Obamacare is a Complete Failure

[pd1112]

How on earth does that support the notion of entitlement? There is no car because it is WILDLY expensive to operate one in manhattan. Monthly parking is at least 400 dollars, and at most 800. Insurance is high. Gas costs are high. Mechanics are super expensive in the borough. Street parking is nearly impossible and garage parking is easily 10 dollars an hour.

Welcome to New York City.

And are you supposed to check availability of every known type of specialist before you sign up? Because I, a medical student, didn't even do that. How is Joe Schmoe supposed to be expected to?

I expanded on it in the next post, saying you'd think that (not having a car) would be one of the things on your mind when choosing a plan. I wasn't saying she should have a car.

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[pd1112]

You give people way too much credit.

My whole point in the first place - entitlement.

 

[BrooklynBulls]

I expanded on it in the next post, saying you'd think that (not having a car) would be one of the things on your mind when choosing a plan. I wasn't saying she should have a car.

Now respond to my next point-- do you reasonably expect people to survey which specialists are available in any specialty? Particularly when you live in the most population-dense and doctor-rich city in North America? Is that not asking too much of the average consumer? Are you currently aware of where your nearest Rheumatologist under your coverage is?

 

[Mad Jack]

america's healthcare is ****ed, more at 11

this is exactly zero news to anyone who has an inkling of what a successful health plan looks like in every other developed country.

The thing is, it just got way more ****ed. And a lot of medical students don't know just how ****ed up things have gotten, hence the point of this thread. People in the field need to know what's happening.

 

[Ismet]

My whole point in the first place - entitlement.

Uhhh there's a big difference between entitlement and not knowing any better.

I take it you haven't gotten to 3rd year yet? Probably best not to approach your lay-patients with the notion that they're entitled when they really just don't know any better.

 

[Mad Jack]

I expanded on it in the next post, saying you'd think that (not having a car) would be one of the things on your mind when choosing a plan. I wasn't saying she should have a car.

I already explained the difficulties inherent in selecting a plan. There are a lot of plans and a lot of specialties. People don't have infinite time to sort through these things. You're gonna have a bad time come rotations if you don't realize that people aren't perfect things with infinite amounts of time and money to spend selecting their health plans.

 

[Silent Cool]

I'm going to be a psychiatrist. Half of psychiatrists don't accept insurance at all and most are solo practitioners.

Great OP.

Every week you change specialties!

Re: Obamacare/ACA--all that needs to happen is this:

1) Allow people to purchase insurance across state lines
2) Uncouple insurance from employment, such that employees get the money instead
3) For those who are unable to afford insurance, just give them money; states on average spend 6K per medicaid recipient. Just give them 6K per year and let them buy their own insurance (which would be cheap if you could buy it across state lines). Note that this last proposal is an adaptation of Milton Friedman's 'Negative Income Tax'

http://en.wikipedia.org/wiki/Negative_income_tax

 

[Mad Jack]

Great OP.

Every week you change specialties!

Re: Obamacare/ACA--all that needs to happen is this:

1) Allow people to purchase insurance across state lines
2) Uncouple insurance from employment, such that employees get the money instead
3) For those who are unable to afford insurance, just give them money; states on average spend 6K per medicaid recipient. Just give them 6K per year and let them buy their own insurance (which would be cheap if you could buy it across state lines). Note that this last proposal is an adaptation of Milton Friedman's 'Negative Income Tax'

http://en.wikipedia.org/wiki/Negative_income_tax

I've been on the psych train for months. Probably won't get off because reasons.

I can't handle the rotating shifts of EM. I can't handle the long hours of an IM residency and length of the IM+Pulm/CCM path. Anesthesia is dying. So that leaves me with psych, and possibly FM, but far less likely.

 

[maxxor]

Surgery. Come...let the hate flow through you...embrace the dark side...

Or he could go literally dark side and join us over in the reading room.

 

[Ismet]

I've been on the psych train for months. Probably won't get off because reasons.

