more than worth the cost.
We can of course agree to disagree here. However, I think it is clear from all analysis that anyone has ever done that we're not heading towards a sustainable path - I don't think this bill necessarily accelerates it, but it certainly doesn't stop us from that path either.
If you have a commission that recommends, as one did, about mammograms starting at 40 vs. 50. It was roundly criticized. Their point was that we as a society have to draw the line somewhere. A woman getting a mammogram in her 40s has 1/1800 chance of it saving her life, while in her fifties, it is 1/1200. I think it's a discussion that we as a society need to have. Where do we draw the line - what is enough? If we lower it to 30, we might save 1/3000. If we make it 60, we may do 1/600. It's all odds, and we (somewhat arbitrarily) choose 40 now, but you saw the political recriminations when they suggested that 50 may not be a bad age to start for mammograms. And that was for a single optional test! If you wanted to save maximum possible lives, you'd get everybody in the country have a full spectrum of tests every three months. But at some point, it gets ridiculous. If we want to reduce costs, we have to decide what that point is, and budget accordingly. I don't see it happening though, but maybe that's just because I'm a pessimist.
And if that's bad, imagine when someone brings up the idea of deciding when to pull the plug! It's just not politically workable unfortunately, and we all suffer as a result.
For me, the only surefire way to contain the costs over a long period and have healthcare as a non-bankrupting cost on our system would be to have a single payer. But that's a whole another argument that is a mere fantasy in the near or the midterm future.
Unlike the pre-allo thread, I hope we can continue to have a civil, intelligent discussion here
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Interesting.... how does single payer avoid or address the problems outlined?
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It allows us a more direct control of the total expenditure on health care, so we may make proper rationing decisions based on whatever criteria we decide and whatever resources we choose to allocate to it.
Assuming of course, we have the political and social will for it. Will not happen as long as prominent people start throwing out death panels in order to get publicity and use fear mongering. Of course, Single Payer with crappy rationing is almost as bad as private insurance with crappy rationing - except maybe that until you go bankrupt, you're covering everyone while you do it. Small consolation, and perhaps why I don't have any hope, any direction we choose go.
Assuming of course, we have the political and social will for it. Will not happen as long as prominent people start throwing out death panels in order to get publicity and use fear mongering. Of course, Single Payer with crappy rationing is almost as bad as private insurance with crappy rationing - except maybe that until you go bankrupt, you're covering everyone while you do it. Small consolation, and perhaps why I don't have any hope, any direction we choose go.
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I must not have been paying attention. I thought this was EXACTLY what Obama/Pelosi were selling it as?
Lokhtar said:
21.3% cut goes into effect starting April 1.
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They were and are touting expansion of coverage, banning of industy practices, and bending the cost curve down.
The last claim is almost unequivocally untrue and if they are claiming this bill addresses that issue in any serious way (which some are), they are lying. Many of the cost-cutting provisions were cut out of this bill early.
That's the yearly cut that is always postponed. They are going to pass a bill to permanently get rid of that, if what I am hearing is true. Of course, it's politics, so it's never to sure a bet. That cut, of course, does not originate from this bill.
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Authoritarianism. Got it.
Hardly. It's a representative democracy. We decide as a republic how much to spend on FBI or the military, or NASA, we decide locally how much to spend on police, I feel we should decide as a republic how much and what we should spend on health care instead of basing it on how much money you have. I don't think healthcare should be treated as a commodity like TVs, or computers. Just like we don't treat protection from crime by the police as a commodity to be afforded only to some.
Every other first world democracy agrees with that. You don't, and that's fine, I understand. But I would humbly put forth that the idea is hardly authoritarian.
Of course, on this issue, I don't think we'll agree. I've lived in a country with socialized medicine, and I can't believe we don't have it here. I find it much better. On the other hand, some people (such as perhaps yourself) don't want that all, and so I suppose we'll be voting for different candidates and both of us hoping that some common sense wins out (our definition of common sense probably don't align either, on this topic
).I am not sure if it is within the scope of this thread to decide whether we should or should not have single payer though. I'd be happy to discuss it on another thread. Here, I'd like to discuss the current bill and it's effects. I sure as hell spent way too much time reading and re-reading the whole damn thing, and I want to get at least some use out of it in a discussion
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1. We are not now, nor were we ever, intended to be a democracy. In fact, the founders went to great lengths to protect against that.
