Supreme Court: Mandate Stands

[henge]

OK, you obviously have a slight handicap in imagination, so let me give you this one: we're not forcing you to accept patients with government insurance, we're just going to tax you $5,000 for every non-government insured patient you take.

Well, you certainly don't know me well enough to assess my imagination, and if I am handicapped in that regard perhaps you could manage some sympathy, or at least some more polite condescension.

You originally presented an example about the quartering act, I showed why to my (unimaginative) mind, that example was distinguishable. You haven't said you disagree with my analysis as it applies to the scenario you presented.

Now you have generously provided me with another example, which provides that you would be taxed at different levels depending on the source of your revenue. If your revenue comes from a Medicaid patient, you pay no (or less) tax, and if it's from a private pay patient, you pay more tax. I imagine (see, I can learn!) you think this arrangement would be unconstitutional.

I may lack in imagination, but doesn't this already happen all the time? If I get revenue from, say, a municipal bond or certain government-favored investments (analogous to your Medicaid patient), I pay no federal tax; if I get interest from my private bank (analogous your private pay patient), I get taxed at up to 35%. And there are tons of credits and deductions in the Tax Code that do much the same thing. There is not a constitutional remedy for every gripe. Sometimes your protection against perceived abuses lies with Congress, not the SC, or so I imagine.

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[crazyozone]

So what? Assets and income are two seperate things. My point is none of reported income is going to overhead..it would have been put into the business BEFORE it was reported as income because you're going to get taxed on that income if you report it.

Yeah you're right. That's not what I meant though. What I meant is that someone is not really making 220k when they use much of their assets to pay for private practice. The payroll may say that they make 220k but eventually most of that will not go to things like the mortgage.

 

[Amnipotem]

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[henge]

I dont know your link doesnt open and I dont know what page 215 of section 1501 of some 25 year-old bill that never passed said.

To recap:
1. you blasted the ACA as being "liberal socialist ideology"
2. Intending to show that the ACA was not previously viewed as liberal socialist ideology, I replied saying that the ACA was based on a plan by the Republican Heritage Foundation.
3. You said "None of the republican options threatened penalties on individuals."
4. I pulled a bill from the history of health care reform site I had earlier cited. That bill, sponsored by a Republican, provides for mandatory health insurance coverage and imposes a tax (which looks as much like a penalty as does the provision in the ACA) on individuals who do not get health insurance.

I think this demonstrates that the Reps did, in fact, propose options that threatened penalties on individuals.

The link worked when I just clicked on it. Might be your security settings. If you want to look, check the link I provided next to the Heritage reference, then click on the 2d pdf down (Chafee's bill).

 

[Wolverines83]

I take your point and thank you for getting the real numbers for single individuals into the discussion. In your example, though, you only cited the 2014 penalty. By the time it ramps up, the flat dollar penalty ($695) would be greater than the percentage penalty, so the penalty would be $68/mo. That's about the cost of a high-deductible catastrophic insurance plan for a young healthy person. Given the choice of paying $68/mo and getting either bare-bones insurance or nothing at all, people will be incentivized to take the former option.

I agree that the penalty should be stiffer to ensure full compliance, but political considerations prevented that, and it's just as well. As it stands, I think the mandate will still do the job it needs to do, all while not offending Justice Roberts' fee-fees.

Ok, fair enough. We differ on opinions, nothing wrong with that. One last reply though.

Don't use today's premiums as a measure of the future premiums, even for catastrophic coverage plans. Those plans are now required by the ACA to provide for 3 primary care visits as well as "preventative services" (both of which are exempt from the deductible) which will raise their premiums. What is considered "preventative services" by a bunch of politicians? Who knows. Gotta love ambiguity. Also, according to the ACA, only up to the age of 30 are you allowed to keep your catastrophic plan, regardless of your health.

Personally I think the whole solution is catastrophic plans coupled with HSAs...but that's just me. Get people to "have a dog in the fight" with coverage for when they get in trouble. But I suppose that point's moot!

 

[henge]

Personally I think the whole solution is catastrophic plans coupled with HSAs...but that's just me. Get people to "have a dog in the fight" with coverage for when they get in trouble. But I suppose that point's moot!

The point isn't really moot. Regardless of what happens to ACA, there are going to be changes in health care law in the future. The provision allowing under 30s to have catastrophic coverage could easily be extended in the future. If I were a betting man, I would bet on that happening within 5-10 years.

 

[eHombre]

Ok, fair enough. We differ on opinions, nothing wrong with that. One last reply though.

Don't use today's premiums as a measure of the future premiums, even for catastrophic coverage plans. Those plans are now required by the ACA to provide for 3 primary care visits as well as "preventative services" (both of which are exempt from the deductible) which will raise their premiums. What is considered "preventative services" by a bunch of politicians? Who knows. Gotta love ambiguity. Also, according to the ACA, only up to the age of 30 are you allowed to keep your catastrophic plan, regardless of your health.

Personally I think the whole solution is catastrophic plans coupled with HSAs...but that's just me. Get people to "have a dog in the fight" with coverage for when they get in trouble. But I suppose that point's moot!

It may be difference in outlook =). You seem a bit more pessimistic of how this will all play out, while I get the sense that the program will work pretty well, and can be altered to address any shortcomings that arise.