I can't handle the rotating shifts of EM. I can't handle the long hours of an IM residency and length of the IM+Pulm/CCM path. Anesthesia is dying. So that leaves me with psych, and possibly FM, but far less likely.

What about the babies? Peds/child psych/adult psych triple board?


(Jk)
(Now back to your regularly scheduled programming about politics and insurance stuff)

 

[Mad Jack]

What about the babies? Peds/child psych/adult psych triple board?


(Jk)
(Now back to your regularly scheduled programming about politics and insurance stuff)

I thought about peds/psych/child+adolescent, no joke. I'm so indecisive it hurts.

 

[Mad Jack]

Surgery. Come...let the hate flow through you...embrace the dark side...

My hands are too shaky to embrace the dark side

 

[Ismet]

I thought about peds/psych/child+adolescent, no joke. I'm so indecisive it hurts.

You have plenty of time to decide. 3rd year will help immensely.

 

[Mad Jack]

You have plenty of time to decide. 3rd year will help immensely.

Yeah, it definitely will. All I know is that I'm old and I'm tired, so a lot of the specialties I'd be all over when I was 22 I'd rather blow my brains out than go through residency for starting at age 34. Things like psych and PM&R just look better by the day.

 

[Willy38]

You have plenty of time to decide. 3rd year will help immensely.

Regarding that, would you recommend an accelerated pre-clinical to allow for earlier exposure?

 

[fancymylotus]

Wanna hear the worlds biggest joke?

Obamacare dental plans. Lol

 

[Mad Jack]

Regarding that, would you recommend an accelerated pre-clinical to allow for earlier exposure?

For myself that would be kind of pointless- I worked in healthcare for a lot of years prior to starting med school, and rotated everything from peds to neuro to critical care transport etc. For most med students, I think some exposure to all the specialties early on will help them out. We have to do rotations at my school with different specialties starting in first year, so that we're exposed to certain things and start to wonder what specialties might be for us. In second year it accelerates, and you're doing a rotation a week in a different specialty. I think it's pretty awesome myself, as it really seems to break people's preconceived notion of what medicine is and isn't, and where they might fit in.

But that's just like, my inexperienced opinion, man.

 

[Lawgiver]

Great OP.

Every week you change specialties!

Re: Obamacare/ACA--all that needs to happen is this:

1) Allow people to purchase insurance across state lines
2) Uncouple insurance from employment, such that employees get the money instead
3) For those who are unable to afford insurance, just give them money; states on average spend 6K per medicaid recipient. Just give them 6K per year and let them buy their own insurance (which would be cheap if you could buy it across state lines). Note that this last proposal is an adaptation of Milton Friedman's 'Negative Income Tax'

http://en.wikipedia.org/wiki/Negative_income_tax

#1 is a very bad idea. I'll let someone who uses reason explain it.

http://voices.washingtonpost.com/ezra-klein/2010/02/selling_insurance_across_state.html

 

[Stagg737]

Great OP.

Every week you change specialties!

Re: Obamacare/ACA--all that needs to happen is this:

1) Allow people to purchase insurance across state lines
2) Uncouple insurance from employment, such that employees get the money instead
3) For those who are unable to afford insurance, just give them money; states on average spend 6K per medicaid recipient. Just give them 6K per year and let them buy their own insurance (which would be cheap if you could buy it across state lines). Note that this last proposal is an adaptation of Milton Friedman's 'Negative Income Tax'

http://en.wikipedia.org/wiki/Negative_income_tax

Not terrible ideas, but there are problems with each one.

1) Easily said, but we all know how insanely difficult this would be in terms of the legal and bureaucratic aspects. Especially since states all want to regulate themselves and don't always play nice, especially when money is involved.
2) I'm assuming the purpose of this is to allow them to buy insurance with that money? That would be great, but realistically a lot of people would probably either not buy insurance or they would buy the cheapest plan possible and spend/save the rest on something else. So what happens when people don't have insurance that can pay for their medical bills and don't have the money themselves?
3) Once again, people are irresponsible. Even so, people who can't afford insurance probably can't afford other things like adequate housing, clothing, or even food. So why wouldn't they take that 'free money' and spend it on those things?