2. What you are describing is socialized medicine. This employs a socialistic construct. Socialism is a form of authoritarianism. It employs a compulsory theft mechanism, at the barrel of a gun and under threat of imprisonment, in a discriminatory manner, to provide for private consumption goods and services in a disproportionate manner. The tyrant is the majority; one should not be able to use their vote as a weapon to confiscate the property of others. When one removes the decision making capacity from the private sector (be it an individual or a coalition of the willing) and transfers it to the state, that too is authoritarianism -- your failure to appreciate as much none withstanding.
As for the current bill -- the consequences were clear to many before its passage... and will be clear to many more over the coming months. Premiums will escalate at a rate greater than "doing nothing" for now the insurance companies will be faced with actuarial uncertainty combined with looming capital holdings pressures. Employer groups (those who represent a great many of the "healthy") will perform simple accounting analyses to determine whether to pay the fine or continue to offer coverage. Individuals will do likewise, and the removal of the relative penalties associated with getting sick in the absence of insurance will cause many to simply opt out while they're healthy. This leaves fewer "healthy" people in the pool and causes the costs to be distributed over a smaller base.
Further, the taxes levied upon the insurer, device maker, and pharmaceutical company will all flow back to the consumer in the form of increased premiums as well.
Make no mistake -- this bill had several intents and purposes; improving the nations health care system apparently was not one of them. It is a major tax bill. It is a major new entitlement. It furthers the nanny state and enables increased dependency. It buys votes. It punishes "the rich". It redistributes wealth. It throws a bone to major labor unions. It does NOT improve our health care system -- and provides the equivalent of a fan -- and fuel -- to a burning fire.
2. What you are describing is socialized medicine. This employs a socialistic construct. Socialism is a form of authoritarianism. It employs a compulsory theft mechanism, at the barrel of a gun and under threat of imprisonment, in a discriminatory manner, to provide for private consumption goods and services in a disproportionate manner. The tyrant is the majority; one should not be able to use their vote as a weapon to confiscate the property of others. When one removes the decision making capacity from the private sector (be it an individual or a coalition of the willing) and transfers it to the state, that too is authoritarianism -- your failure to appreciate as much none withstanding.
As for the current bill -- the consequences were clear to many before its passage... and will be clear to many more over the coming months. Premiums will escalate at a rate greater than "doing nothing" for now the insurance companies will be faced with actuarial uncertainty combined with looming capital holdings pressures. Employer groups (those who represent a great many of the "healthy") will perform simple accounting analyses to determine whether to pay the fine or continue to offer coverage. Individuals will do likewise, and the removal of the relative penalties associated with getting sick in the absence of insurance will cause many to simply opt out while they're healthy. This leaves fewer "healthy" people in the pool and causes the costs to be distributed over a smaller base.
Further, the taxes levied upon the insurer, device maker, and pharmaceutical company will all flow back to the consumer in the form of increased premiums as well.
Make no mistake -- this bill had several intents and purposes; improving the nations health care system apparently was not one of them. It is a major tax bill. It is a major new entitlement. It furthers the nanny state and enables increased dependency. It buys votes. It punishes "the rich". It redistributes wealth. It throws a bone to major labor unions. It does NOT improve our health care system -- and provides the equivalent of a fan -- and fuel -- to a burning fire.
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Yes, I realize the point of a republic. You are arguing semantics, we clearly colloquially refer to ourselves as a democracy. I know we don't have majority rule on every measure, that's why we have a constitution and elected representatives.
Yes. As done free education, police, etc. If you were looking for an anarcho-capitalistic system, good luck finding it in the US, now or ever. Probably late nineteenth/early twentieth century came close.