A few quibbles:
(1) The language says that only the prevention benefits aren't subject to the deductible; there may be some co-pays involved.

(2) The catastrophic plan is also available for those who are exempt from the mandate. This group would include individuals whose income is not high enough to be subject to the tax penalty, but who do not qualify for their state's Medicaid program for whatever reason (e.g., their state refused to participate in the Medicaid expansion).

(3) The catastrophic insurance plus HSA solution, while better than nothing, is not enough. There will be a large disincentive for these patients to seek follow-up care or comply with prescribed medication schedules. Patients can't negotiate with their doctors, hospitals or pharmacies for lower reimbursement rates like insurance companies can. It's unrealistic to expect low-income patients to pay 100% cost for medications or procedures. The deductible on these plans is quite high, equal to the HSA annual contribution limit, $5950. For someone making $50k/yr, that's fine, I guess. At $20k/yr that gets to be pretty steep.

 

[crazyozone]

Based on the few articles I have skimmed, it seems as if Obamacare is predominantly concerned with establishing the system first and foremost and the reduction in physician salary is either collateral damage or alternatively a way of encouraging physicians to accept more people with public coverage. By making public coverage more attractive, Congress is hoping to displace private coverage. With fewer in private coverage and hence fewer capable of paying higher fees, Congress is hoping that physicians will be forced to intake more publicly funded patients. Reducing salaries does not seem like the end, but rather the means to an end. That's just one of the point of view though, and I'm not sure how realistic it is. One study suggested that physicians will opt out and choose to work fewer hours, which is the opposite of what we're striving for. I think there are definitely going to be issues with the supply of physicians. One option could be making medical school easier to get into and an undergrad program, like it is in other countries with universal healthcare systems. Doesn't seem like other developed countries have a problem attracting talent even though they have laxer standards.

I've seen a few clips of Obama as a senator saying he really wanted a single-payer system so I think you may be right, although just like you I'm speculating.

I think most people agree that getting everyone covered was a necessary thing. Democrats may have shoved it down everyone's throat by passing a 2k page bill before reading it (or letting anyone else read it), but Republicans have proposed a mandate before regardless of what they say now.

These are the biggest problems I see with this law, although I'm obviously no expert as a medical student-- I don't think anyone on this site can be an expert:

With another 30 million people coming to the same number of doctors I think quality overall will go down. This will lead to a two-tier system where most people will wait an hour to see their doctor for 10 minutes (however helpful that can be), while the rich will just pay for more time with their doctor.

The second big problem I see is really just a magnification of a current problem. Medical advisory boards for insurance companies are not going to approve a low-risk prostate patient for a bone scan even when other signs point to the fact that the patient needs it. The doctor will have to spend an hour on the phone explaining to the insurance why the patient needs the scan. If the patient doesn't get the scan and something goes wrong, the insurance is not responsible. The government is not responsible. The physician will be liable and likely be sued. Add 30 million people and you have more of these cases.

Any thoughts?

 

[sean842]

As future members of the medical profession, I would hope that everyone here has the best interest of patients at heart. With that said, most conservatives, myself included, agree that the current health care system does not work. However, lets not get caught in the false dilemma and think that increased government intervention is the best way to go. I liken this to the drunk who woke up with a hangover and thinks another beer is the solution to his problems, it is a temporary fix but really it is the reason he is hungover in the first place. Most conservatives opt for another course, that of less regulation and a more free enterprise in the health care market thinking that will ultimately improve access to care, control costs, and improved quality. Conservatives care just as much about patients as the obamacare supporters, that is why we argue so intensely that this is a step in the wrong direction.

Under the terms of the health bill it actually makes more sense for me, as a health 23yo male, to take the tax penalty and opt out of having health insurance. Now normally I wouldn't give good money away for no good reason, but under the act provisions I can quickly and easily opt back into to insurance market should I need it and can't be denied for pre existing conditions. As more healthy individuals realize this they will opt out of the insurance market, leaving health insurance companies with only a risky pool of individuals. Now they can't charge people of the same age and geographic region different premiums, but there is nothing to stop them from charging everyone the same higher premium. With only risky individuals left in the pool of insured, premiums will rise, and as premiums rise this cycle is likely to get worse as more and more healthy people opt out. As a conservative who cares about patients having access to care and the best possible outcome, it concerns me that this will ultimately limit patients access to care, not increase it as intended.

Secondly, we are all talking about salaries, and I'm sure that some people are in this for greed. But I think most doctors are in this to help people and provide a comfortable middle class income for their families. I don't have lavish tastes, but I do have a wife I love and want to provide for her and our family. I would have a hard time convincing her that the best career move I could make for our family was to take our family ~200k in debt and forgo 7 years of earning potential for a career that works me 60 hrs week and may not pay us enough to dig ourselves out of the financial hole we dig. It's not about being greedy, it's about doing what is in the best interest of your family. All told the opportunity cost of going to med school, paying tuition, forgoing approximately 50k/yr in salary as a college grad and the interest capitalization it affords is approximately 500-750k hole when time valued out over the whole process. Ultimately our nations best and brightest aren't stupid, they can do math. Many of them will see these obstacles to medicine and opt for business, law, IT, etc...it may not pay as well, but it has a lower barrier to entry (we are already seeing this in primary care, and in a few years will see that one step lower on the decision tree.) There are plenty of martyr's here on SDN, but there aren't enough martyr's in this country to take care of our aging baby boomers for peanuts.