 

[Stagg737]

#1 is a very bad idea. I'll let someone who uses reason explain it.

http://voices.washingtonpost.com/ezra-klein/2010/02/selling_insurance_across_state.html

Basically, except there's no reason that the poor state buying out the insurance companies would be limited to conservative states. Illinois is such a financial disaster that the federal government cut their line of credit at one point, and a good number of the politicians would throw their mother in front of a bus for another year in office. Blaming a single party for the abomination that is and will be U.S. healthcare is just naive. Besides, it's not like the ACA doesn't screw a huge percentage of U.S. citizens over anyway, the poor included.

 

[pd1112]

Now respond to my next point-- do you reasonably expect people to survey which specialists are available in any specialty? Particularly when you live in the most population-dense and doctor-rich city in North America? Is that not asking too much of the average consumer? Are you currently aware of where your nearest Rheumatologist under your coverage is?

Uhhh there's a big difference between entitlement and not knowing any better.

I take it you haven't gotten to 3rd year yet? Probably best not to approach your lay-patients with the notion that they're entitled when they really just don't know any better.

Plus who can even reasonably anticipate what specialists they will need in the future?

I currently have no needs for a rheumatologist, an ID doc, an orthopod, an oncologist.

But even as a physician with presumably a higher than average ability to forecast my own future needs...how the f am I supposed to know what doctor I will need in the next 5-10 years?

I already explained the difficulties inherent in selecting a plan. There are a lot of plans and a lot of specialties. People don't have infinite time to sort through these things. You're gonna have a bad time come rotations if you don't realize that people aren't perfect things with infinite amounts of time and money to spend selecting their health plans.

I was just speaking from my own experience. I spent about 20-30 minutes comparing plans last year when my parent's plan ended. Some classmates chose plans from the website because they didn't want to pay the higher premium from our student plan. Being that it was my first time personally buying insurance of any kind, I wanted to know what I was getting for $2k-3k. It was not more than a few clicks and typing a zip code on each website to view a list of providers and hospitals in the networks (so yes, actually I am aware of the nearest rheumatologist in my network). Sure, I'm more informed on the topic than the average American since I'm in the field. No, I haven't made it to MS3 yet, but I worked full-time in an ED for 2 years prior to school - I'm well aware of the (lack of) intelligence of patients. If she really looked at the plans at all, other than just clicking on the cheapest, then I'll send her my apology. I was reading between the lines and guessing she just chose the cheapest and assumed all was well. To me, it's both naive and entitled to think any multi-thousand dollar investment will take care of itself. It absolutely does not take infinite amounts of time and money to look into it and do a little research, especially when 58% of American adults have smart phones, 74% have internet, and libraries are free. It's not changing my attitude towards patients or how I interact with them - I chose this field just like the rest of you. It's just disappointing from a medical professional standpoint and from the prospective of our society as a whole, that most people care more about Candy Crush (9 billion games/day last year) or Trivia Crack (270k new downloads/day). And I hope I won't have a bad time come rotations just for thinking so.

 

[Dr.Sticks]

Do you know a lot of doctors that can actually survive that way and not comply with medicaid laws and all that? I know of a few hospitals in CA that do that I think but mainstream it's almost impossible no?

The Concierge model of medicine seems to be getting to be pretty popular;

Anyways the problem with our health care system is that a bunch of lawyers are designing it, instead of doctors.
I'm not a doctor, at least not yet. So I can't honestly say what needs to be done, however I'm willing to point out that insurance companies are a problem. The reimbursement rates and all, that's why prices at the hospital are so inflated.

Anyways with that said, obviously Obamacare will fail. Lawyers don't know anything about health care..

Besides what's so great about this plan? It's just forcing people who can't afford insurance to somehow afford insurance. That's genius alright, plain genius. Legendary legislation, yup!

Anyways I don't have a plan, I'm not a doctor. Let the doctors decide not corporations, and lawyers. Dr.Carson did make this point in his highly controversial speech at the Prayer Basket or something..
With that said, I think more politicians who happen to be medical professionals would be a good thing to happen.