Really? Doctors are going to prison in Canada and forced to treat patients?
You are arguing against the power of any sort of government to collect any type of taxes? That's what any tax is, right? If that is your opinion, that's fine. I do not share it. I personally like my police protection and the public school I went to, both of which I now pay taxes for as an employee and a property owner. I don't consider it theft from me. I don't see why healthcare is a less essential service than education and/or police.
I'll make a decision on whether it was worth it by seeing in ten years how many people died for lack of healthcare compared to the previous ten. That will be my criteria. You can use different criteria to judge it.
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This is not semantics at all; it is a much more base argument than that. It is principle. It is intent. It is base structure. There is no way to twist "democracy" into "republic" via semantic manipulation.
Police is completely different. One of the legitimate purposes of government is to protect its citizenry, uphold contracts, and protect property rights. The provision of a common defense would include a law enforcement mechanism. Public education is another matter entirely -- and one that I do not care to get into at this point.
If they try to treat them outside of the Medicare system, yes. Look it up. Canadian healthcare is a fascist system and one that I don't care to emulate.
Again, police is different. Police serve to protect you from others who would violate your person and property. It is a legitimate use of force. Of course you like the government providing for you personal consumption / betterment goods and services financed off the the back of another... that is the "new" way apparently.....
Pretty f'ing bold experiment that you are advocating there.... a fascist trial of tyrannical force "just to see what happens". Abrogation of contracts... unfunded mandates... annexation of property rights.... way to go, friend. I'm sure you'll be loved by your colleagues -- when you actually become a productive member of the working class.
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Regarding the "late 19th/early 20th century" comment: I'll give credit where credit is due -- at least you have an appreciation of the damage to freedom and liberty that the early 20th century and the Progressive movement of the day provided.
History has shown time and again that national prosperity is inextricably tied to the economic freedom enjoyed by its citizenry. When these freedoms are removed, a predictable and inevitable decline in both national prosperity and influence invariably ensues. This time will be no different.
History has shown time and again that national prosperity is inextricably tied to the economic freedom enjoyed by its citizenry. When these freedoms are removed, a predictable and inevitable decline in both national prosperity and influence invariably ensues. This time will be no different.
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True. But unfortunately seems like the USA is in a severe decline. Kind of like the Roman Empire. The citizens of Rome felt entitled to free stuff such as free bread provided by the government because they were in the "richest/biggest/most powerful empire." Then Rome fell soon after.
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No, you are arguing semantics not because democracy and a republic are the same in a technical definition, but that when we use the term democracy colloquially, we use it as an umbrella term that refers to the 'free world' and covers everything from direct democracy, to a republic, to even a constitutional monarchy. You know full well what I meant, and if you didn't, you do now.
If you think that, then I think we can call it a discussion here - the Canadian system is one that I would very much like to emulate. Just a philosophical difference.
Not all services. I would class healthcare as an essential service.
Pretty f'ing bold experiment that you are advocating there.... a fascist trial of tyrannical force "just to see what happens". Abrogation of contracts... unfunded mandates... annexation of property rights.... way to go, friend. I'm sure you'll be loved by your colleagues -- when you actually become a productive member of the working class.
I'm an older non-trad student and I've been working for many years (well, many being about a decade..). And no, my views are not out of the mainstream.
Yes, I know full well what it means to have a mortgage and bills. I don't think we need to get personal here.
The economic system of that era certainly had its advantages, mainly for a few people, but on the whole, I'd not want it back again.
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Out here in the working world -- surrounded by people who have worked their asses off in order to get ahead and provide a more secure home for their families -- I can assure you that your views are "out of the mainstream". You advocate for the declaration of eminent domain over our most valuable asset -- our intellectual property. This amounts to nothing more than an advocacy of theft.
Perhaps you should do a little more background work on what defines fascism and what is a fascist system. A centralized sole financier and controller, with dictated rates and wholly regulated, wed with private ownership of the actual means of production is as corporatist / fascist as it gets.
Even the architects of the bill have said that a main purpose was the redistribution of income.