Okay so conservatives don't like the health care bill, that doesn't mean that we think the status quo is optimal. As advocates of free enterprise and market efficiency we recognize the perverse incentives the current market creates and want to reform the system to create more competition.

Few liberals would argue that the auto insurance market needs reform. In fact, it works quite well. There are at least a dozen competitors I can name off hand, and they compete intensely for your dollars. This has led to some seriously annoying commercials, but namely increased efficiency in the system and a drop in costs as customers are free to move between providers. There are subtle differences between auto and health insurance markets. Namely, liberals love to point out that people can opt out of the auto insurance market by not owning a care, but everyone needs health care. That is true to an extent, but on the whole I doubt the majority of people could go without a car. Secondly, auto insurance functions much like a high deductible plan would function. We have all heard the argument about low deductible plans causing runaway costs and I tend to agree with them. Auto insurance that covered my oil changes isn't insurance its a pre-payment plan. Insurance is meant to cover you in the event of an unforseen instance, oil changes aren't unforseen. No one is arguing that grandma should get her cancer drugs, but I certainly didn't need the $6000 carbon fiber knee braces I got after ACL surgery, but why not, they were free to me and I'm a sucker for a good deal! Extravagant spending like this is unlikely to stop until the patient has a reason to control costs.

So why doesn't the health care industry work like this? One of the major contributors is the tax exemption from employer provided health care. I'm a HS teacher before leaving for med school and have employer provided health care. Say my health insurance costs my employer $5000 a year. Now since this is tax exempt, to me this is the equivalent of a $6250/yr income increase since I don't pay taxes on this. This is a win win for both my employer and for me, hence the explosion in employer provided health insurance. However, at a time when I was self-employed, I comfortably paid for a high deductible plan for my family on only a few hundred a month. Note the difference in price, my employer provided plan costs my employer close to twice as much per month than a high deductible plan cost me privately. If given the choice on the private market, most consumers would opt for a high deductible plan. But right now I don't have to because my employer gives me a nice, but largely irrelevant perk, I would gladly take the cash (if it were tax free of course) and buy my own cheaper plan if given the choice, but I can't.

How does this create a perversion in the health insurance market? Well, as it turns out, my health insurance kind of sucks. But their isn't much I can do about it unless my employer switches providers. In a sense, my health insurance company only cares about providing a good product to my employer and really could care less about providing a good product to me, the ultimate consumer. If I had the option I would certainly take my $6250 "income" and take it to another health insurance company. As Humana, BCBS, United, etc realized the mobility of customers they would have a much larger incentive to provide a decent product. Doing away with the tax exemption would move health insurance decisions out of my employers hands and back into mine. This kind of control is in the best interest of the patient and this is the kind of thing that Obamacare is in direct opposition of. Obamacare provides serious financial consequences to employers that don't provide health insurance for their employers. Sure, more insured people sounds great on paper in the short term, but the long term sustainability of those newly insured is far more dependent on the manner in which the insurance market operates.

Now let the flaming begin, but remember that this isn't an argument of whether we should care about the underserved and destitute but more a debate about the best way to accomplish those goals. Remember that health insurance suffers from 3 fundamental problems, access, cost, and quality. Obamacare makes no mention of quality, and its attempt to control costs are likely to impinge on quality. Ultimately this this oversight is likely to impinge on the first in the long run. This ultimately harms the patients it seeks to help.

 

[Wolverines83]

It may be difference in outlook =). You seem a bit more pessimistic of how this will all play out, while I get the sense that the program will work pretty well, and can be altered to address any shortcomings that arise.

A few quibbles:
(1) The language says that only the prevention benefits aren't subject to the deductible; there may be some co-pays involved.

(2) The catastrophic plan is also available for those who are exempt from the mandate. This group would include individuals whose income is not high enough to be subject to the tax penalty, but who do not qualify for their state's Medicaid program for whatever reason (e.g., their state refused to participate in the Medicaid expansion).

(3) The catastrophic insurance plus HSA solution, while better than nothing, is not enough. There will be a large disincentive for these patients to seek follow-up care or comply with prescribed medication schedules. Patients can't negotiate with their doctors, hospitals or pharmacies for lower reimbursement rates like insurance companies can. It's unrealistic to expect low-income patients to pay 100% cost for medications or procedures. The deductible on these plans is quite high, equal to the HSA annual contribution limit, $5950. For someone making $50k/yr, that's fine, I guess. At $20k/yr that gets to be pretty steep.

I realize the HSA/catastrophic plan doesn't work for low income...I actually didn't intend for it to be a solution for them.

I see your point about not wanting to seek follow up care. My point is that having a dog in the fight (financial well-being on the line) would encourage people to lead healthier lives (this, of course, excludes those who will never take care of themselves regardless of consequences). I take very good care of my teeth because I hate dental bills!

I guess we're digressing from the original topic and I said the last post was my last post so this is my last post unless I have another post.