Besides, as a believer in Jeffersonian Democracy the most educated should be in office.

I'm going to go out and say PhDs in certain fields, and Doctors happen to be the most educated. (I don't count Naturopathic Doctors even though medicare accepts them)

 

[SpinalFusion]

If you're truly interested, run the numbers for yourself and see how even if a patient has to eat his/her 5k deductible every 3 years, they still save money with better care.

If you're arguing, then nothing I say will change your mind anyway.

I'm not kidding either, run the numbers and see how people would actually spend on yearly care thats leagues above what insurance can provide in quality. I was blown away when I started researching DPC 2 years ago.

Not at all actually. After todays discussion I wanted to find out some more about DPC, and ran across a great article about a Seattle FP who seems to be doing pretty well on it: http://www.dpcare.org/ http://time.com/3643841/medicine-gets-personal/.

This model definitely seems to have the potential to be a major player in the Primary Care World. I'd really like to hear from any Physicians who are actually using it now!

 

[GunnerBMS]

If republicans weren't so obstructionist and Obama had some bawls then we could have had single payer

 

[notbobtrustme]

The Concierge model of medicine seems to be getting to be pretty popular;

Concierge pretty much only works in like 50 zip codes in the US or if your patient population is pretty healthy. If they require lots of medications/hospitalizations/interventions, concierge doesn't work for them.

 

[Nasrudin]

Concierge pretty much only works in like 50 zip codes in the US or if your patient population is pretty healthy. If they require lots of medications/hospitalizations/interventions, concierge doesn't work for them.

I see an upside to this. You only contract with people motivated to be healthy. Sure...you leave behind a lot of wonderful people who are unfortunate, unlucky and need help.....but what are you going to do. America said no to single payer health care. *****s lined up to picket saying ".....no government in my Medicare..." I just don't have the energy to fight stupid. Or to worry about how it has won, and how Idiocracy is so much more than just good comedy.

I love this thread. I think it points to a small but determined group of innovators who are leaving vast bureaucracies and unmotivated yet entitled patients behind. And even if it's the middle class being left high and dry....I want to go there with these innovators. To welcome the struggling middle class to a model that is at least responsive to them as patients. Nothing against the wealthy of course. There's always Medicare at least for the poor. Anyway, nothing convinces me more of this than experiencing the bureaucratic warfare it takes for hospitals to just get paid from insurance companies.

If Madjack's assessment is correct that this is getting worse then every able mind and bodied physician should be looking for a way out.

 

[NickNaylor]

The psych applicants in our class had a dinner with our clerkship advisor who also advises on the residency application process, and we talked about the ACA for a bit (in addition to the other firebrand topic of NP providers). In his view, the ACA has actually been a huge help to our institution; patient volumes are up, and more patients that live right next to the medical center but who have never received care here before are getting their care here. Reimbursements generally are up since more people are transitioned from state safety net services to actual insurance plans. Granted, I think this is largely driven by the fact that the overwhelming majority of patients seen at our institution are uninsured and poor - theoretically the population that would be most helped by the ACA.

I'm not convinced that the ACA has helped the public as a whole, but for our institution, at least, it seems to have been a help to both the people coming to see us and the institution in terms of revenue generated.

 

[charmiedermie]

If republicans weren't so obstructionist and Obama had some bawls then we could have had single payer

Is that a good thing? Maybe you're joking, but you think the real solution for patients and doctors is for the federal government to be the one and only payer of all healthcare services?

 

[AM508]

Is that a good thing? Maybe you're joking, but you think the real solution for patients and doctors is for the federal government to be the one and only payer of all healthcare services?

I know eh? With the governments history of money wasting inefficiency I can't see that working well. These are the same folks who paid millions for a broken website. We also can't forget the VA waiting list scandal. They failed to manage the care of a subset of the population, imagine if they had to manage the care of the entire population...that is downright scary. I'll keep my right to choose my insurance

 

[ScrubsMD]

Is that a good thing? Maybe you're joking, but you think the real solution for patients and doctors is for the federal government to be the one and only payer of all healthcare services?