[YOUTUBE]http://www.youtube.com/watch?v=TPRPqeYi-60[/YOUTUBE]
...and the jackass in chief himself campaigned vigorously against the measures that he ultimately purchased and bribed through the legislative process. The man is a lying ideologue.
[YOUTUBE]http://www.youtube.com/watch?v=EoSnqofelsQ[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=EwzYVEunPQ0[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=xvcxYMIT_rs[/YOUTUBE]
So, if you want to keep arguing this socialist BS, feel free. You're in good company.
Perhaps you should do a little more background work on what defines fascism and what is a fascist system. A centralized sole financier and controller, with dictated rates and wholly regulated, wed with private ownership of the actual means of production is as corporatist / fascist as it gets.
Even the architects of the bill have said that a main purpose was the redistribution of income.
[YOUTUBE]http://www.youtube.com/watch?v=TPRPqeYi-60[/YOUTUBE]
...and the jackass in chief himself campaigned vigorously against the measures that he ultimately purchased and bribed through the legislative process. The man is a lying ideologue.
[YOUTUBE]http://www.youtube.com/watch?v=EoSnqofelsQ[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=EwzYVEunPQ0[/YOUTUBE]
[YOUTUBE]http://www.youtube.com/watch?v=xvcxYMIT_rs[/YOUTUBE]
So, if you want to keep arguing this socialist BS, feel free. You're in good company.
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... and you (and everyone else) using a term incorrectly "colloquially" does not make it correct... it does make it ignorant and even intellectually dishonest if one understands the difference... but it does not make it right in any way, shape, or form.
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Let's approach this from another angle. I would like for you to defend this bill -- or your position -- in such a way that it does not involve governmental commandeering of the medical professional's livelihood... and does not involve further income redistribution. In short, make a case that does not involve authoritarian tenets.
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I have lots of problems with this bill, so I won't defend it. I do think it's better than the status quo, but that is a different discussion.
As for my position...you want me to defend my position - single payer - without invoking the government?
That's like asking someone to defend the US invasion of Afghanistan without mentioning 9/11.Let me ask you a question. Should we repeal medicare? What, if anything, should be in its place?
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You seem to think I disagree with that? I don't like the insurance mandate. Instead of having to purchase a private service, I'd much rather have the option to buy into medicare.
Well I can't speak for your circle of acquaintances. But at my office, medicare for all is pretty popular, and the public does support the expansion of medicare.
-http://www.washingtonpost.com/wp-srv/politics/polls/postpoll_121509.html
63% is pretty mainstream. Even if it drops to 30-40% if you say medicare for all, instead of 55, it's still pretty mainstream if a third or more of your country believes it.
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Look, when you ask the question, "Do you want someone else to pay for something that you now have to, freeing up that money for frivolous discretionary items?", you naturally get an answer of "Yeah, that sounds pretty good." The more telling thing from your statistic is when faced with the question, "Do you believe that government should just go ahead and complete its takeover of your healthcare system?" the tune changes precipitously.
..and again, care should be taken to prevent the vote from becoming a state sanctioned mechanism of theft.
..and again, care should be taken to prevent the vote from becoming a state sanctioned mechanism of theft.
Are you like for abolishing all kind of taxes? "state sanctioned mechanism of theft" just sounds to me like hollow conservative ideologist propaganda - it makes NO sense unless you're an anarcho-capitalist. Otherwise, you'd be supporting in one way or another "state sanctioned mechanisms of theft." Obviously, the crushing majority of people believe that "state sanctioned mechanisms of theft" ARE necessary, be it for maintaining roads, enforcing security, or ironically in cases of many Republicans, building a huge army to wage wars and engage in nation building. The real question is in which cases do we think such "state sanctioned mechanisms of theft" are necessary, and health care has a damn good case. Universal health care is on the UN declaration of human rights back from 1948. Access to health care and a proper safety net are absolutely necessary for any kind of decent human well being, and the US constitution after all mentions that humans are endowed with the rights to life, liberty and the pursuit of happinness. What I find slightly ironic is that universal health care is actually in the Iraqi constitution.