 

[Wolverines83]

How does this create a perversion in the health insurance market? Well, as it turns out, my health insurance kind of sucks. But their isn't much I can do about it unless my employer switches providers. In a sense, my health insurance company only cares about providing a good product to my employer and really could care less about providing a good product to me, the ultimate consumer. If I had the option I would certainly take my $6250 "income" and take it to another health insurance company. As Humana, BCBS, United, etc realized the mobility of customers they would have a much larger incentive to provide a decent product. Doing away with the tax exemption would move health insurance decisions out of my employers hands and back into mine. This kind of control is in the best interest of the patient and this is the kind of thing that Obamacare is in direct opposition of. Obamacare provides serious financial consequences to employers that don't provide health insurance for their employers. Sure, more insured people sounds great on paper in the short term, but the long term sustainability of those newly insured is far more dependent on the manner in which the insurance market operates.

Yep

 

[startoverat40]

sorry, got double posted.

 

[startoverat40]

sean842, conservatives don't trust the govt run by corrupt politicians, and liberals don't trust insurance companies run by greedy leeches. so what's the solution?

the corruption in govt can be fixed to some extent, but the greediness of the leeches cannot. conservatives dont' even seem to see that as a problem. but I personally don't think that human lives are tradable commodities on the "free market", and so we can't leave healthcare financing in the hands of greedy leeches.

I think the govt can be fixed by putting strict controls over campaign financing and end all the lobbyist money bribing our govt. maybe that's a far fetched proposition, but I think a constitutional ammendment like proposed by Bernie Sanders will go a long way.

It is simply not true that anything run by the govt is a failure. the VA system is much better than HMOs, and medicare/medicaid have only 2% admin overhead cost.

insurance companies can make profts off of elective nose jobs, but not on the basic healthcare and lives of our citizens.

 

[henge]

Conservatives care just as much about patients as the obamacare supporters, that is why we argue so intensely that this is a step in the wrong direction.

I don't doubt your personal commitment to caring for patients, but I do think there is an ideological difference between liberals and conservatives on health care. I do not believe access can be broadened significantly without the government spending money to subsidize care for the less well off and those who are expensive to insure. I do not believe the Reps would back any program that cost the government money. For all the talk about freedom and choice and efficiency, my perception is that Rep opposition is mainly based on cost and, in light of the fact that such opposition has been vehement even though the ACA is based on mandate plans that the Reps proposed in the 1990s, often simple partisanship (sorry, but that is how it looks to me. I understand you will disagree with that, and again, I am in no way suggesting your motives or the motives of any on this board are motivated by partisanship).

Under the terms of the health bill it actually makes more sense for me, as a health 23yo male, to take the tax penalty and opt out of having health insurance. Now normally I wouldn't give good money away for no good reason, but under the act provisions I can quickly and easily opt back into to insurance market should I need it and can't be denied for pre existing conditions. As more healthy individuals realize this they will opt out of the insurance market, leaving health insurance companies with only a risky pool of individuals...With only risky individuals left in the pool of insured, premiums will rise, and as premiums rise this cycle is likely to get worse as more and more healthy people opt out.

The ability to opt in and out of insurance seems to be a major objection conservatives raise, but this problem is addressed by the ACA, which:

"appropriately establishes an initial open enrollment period...as well as annual open enrollment periods in subsequent years. In an open enrollment period, people would be free to sign up for a plan or switch plans. Only in limited circumstances would people be able to enroll in or switch plans outside of an open enrollment period. This restriction is a critical feature: it ensures that individuals and families don't wait until they get sick to enroll in coverage, or switch to more comprehensive coverage when they are about to have an expensive medical procedure."
http://healthaffairs.org/blog/2011/...xchanges-open-enrollment-and-switching-plans/

Since the ACA limits open enrollment periods, people can not "quickly and easily opt back into the insurance market" as you suggest. People would bear real risk if they tried to game the system like you propose.

Ultimately our nations best and brightest aren't stupid, they can do math. Many of them will see these obstacles to medicine and opt for business, law, IT, etc.

Almost 44,000 people applied for admission to MD schools this year, up from 34,000 in the early 2000s (though down from the all time peak of 47,000 in the 1990s).
https://www.aamc.org/download/153708/data/charts1982to2012.pdf

Mean MCAT scores have risen fairly steadily from 26.9 in 2000 to 28.2 in 2011.
https://www.aamc.org/download/161690/data/table17.pdf

The total number of students trying to match thru NMRP has increased from under 25000 in 1990 and under 35000 in 2007 to almost 38000 in 2011.
http://www.nrmp.org/data/resultsanddata2012.pdf

It looks like many, many people still find medicine attractive.

liberals love to point out that people can opt out of the auto insurance market by not owning a care, but everyone needs health care.

Actually, conservatives like to make the opt out argument; it supports their view on how the mandate was unprecedented and oppressive.

Extravagant spending like this is unlikely to stop until the patient has a reason to control costs.

I'm not opposed to high deductible plans, but you shouldn't expect too much. The vast majority of medical spending goes to a small number of patients-- some older data shows 49% of expenditures goes to 5% of patients and 97% goes to the top half http://www.ahrq.gov/research/ria19/expendria.pdf Few could afford deductibles so high that they made a major dent in out of total expenditures. Having "skin in the game" will make a difference, but not too much.

And, beside, the ACA allows for high deductible plans for insureds under 30. It would be simple to extend that eligibility.

So why doesn't the health care industry work like this? One of the major contributors is the tax exemption from employer provided health care. ...

I believe the ACA takes away the tax favored status for so-called Cadillac plans.If you think this is desirable, there is no reason the definition of Cadillac plan could not be amended to include most plans.