In reality we will end up with a hybrid system of some kind with a single payer base. With the ACA we have some medicaid/medicare creep already. However, who knows when this will happen.

Why we haven't pulled this band-aid off yet is anyone's guess. When Nixon pushed for a hybrid single payer with Kennedy in the 70s politics got in the way. With Hillary care in the 90s politics got in the way. With the ACA, politics got in the way. And I bet even with a Republican Congress now there won't be a permanent doc fix in the next few months. Politics will get in the way of that...

 

[charmiedermie]

In reality we will end up with a hybrid system of some kind with a single payer base. With the ACA we have some medicaid/medicare creep already. However, who knows when this will happen.

Why we haven't pulled this band-aid off yet is anyone's guess. When Nixon pushed for a hybrid single payer with Kennedy in the 70s politics got in the way. With Hillary care in the 90s politics got in the way. With the ACA, politics got in the way. And I bet even with a Republican Congress now there won't be a permanent doc fix in the next few months. Politics will get in the way of that...

Single payer has no hybrid. Maybe there might be supplemental plans but not full private insurance plans. Paul Krugman's articles recommends we follow Medicaid's example - yes not a typo, Medicaid, not Medicare.

 

[Mad Jack]

If republicans weren't so obstructionist and Obama had some bawls then we could have had single payer

I'm sure single payer will work out great for physician incomes...

 

[ScrubsMD]

Single payer has no hybrid. Maybe there might be supplemental plans but not full private insurance plans. Paul Krugman's articles recommends we follow Medicaid's example - yes not a typo, Medicaid, not Medicare.

In most instances it would be considered supplemental, but there are some countries with viable hybrid systems. New Zealand for example.

 

[ScrubsMD]

I'm sure single payer will work out great for physician incomes...

I doubt the average American gives two s**** about physician incomes. They don't say "don't go in it for the money" for nothing.

 

[Mad Jack]

I doubt the average American gives two s**** about physician incomes. They don't say "don't go in it for the money" for nothing.

I don't care what average Americans want to do with my life. It's kind of my life.

 

[KnuxNole]

Point taken, I admittedly never considered NYC residents would not even own a car. That being said, it almost supports the notion of entitlement. Is it too much to ask to spend 5 minutes to look into the network before signing up? Isn't that the whole point of the website, so you can "shop and compare?"

They should make it easier for the layperson. If I was to get insurance, I would be confused with all those options :O

 

[charmiedermie]

I doubt the average American gives two s**** about physician incomes. They don't say "don't go in it for the money" for nothing.

I hope u remember this after finishing med school and residency and u have loan payments to make. You will care about the money u make. U can bet everyone else is getting their cut.

 

[charmiedermie]

In most instances it would be considered supplemental, but there are some countries with viable hybrid systems. New Zealand for example.

Where there are competing plans in the private market?

 

[ScrubsMD]

They should make it easier for the layperson. If I was to get insurance, I would be confused with all those options :O

My family just switched plans. Some are a lot more confusing than you may think.

For instance my new plan has "covered providers" where my insurance will pay a variable rate.
"In network providers" where they will split costs 70:30.
And "preferred providers" which are actual docs in network.

However the average person will, if they even do this, look up docs that take this insurance and say oh my doctor takes this insurance when they are just a "covered provider."
It's too convoluted for the average Joe.

 

[ScrubsMD]

Where there are competing plans in the private market?

Considering they have equal outcomes at half the per capita price, who cares about "competing plans"? The free market is great but there is a reason why it is so expensive in the us...

Granted, there will need to be reforms and watchdogs in place.

 

[charmiedermie]

I don't care what average Americans want to do with my life. It's kind of my life.

I didnt know for some people how the average american perceives their salary is a factor.

 

[ScrubsMD]

I don't care what average Americans want to do with my life. It's kind of my life.

I said nothing about your life? You can do whatever you want with it...

Reimbursements on the other hand is their business, since they make up the vast vast, vast, vast majority of constituents in this country.