The hand wringing is this subforum is a bit amusing. If I had to wager a guess, it's probably because the very high physician salaries will slightly go down. (and that's coming from someone who got in and will enroll in med school).
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Obviously the wording makes a big difference. If you say, "Do you think we should show full nudity at 5pm on networks?", you'd get people saying no. If you say, "Do you want to follow Hitler and put restriction on our first amendment right to freedom of speech by disallowing explicit programming at 5pm on networks?", you'd get a different proportion of people saying no.
The point is, people who have medicare, don't want to give it up. If you tell people you can get medicare earlier, they are all for it. So why not just have medicare available from the beginning for everyone?
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Yup, as I mentioned earlier in the thread, you'd have to be against all taxes.
Are all taxes theft, or just the ones you disagree with? I'd certainly don't want my tax to go fight the war in Iraq, does that mean it was theft from the US government?
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1) cost
2) who doesnt like something for free?
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1) Considering the overall budget and what we spend on healthcare already, it's not more expensive - it's actually a lot cheaper. Except that instead of paying health insurance companies, we'd pay the government in taxes. Either way, the money is going out of our pocket. The difference is which middle man it goes through - the insurance companies or the government.
2) Of course. But it's hilarious when I hear how people oppose 'government takeover of health care', when they clerly don't oppose expansion of medicare - which would be direct control of healthcare by the government.
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Where to start... OK, I had a well thought out and referenced response -- until my 18mo hellion hit the lit button on the powerstrip... but here's the Reader's Digest version:
Anarcho-capitalism has its merits, but has never and will never hold up in reality. Why? Human nature. Governments evolve out of chaos for reason. Granted, they eventually devolve into a period of chaos -- but rise again invariably in some form or fashion. To this end, yes, some form of taxation is seemingly necessary; yet the fact remains that any tax is a government sanctioned confiscation of property -- and, as such, should be limited to the bare minimum necessary.
Before going into this much further I would like to pose a couple of questions to you (whoever) in order to gauge how much you have thought about these things:
- what is "money"
- what is "the state"
- why do we have taxes
- what is the proper role of government in a Constitutional Republic? A free society?
As for the last portion of your post: you're inexperience is showing. Most practicing docs have no "salary"; they earn whatever monies are in excess of their costs. On what basis do you make your assumption "very high salaries may go down slightly"? First you demonstrate a judgement bias..... only to follow up with an answer pulled straight from the splenic flexure.
Yes, and yes.
Again, not against all taxes -- just against a system that creates two classes with disproportionate burdens and equal voting privilege. Look at our current income tax system: mid 40% range -- of W2 filers -- have zero federal tax liability at the end of the year. This creates a system of roughly equal parts -- tax producers and tax consumers -- with virtually equal voting power. When posed with the question of "should we raise taxes" or "should we have a new government program" those who are net consumers naturally respond "hell yes". Why? Because they don't bear the tax burden and will likely benefit from the redistribution. This is nothing new -- one of our Founding Fathers understood and argued this all those years ago (and I would have to listen to a ton of old lectures again to remember which one it was). This is the true problem with funding government -- particularly welfare programs -- via a progressive income tax. In essence this is what the state is telling you: we own you and your labors. Your income falls under our ownership; we get paid first and we determine how much you are allowed to keep.
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I'll attempt:
Off the top of my head:
1. A sort of standardized unit of 'value' that serves in exchange of goods and services. All the money in a system can be thought of as the sum 'value' of all the goods and services produced by a society.
2. In some ways, administering "fossa et furca" (sorry, I took many years of Latin - had to throw that out there
). Or, the power of the 'pit and the gallows' as it was known in the middle ages. More broadly, a system of administration where (ideally of, by and for the people) laws are enforced.3. Debatable. It depends on what the society decides, there are multiple ways to go in order to forge a successful society. It depends what type of society you want. In my ideal world, the government would provide a structure whereby basic necessities are regulated and provided for the common good (e.g, defense, police/fire protection, enforcement of laws and rights, education, healthcare, etc). And of course, the power of pit and gallow to make sure the laws are enforced. It's power would be limited by a constitution or some form of charter which would place limits on it's authority and guarantee certain rights to the citizens.