If given the choice on the private market, most consumers would opt for a high deductible plan. But right now I don't have to because my employer gives me a nice, but largely irrelevant perk, I would gladly take the cash (if it were tax free of course) and buy my own cheaper plan if given the choice, but I can't.

This is interesting. I was not aware this had been researched. Please provide a link showing most consumers would so opt.

Note there are other tax favored benefits, like 401k contributions, etc. Given that employment is a voluntary arrangement, and that employers have to attract staff, one would think that employers provide more of the other tax favored benefits instead of health insurance. Has that happened?

In a sense, my health insurance company only cares about providing a good product to my employer and really could care less about providing a good product to me, the ultimate consumer. If I had the option I would certainly take my $6250 "income" and take it to another health insurance company. As Humana, BCBS, United, etc realized the mobility of customers they would have a much larger incentive to provide a decent product.

Your employer likely has greatly superior bargaining power due to the number of lives it can steer to the insurer, i.e., quantity discounts. Big employers routinely negotiate much better rates for their employees than their employees could get on their own.

Moreover, what do you do about people with pre-existing conditions, perhaps the major beneficiaries of ACA? Right now, they can get employer-provided insurance without rating because their employer is delivering a whole group of insureds. Why would an insurer take on individuals with pre-existing conditions without being guaranteed a group of healthier employees?

The individual insurance market is a morass that you should do your utmost to avoid. Without major reformation--community rating (like ACA does) ,systematized insurance products readily comparable through internet searches (like ACA can do)--it would be disastrous for many to be thrown into the individual market.

 

[xf3rn4nd3sx]

I can't believe there's been 5 pages bitching about how you will only be paid 200k instead of 400k. No comment on providing healthcare to people. It's pathetic that these are the types of people who are in medical school now.

I'm not in medical school, my girlfriend is, and I know how hard you work. Yet you should also realize that other professions work just as hard, if not more. I thought the difference between us and you was that you actually cared about people and liked what you do more. Apparently most of you are just good liars who lied your way into medical school and don't actually give a crap about helping people. For the record, investment bankers work on average 100 hour weeks and work far more than doctors. I am a lawyer and I work 60 to 70 hour weeks on average and I make less than 200k. So do most lawyers. So quit your bitching. You're not special snowflakes.

Lol? You're making less than 200k, but how old are you? Your girlfriend is in med school. You're probably not even resident age yet. So while you compare yourself to us stating you make less than 200k. We were 200k in the hole. In the next 10 years, when your income goes up astronomically, we would be making 50k and still have over 200k in debt. Corporate lawyers start at 25 typically with a salary over 200k. Partner can be made by 33. Salary at this point is high six figures to low seven figures. You're comparing apples and oranges. And btw, investment bankers don't average 100 hours per week. I interned at a banking firm. My brother is a banker. You average 80 hours per week and have the occasional 100+ hour week when working on a big deal. Keep in mind, many of these hours include sitting around doing nothing once you have finished your work because you can't leave until your MD or VP says you're done.

None of us are saying we don't care about helping people. If we didn't we wouldn't have entered this field. We'd be in law, like you, or finance. We're not complaining about the fact that our compensation is being slashed. We're complaining that our compensation is being slashed for no reason. Cutting our pay isn't helping patients or reducing health care costs. They're still going up. If your law firm boss came to you and told you that he was slashing your pay by 20% because he felt like it, how would you feel? You'd be a fool not to care.

Some of you come off as extremely self-entitled. "I got into medical school. I deserve a 500k salary even though I have to work *gasp* 60 hour weeks." Grow up. You're still going to make a decent living. But now you might actually have to care enough about what you do to stick with it.

And yes, 100 hour weeks is far more than what most doctors (not residents) work. If you prefer, you could always be a lazy doctor and do family medicine.

Wow. Not even sure how to respond to this. The ignorance is overwhelming. Lazy doctor and do family medicine? We don't have to work 100 weeks anymore because we did that as a resident; for 7 years. We had 200k in debt. Now we work 60+. How can you, as someone younger than the average resident, making under 200k when the average resident makes 50k, complain to us about salary? We aren't saying we deserve 500k. We're getting 500k. We're wondering why it's being cut for no reason. Please learn to read carefully before making such rash assumptions. And shouldn't you be chasing after some ambulance?

Do you have reading comprehension problems? Let me summarize: This thread has discussed how physician salaries are NOT responsible for rising health care costs, yet are unfairly and **unwisely** threatened compared to other healthcare worker salaries. This is driving the best and brightest away from medicine and into other fields, such as banking or finance. This is about economics.

People can whine all they want about how we need an ideological vision for healthcare, but it won't be sustainable. You cannot compare European/Canadian,blah,blah,blah healthcare delivery systems to our own - you overlook the enormous overall educational and financial differences between us and them

Yes, Exactly.

I skimmed the thread and the majority of the thread consisted of whining about salaries. Not one mention of patients and how Obamacare will increase coverage to those who can't afford it.

Henge is correct, in that there's a huge difference between a suspect right and what's essentially a non-right. Congress can tax and spend for the general welfare and has wide purview under this power. This isn't the first time SCOTUS has construed the Taxing and Spending Clause broadly.