 

[Mad Jack]

I said nothing about your life? You can do whatever you want with it...

Reimbursements on the other hand is their business, since they make up the vast vast, vast, vast majority of constituents in this country.

Not my fight since I'm dodging the market anyways I guess. I can't afford the >80k (on average) in billing costs taking insurance and setting up a Medicare compliant EMR would cost me while being able to stay in private practice.

When doctors start opting out of insurance entirely due to poor reimbursements (it hasn't happened yet, but mark my words, there will be a tipping point), it'll be interesting to see how things start to change.

 

[charmiedermie]

Considering they have equal outcomes at half the per capita price, who cares about "competing plans"? The free market is great but there is a reason why it is so expensive in the us...

Granted, there will need to be reforms and watchdogs in place.

What do u mean equal outcomes? You think people on govt insurance have the same health outcomes as those with private insurance? You really think that the numbers are that straightforward that other countries have better cancer survival rates than the US?

 

[Mad Jack]

http://www.wfaa.com/story/news/heal...ing-after-refusing-health-insurance/20226959/

An anecdote that supports my "people will start paying for middle-class concierge care because their insurance won't have a large enough provider panel for them to actually see any physicians" theory.

 

[Stagg737]

My family just switched plans. Some are a lot more confusing than you may think.

For instance my new plan has "covered providers" where my insurance will pay a variable rate.
"In network providers" where they will split costs 70:30.
And "preferred providers" which are actual docs in network.

However the average person will, if they even do this, look up docs that take this insurance and say oh my doctor takes this insurance when they are just a "covered provider."
It's too convoluted for the average Joe.

That plan sounds like pretty much any plan I've ever seen, and it's really not that complicated if you take an hour or so to learn how the system works.

I really don't think it's that complex, I just think the average american is either too lazy/unmotivated/shortsighted to take the time to understand it, or they are just too stupid as you said in the last sentence. Plus not all states have places where you can easily compare insurance plans and get info beyond premium, deductible, and co-pays. In some places you have to dig to get that information, and the average joe here wants instant gratification, not to spend time planning and learning about things that may never happen.

 

[ScrubsMD]

Not my fight since I'm dodging the market anyways I guess. I can't afford the >80k (on average) in billing costs taking insurance and setting up a Medicare compliant EMR would cost me while being able to stay in private practice.

When doctors start opting out of insurance entirely due to poor reimbursements (it hasn't happened yet, but mark my words, there will be a tipping point), it'll be interesting to see how things start to change.

This will happen with PC, plastics, and derm, and that's it. So ill mark your words. What other specialties can do this?

They wouldn't have any patients that could afford treatment except millionaires.
So the doc backs out of insurance, gets no patients, makes no money, and is then forced back into the system to feed their family.

 

[charmiedermie]

I said nothing about your life? You can do whatever you want with it...

Reimbursements on the other hand is their business, since they make up the vast vast, vast, vast majority of constituents in this country.

That has nothing to do with the average American. Third party payers is to negotiate the lowest reimbursement and doctors try to negotiate as high as they can for what they think theyre worth. Im not satisfied with what u reimburse me? Then your company along with your policy holders get dropped. See Seattle Childrens Hospital.

 

[ScrubsMD]

What do u mean equal outcomes? You think people on govt insurance have the same health outcomes as those with private insurance? You really think that the numbers are that straightforward that other countries have better cancer survival rates than the US?

In one word: yes.

For some reason people seem to think that since we pay twice as much we get better care yet study after study. Meta analysis after analysis shows this is not the case at all. Do a search.

http://www.openmedicine.ca/article/view/8/1

 

[Mad Jack]

This will happen with PC, plastics, and derm, and that's it. So ill mark your words. What other specialties can do this?

They wouldn't have any patients that could afford treatment except millionaires.
So the doc backs out of insurance, gets no patients, makes no money, and is then forced back into the system to feed their family.

Psychiatry, for one. And primary care is becoming more and more viable. Urgent care is another possibility. There's a very successful A&I doc in town that doesn't accept insurance, and he's got a practice that's so backed up that he can't accept any new patients.