I'm sure I've missed a lot. That was a quick five minute response.
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Well, people who make more also pay more for everything, including, for example, the military. I class healthcare as just as important. The only way not to have unequal tax burden in terms of pure dollar amounts is to have the same dollar amount of taxes for people making $8/hour to people making $500/hour. That would be impractical as there would be zero revenue to do anything for the government since the tax rate would have to be close to zero for the $8 guy to afford it. Or you could give more voting rights to people who have more money - so bill gate's kid would have 'more votes' than the entire population of inner city Philadelphia - effectively ending the system of government of and by the people.
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Well, alright, were getting somewhere. While there really are no concise and uniformly accepted definitions, the best definition of state that I have run across goes something like this:I'll attempt:
Off the top of my head:
1. A sort of standardized unit of 'value' that serves in exchange of goods and services. All the money in a system can be thought of as the sum 'value' of all the goods and services produced by a society.
2. In some ways, administering "fossa et furca" (sorry, I took many years of Latin - had to throw that out there
3. Debatable. It depends on what the society decides, there are multiple ways to go in order to forge a successful society. It depends what type of society you want. In my ideal world, the government would provide a structure whereby basic necessities are regulated and provided for the common good (e.g, defense, police/fire protection, enforcement of laws and rights, education, healthcare, etc). And of course, the power of pit and gallow to make sure the laws are enforced. It's power would be limited by a constitution or some form of charter which would place limits on it's authority and guarantee certain rights to the citizens.
I'm sure I've missed a lot. That was a quick five minute response.
The state is a geographically delineated monopoly of force for the purposes of being the end arbitrator in all disputes.
The proper role of the state is to protect the person and property of its citizenry from threats. This means that the states sole responsibility is to defend and uphold the rights and liberty of its citizenry, to enforce the law and guard against theft and violence. A right is the sovereignty of action, constrained only by others rights to their property and person. Anything that requires the action of another cannot be construed as a right; it is a good. Now, if we are speaking of legal rights that is another matter entirely and is not one of right at all, it is a matter of state sanctioned privilege. Again, no one has the right to lay claim to anothers person or property .
Money is simply an agreed upon medium of exchange that has certain characteristics. It evolves spontaneously across societal structures, time, and place out of the inherent limitations of the bartering system. Nothing overly fancy there.
Why do we have taxes? Thats one that is not as easily arrived at. In short, we have taxes to provide a base (and certain) need for the nations chosen currency. If taxes were only to pay for government debts and operations and the government owns the printing press why would we need the elaborate confiscation mechanism? We would not. The reason for taxation is that it provides a demand for the currency, providing for a stability in the currency. The citizen is forced to pay an amount under penalty of law and threat of imprisonment in the nations chosen currency . Thats about it.
Again, don't go all polar and miss the fact that this is a discussion of margins... I know that were not likely to ever convince the other of the error of our ways but one side relies upon covet means and coercive theft by force for its agenda while the other does not . Im fairly comfortable with not being the tyrant.
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I suppose I just disagree that healthcare is a discussion about margins. To me, if you're going to have a government, you need to have collective healthcare, like you have collective defense.
A very libertarian view of the state. I wouldn't agree with that.