You're just looking at the surface, not the fine print. If we could afford giving health care to everyone, then sure.
a) We already have a shortage of doctors with the current number of insured patients. With 30 million more, who exactly is going to be taking care of them? There are absolutely not enough doctors in the country. The number of residents has been manipulated to create this shortage.
b) Health care INSURANCE does not equate to health CARE. As I said above, there will not be enough doctors to take care of these of these newly insured patients. For example, the average neurosurgeon currently is above 50. They will mostly be retiring in the next 10 years. This average age means that not enough people are entering the field. There is already a shortage. This is occurring in multiple field, not just neurosurgery. Compensation has gone down, this has removed some incentive to enter the field. Number of residents has been slashed. These in combination have greatly reduced the number and increased the number of hours worked, decreasing lifestyle quality, to further reduce incentive to enter the field.
c) HOW MUCH IS THIS GOING TO COST US? With the amount of debt we have can we afford another expenditure? This is estimated to cost us over $1 trillion (and that estimate is by a member of Obama's administration so it is likely deflated). When medicaid came into effect, costs grew astronomically over the years. It cost much more than estimated. Expect this with ObamaCare.

 

[BOOYA18]

The individual insurance market is a morass that you should do your utmost to avoid. Without major reformation--community rating (like ACA does) ,systematized insurance products readily comparable through internet searches (like ACA can do)--it would be disastrous for many to be thrown into the individual market.

This is interesting. I was not aware this had been researched. Please provide a link showing this would be disastrous.

 

[xf3rn4nd3sx]

Yep

Sean is exactly right.

sean842, conservatives don't trust the govt run by corrupt politicians, and liberals don't trust insurance companies run by greedy leeches. so what's the solution?

the corruption in govt can be fixed to some extent, but the greediness of the leeches cannot. conservatives dont' even seem to see that as a problem. but I personally don't think that human lives are tradable commodities on the "free market", and so we can't leave healthcare financing in the hands of greedy leeches.

I think the govt can be fixed by putting strict controls over campaign financing and end all the lobbyist money bribing our govt. maybe that's a far fetched proposition, but I think a constitutional ammendment like proposed by Bernie Sanders will go a long way.

It is simply not true that anything run by the govt is a failure. the VA system is much better than HMOs, and medicare/medicaid have only 2% admin overhead cost.

insurance companies can make profts off of elective nose jobs, but not on the basic healthcare and lives of our citizens.

Hahahahahah. THE VA SYSTEM??? ARE YOU JOKING? Have you ever seen how the VA hospitals work? It's absolute garbage. There are very, very few decent VA hospitals. The majority are a complete joke. Patient care sucks. A VA hospital recently infected 1800 people with HIV. There is much more paperwork. Added to this, vets often have to travel 60+ miles to get to a VA hospital. The government pays for this travel. That's a HUGE waste of money and we tax payers are paying for it.

You clearly have not seen a VA hospital. And if you have, it can't have been more than 1. The vast majority are absolutely disgusting.

EDIT: Have you not read about Walter Reed? This was one of many. Investigations have revealed many VA hospitals providing inadequate care. There are frequent complications and just blatant incompetency. More recently, a wrong testicle was removed from a vet.

So yes, I stand by my statement. The government cannot run anything effectively.

 

[startoverat40]

Sean is exactly right.



Hahahahahah. THE VA SYSTEM??? ARE YOU JOKING? Have you ever seen how the VA hospitals work? It's absolute garbage. There are very, very few decent VA hospitals. The majority are a complete joke. Patient care sucks. A VA hospital recently infected 1800 people with HIV. There is much more paperwork. Added to this, vets often have to travel 60+ miles to get to a VA hospital. The government pays for this travel. That's a HUGE waste of money and we tax payers are paying for it.

You clearly have not seen a VA hospital. And if you have, it can't have been more than 1. The vast majority are absolutely disgusting.

Are you talking about army hospitals or VA? they are different.

was it proven that they were infected with HIV at the VA? a miniscule number were found actually infected.

http://www.boston.com/news/nation/a...nfection_issues_lead_to_13000_veterans_tests/
So far, VA officials say, tests on nearly 12,000 patients have found eight HIV-positive results and 61 confirmed cases of hepatitis B or C, including three hepatitis cases at Dayton. It's not known how many of the positives resulted from treatment at VA hospitals or from unrelated causes -- officials say testing may not be able to determine the origin of the infections.


Infections related to medical treatment are a problem at public and private hospitals nationwide. The VA, as a government entity, must report infections publicly but most public and private hospitals do not.

that goes to show that govt run services are more accountable than private ones.

 

[startoverat40]

EDIT: Have you not read about Walter Reed VA?

http://www.pnhp.org/facts/single-payer-faq#walter_reed

1. Walter Reed Army Medical Center is an Army hospital and is run by the Department of Defense. The VA hospitals are run by the Veterans Administration (Veterans Health Administration), a separate organization. The news media has clouded this fact and has led the public to presume that all government-run health efforts fail. The VA health system continues to receive the best quality scores of any segment of the U.S. health system, with the most satisfied patients. It beats the best HMOs in quality ratings, has a model information system, and focuses on primary care. It has led in addressing medical errors and in its application of AHRQ quality guidelines to both inpatients and outpatients. In 2004 it won the Baldridge Prize for quality and patient-safety improvements.

 

[sean842]

sean842, conservatives don't trust the govt run by corrupt politicians, and liberals don't trust insurance companies run by greedy leeches. so what's the solution?.