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It is very hard to come to any middle ground on this issue as well... I wish I could see it in pure black and white and fully agree with either side and be done with it. Everything in the above statement is dead on (maybe not the last 2 sentences)... but how do we address this? And should we even address this (that is, do I believe this system does not better us as a society?). I mean, if this was really a huge problem for the rich/management, they wouldn't try to make as much money, the wage difference would become more equitable between management and workers, and tax burden would be more shared (and some entitlements wouldn't be as "needed"). But the rich still make out MUCH better than the poor, so that difference, even if just slight, is still motivation enough to prevent everyone from relying on the nanny state... yes Welfare and some of those programs do not encourage people from getting off of those programs, but those programs aren't necessarily like being on vacation either. Now, as the social programs get better and better and the benefit of being "the rich" becomes less and less, the extrinsic motivation to be productive decreases. But that also leads to another problem with general human nature, society, or whatever. Many actions, practices, etc, are done solely for the Extrinsic Motivation. So much of peoples work is done solely as a means to aquire Money to exchange for goods and services, to survive, and live. The only way true socialism works, and one of the major reasons these utopia ideals don't work, is for people to have intrinsic motivation to perform their task (that is, the reward comes not from an external source that rewards you with something not explicitly connected to the work, but the motivation to practice medicine is the interest of medicine, the gratitude of patients for helping them, and the sense of satisifaction, etc). But this never will happen, and thus while Socialism might sound great in theory, that extrinsic motivation is so much more powerful than the intrinsic motivation and a system designed with that in mind will be more successful. And even with the social programs in America, the system is still in place motivates the good majority of individuals, and I would argue that at times it is valuable to sacrific a bit of the motivational force to benefit society as a whole. I think providing healthcare is a necessary sacrific over some of the other social programs, but I do admit I am a bit biased thinking that healthcare is the most important topic ever
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I know you would not. You are a soft authoritarian -- not sure which, if any, typical label best fits your espoused positions though.
Here's the thing -- this country was founded by those who believe as I do. In fact, our central governing document (that has been largely ignored for better than a century) is crafted in such a way that it reflects these positions. Its primary purpose and intent was to shackle the beast that is the state. There is no way to protect the rights of the individual absent this core structure. You see, they, as students of history and human nature, understood that the state is an aggressive entity by its very nature. There is no way around it really.
I still cannot understand the assigned equivalence of healthcare with defense, police, or fire.... each of these serve to protect you from the untoward action of another -- a legitimate use of force and stated purpose of the state. Aside from public health and communicable disease the same argument cannot be made for healthcare.
Lastly, we are not a collectivist nation. Expunge that concept from your mental construct for the love of all that is holy....
col·lec·tiv·ism   [kuh-lek-tuh-viz-uhm] Show IPA
noun
the political principle of centralized social and economic control, esp. of all means of production.
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drjojo,
The last two sentences were spot on as well; it is a shame that more do not appreciate the situation for what it is.
You point out the very thing that I have been arguing -- this is another example of debating the margins. There are no easy answers -- given today's circumstances. The cause of the individual suffered a series of crushing defeats in the early and mid 20th century; the level of dependence upon the state now makes things very difficult to address.
The last two sentences were spot on as well; it is a shame that more do not appreciate the situation for what it is.
You point out the very thing that I have been arguing -- this is another example of debating the margins. There are no easy answers -- given today's circumstances. The cause of the individual suffered a series of crushing defeats in the early and mid 20th century; the level of dependence upon the state now makes things very difficult to address.
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I don't know if there is one. I'm not a socialist. I am a capitalist, simply not a laissez-faire capitalist. Capitalism is the best system that we have so far, but that doesn't mean it is perfect or could be set in motion without controls.
It's very interesting you mention this. I am, or used to be, in a small way (an EXTREMELY small way mind you) a biographer of John Adams, and have spent a lot of time doing research on the founding fathers, their lives, philsophy, etc. They were a bunch of people who did the best they could - an excellent job, in the end - based on principles they thought would last. It is interesting that many people forget about the Articles of Confederation - it was a trial that failed. So they tried again, and did a much better job (it doesn't mean it was perfectly done).
It is very interesting that you mention their views of the state - the founders themselves differed quite a bit on the nature of the state, and you certainly can't group all of them in one box. I also make a point that many of them, at the time of ratification, still viewed the states as sovergein entities. That's why they limited the Federal government - the states were, in many cases, free to be as oppressive as they wanted. The constitution does not say anything about the states for that reason.
In modern day an age, to say that Maryland is a sovereign nation is a pretty sketchy argument, and not one that I'd buy. Furthermore, to say it is the right thing to do because some (not all mind you) founders thought it was is a pretty ludicrous argument. They themselves would have been quite horrified at such an argumentum ad antiquitatem (appeal to tradition). Adams and Jefferson, politically very different, both would have recoiled in horror at the thought. That's why they created the process by which the people could amend the constitution - they knew they didn't get it perfect.
Let me put another scenario. My house is burning down, the government comes in their fire trucks and puts out the fire. Assuming I live in the boonies, and my house is not a fire hazard to anyone else, why should they do it? It's a service that is paid for collectively for the benefit of all.
I do not advocate the centralized control of all means of production. In matters such as education and healthcare, I do.
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You, by this post, seem to trust the federal government to make rational well educated decisions with this power. I however, am very skeptical of the motives of the federal government run by lawyers. While I am no fan of insurance companies, I am a fan of competition, and a single payer eliminates competition and requires one to believe the government will fairly use monopoly power. The only evidence I see of how the federal government would use monopoly power is current medicare rates. These rates are ridiculously low in the situations in which the government can essentially be a full price fixer, IE specialties that that in effect can not refuse to see medicare/caid patients. See my above lines in this thread that you did not address for more info
Rabbmd said:
Given the current trend of making the "rich" pay for everything, why wouldn't this current trend of populism extend to physician reimbursement with a single payer state. When 40+% of Americans pay NO income tax, yet because of AMT my marginal income tax rate was 43% (state plus federal) last year before medicare and social security taxes, there is a serious problem.
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Really? At its core capitalism is based upon private ownership of capital and market determined price and wage. What you seem to be advocating does not follow. To be revisited below....
I was speaking in terms of their consensus view. Yes, some were for a strong centralized government while others preferred more of a loose coalition; in their compromise they struck a balance that was pretty good for less than a century (unfortunately) after which point the statists won the fight.
You take too narrow of a view. The same logic for the city still holds true -- unless you happen to wholly own an island surrounded by substantial enough waters to prevent the sparks from jumping to a passing vessel... even in the sticks one's property abuts another's, therefore the same rules still apply.
So you are an à la carte socialist....
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Again, unless you are an anarchist, what you support also does not follow. To say I support no private ownership of capital, or market determined price for wages overall, just because I don't support it for a few areas is an extreme misrepresentation of my position. How much could police get if it was free for all, and they didn't have to protect all those poor people? A lot more I bet. That doesn't mean I support the privatization of police firms offering services based on if you can afford them.
Ah yes, that unfortunately wrong outcome of the civil war...the problem was that the civil war put an end to the delusion that states were sovereign entity. And thank goodness for that. It would be an unworkable system in the modern day.
In any case, their compromise did not say anything about the government not getting too oppressive. It only said that about the federal government not getting too oppressive. Have a look at some of the laws on the books of the individual states. I don't think the guy in his home cares much whether it's the state police or the federal marshall that's coming in and breaking in his door to oppress him. To say the founders got a compromise that was perfect, or ideal is just plain not looking at the motives and the outcomes from a realistic perspective. Thankfully, the federal limits have been extended to states as states themselves are no longer seen as independent entities. That means though, as a corollary, that some services that were meant to be provided by the individual sovereign states should not be provided by the federal government.
So you are an à la carte socialist....
Unless you wish for the government to provide zero services, so are you.
No. That is different from not allowing it to make any decisions.
There certainly is a problem. The problem is tax rate that you and I pay is too low (I own a business). We can't adequately pay for the services we need. The new tax increases from this bill will directly affect me. That's OK. Actually, it's not, I don't want my tax money going to subsidize private insurance - I'd rather pay a much higher tax and have single payer.
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Why again though should physicians trust any government single payors when whatever specialties Medicare can be a price fixer they already set rediculously low rates?
What is a high enough marginal tax rate? 60%? 70%. this would seem far less burdensome if greater than 60% of voters actually paid income tax.
What is a high enough marginal tax rate? 60%? 70%. this would seem far less burdensome if greater than 60% of voters actually paid income tax.
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