I completely agree with you, I tend to fear unchecked government power. I also recognize that most private insurance companies are greedy leeches. We agree on both of those points. However, given the right market greedy leeches can do a lot of good. I love my smartphone, but I'm not naive enough to think that andriod made it because they were altruistic, they are just greedy and they had their greed satisfied because I thought they made a useful product. Blackberry on the other hand is just as greedy, and they are probably kicking themselves because they kind of suck and now no one buys their product. Good things can come from markets if given the right market conditions. For one, terrible products don't last. If blue cross blue shield were as cavalier with reimbursements in a truly competitive market they wouldn't last a week. I think we can all agree that would be a good thing to see a few insurance companies go down.

Because I'm not free to switch health care providers the "greedy leeches" are basically given a blank check to screw me over. I'm on the same page with you, but lets not incorrectly assume that the solution is government intervention. Plenty of companies with greedy CEO's provide useful services.

I personally don't think that human lives are tradable commodities on the "free market", and so we can't leave healthcare financing in the hands of greedy leeches.

The philosophical part of me dislikes treating patients as a commodity just as much as you, but lets not get caught up majoring in the minor leagues here. It should be our ultimate goal to improve the delivery of health care and not satisfy our philosophical egos. If treating a patient like a commidity in the broader economic sense (no, don't do this when you are actually with a patient!) lends itself to more effecient delivery of care and better health outcomes then we should all swallow our pride and get over the fact that it feels kind of "icky."

I think the govt can be fixed by putting strict controls over campaign financing and end all the lobbyist money bribing our govt. maybe that's a far fetched proposition, but I think a constitutional ammendment like proposed by Bernie Sanders will go a long way.

Probably so, our govt is very dysfunctional and itself tends to behave as the oligopoly that we all seek to avoid. Do you really think ACA for the dems or patriot act for the reps would have passed if their were 15+ parties represented in our govt? No, but since their are 2 they tend to exert oligopolostic effects.

insurance companies can make profts off of elective nose jobs, but not on the basic healthcare and lives of our citizens

If you take away the ability for a health insurance company to make a profit on basic health care, the natural progression will be to have medical professionals that are very good at doing nose jobs but piss poor at treating a cold.

medicare/medicaid have only 2% admin overhead cost.

This is a loaded stat. Medicaid/care has such low overhead because it really just wites checks, their is no admin cost devoted to deturning fraud or checking claims, etc...

 

[startoverat40]

8 out of 12000 is 6 * 10 ^ -4

1.2 million in US have HIV (0.004)

so prevalance of HIV is much higher than the number found at the VA. given that sometimes people don't know they have HIV, I would argue that those 8 people got it outside of the VA, and happened to find out from this testing due to the scare.

CDC estimates 1.2 million people in the United States (U.S.) are living with HIV infection. One in five (20%) of those people are unaware of their infection.
http://www.cdc.gov/hiv/resources/factsheets/us.htm

 

[xf3rn4nd3sx]

Are you talking about army hospitals or VA? they are different.

was it proven that they were infected with HIV at the VA? a miniscule number were found actually infected.




that goes to show that govt run services are more accountable than private ones.

I was speaking of both. I misspoke about Walter Reed being a VA hospital, but both are still run by government entities. Regardless the point remains. Investigations were done into VA hospitals following the Walter Reed incident. Many were found providing inadequate care. I have seen many VA hospitals. Of these only 1 provided equal care to that of a private institution. And about accountability. They were potentially exposed to HIV. That's still a dangerous level of incompetence. They may not have to report it publicly, but they do have to report it. There are consequences.

Staffing cuts and money cuts have led to inadequate care in many VA hospitals. Sometimes they flat out refuse treatments a patient would benefit from because they are expensive. I know this for a fact, because I have treated patients who have come to my hospital as a result of poor care at a VA.

 

[henge]

This is interesting. I was not aware this had been researched. Please provide a link showing this would be disastrous.

"According to a new analysis by the Department of Health and Human Services, 50 to 129 million (19 to 50 percent of) non-elderly Americans have some type of pre-existing health condition. Up to one in five non-elderly Americans with a pre-existing condition – 25 million individuals – is uninsured.

As many as 82 million Americans with employer-based coverage have a pre-existing condition, ranging from life-threatening illnesses like cancer to chronic conditions like diabetes, asthma, or heart disease. Without the Affordable Care Act, such conditions limit the ability to obtain affordable health insurance if they become self-employed, take a job with a company that does not offer coverage, or experience a change in life circumstance, such as divorce, retirement, or moving to a different state. Older Americans between ages 55 and 64 are at particular risk: 48 to 86 percent of people in that age bracket have some type of pre-existing condition. And 15 to 30 percent of people in perfectly good health today are likely to develop a pre-existing condition over the next eight years, severely limiting their choices without the protections of the Affordable Care Act.

***​

Prior to the Affordable Care Act, in the vast majority of States, insurance companies in the individual and small group markets could deny coverage, charge higher premiums, and/or limit benefits to individuals based on pre-existing conditions. A recent national survey found that 36 percent of those who tried to purchase health insurance directly from an insurance company in the individual insurance market were turned down, were charged more, or had a specific health problem excluded from their coverage.1 Another survey found that 54 percent of people with individual market insurance were worried that their insurer would drop their coverage if they got really sick.2"

http://www.healthcare.gov/law/resources/reports/preexisting.html

There a lot more in the article with links to the studies.

So, being in the individual market means you have no protection against being denied insurance due to a pre-existing condition. Lack of health insurance has very adverse consequences:

"In 2002, the Institute of Medicine (IOM) estimated that 18,000 Americans died in 2000 because they were uninsured. Since then,the number of uninsured has grown. Based on the IOM's methodology and subsequent Census Bureau estimates of insurance
coverage, 137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006. Much subsequent research has continued to confirm the link between insurance and mortality risk described by IOM. In fact,
subsequent studies and analysis suggest that, if anything, the IOM methodology may underestimate the number of deaths that result from a lack of insurance coverage.

http://www.urban.org/UploadedPDF/411588_uninsured_dying.pdf

Links to the studies are in the report.

If you throw 80 million workers with pre-existing conditions into the individual market, many will end up uninsured--over a third if they were rejected at the same rate as current uninsured (though they would likely be healthier so the percentage would be smaller). Not having insurance would result in many not getting care they need, and some would suffer and some would die. Even many of those who get insurance would be worried about losing it. That would be a disaster in my book (though there is, of course, no uniform definition of disaster; in my earlier post I was injecting my view. The post I was responding to said "most" Americans would opt of employer coverage if given the choice. That is an objective standard, which may or may not have been researched).

 

[startoverat40]

the VA system has won awards for quality and is sustainable.

the private system is damn good, but it is becaue it is damn expensive, and it is unsustainable. once something collapses, it makes no difference how good it was before.

end of argument.

 

[xf3rn4nd3sx]

the VA system has won awards for quality and is sustainable.

the private system is damn good, but it is becaue it is damn expensive, and it is unsustainable. once something collapses, it makes no difference how good it was before.

end of argument.

Lol, awards? Who is giving out these awards? It is not as it seems. And don't for a second think that private hospitals don't receive awards. The private system isn't just damn good. It's the best. VA can't even compete. I've seen both with my own eyes. You haven't. VA systems may look great on paper, but are simply awful in practice. Do some research for yourself. It seems you have just looked for the pros of the VA system. Read discussion boards of former patients of the VA. Go to a VA hospital yourself and check it out. You will likely then be less inclined to support the VA system so fervently.

 

[nosleep]

I can't believe there's been 5 pages bitching about how you will only be paid 200k instead of 400k. No comment on providing healthcare to people. It's pathetic that these are the types of people who are in medical school now.

I'm not in medical school, my girlfriend is, and I know how hard you work. Yet you should also realize that other professions work just as hard, if not more. I thought the difference between us and you was that you actually cared about people and liked what you do more. Apparently most of you are just good liars who lied your way into medical school and don't actually give a crap about helping people. For the record, investment bankers work on average 100 hour weeks and work far more than doctors. I am a lawyer and I work 60 to 70 hour weeks on average and I make less than 200k. So do most lawyers. So quit your bitching. You're not special snowflakes.

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

 

[xf3rn4nd3sx]

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

Lol exactly

 

[BOOYA18]

If you throw 80 million workers with pre-existing conditions into the individual market, many will end up uninsured--over a third if they were rejected at the same rate as current uninsured (though they would likely be healthier so the percentage would be smaller). Not having insurance would result in many not getting care they need, and some would suffer and some would die. Even many of those who get insurance would be worried about losing it. That would be a disaster in my book (though there is, of course, no uniform definition of disaster; in my earlier post I was injecting my view. The post I was responding to said "most" Americans would opt of employer coverage if given the choice. That is an objective standard, which may or may not have been researched).

i was responding in offense to the portion of the bill forcing to people to buy insurance, i certainly believe that not denying coverage for preexisting conditions is wrong (and agree with many other portions of the bill), which i also believe was his point at that time. but i may have misinterpreted..not point that those who have preexisting conditions are screwed if they want other insurance from the free market.

whats the thought process on how to handle this massive influx of newly insured? more people, same amount of doctors (med schools apps/populations increasing but with same amount of residencies) and even more of those not heading to primary care?

 

[BOOYA18]

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

hahaha spectacular

 

[startoverat40]

i'd rather look at the data, than rely on internet chatter.

http://www.va.gov/health/HospitalReportCard.asp

How Veterans' Hospitals Became the Best in Healthcare

http://www.time.com/time/magazine/article/0,9171,1376238-1,00.html

But it's becoming more and more "ideologically inconvenient for some to have such a stellar health-delivery system being run by the government," says Margaret O'Kane, president of the National Committee for Quality Assurance, which rates health plans for businesses and individuals. If VA health care continues to be the industry leader, it may become more difficult to argue that the market can do better.

​

 

[JackShephard MD]

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

You exude class.

 

[sean842]

For all the talk about freedom and choice and efficiency, my perception is that Rep opposition is mainly based on cost and, in light of the fact that such opposition has been vehement even though the ACA is based on mandate plans that the Reps proposed in the 1990s, often simple partisanship

The discussion of cost gets lost in translation between the reps and dems. Right now we have an health market that is essentially split between govt/privately insured and uninsured. Now the govt/privately insured buyers exert so much market influence and have so little incentive to conserve resources that they have priced everyone else out of the market so that no one can afford health care unless they hop on the govt/private insurance bandwagon. Now liberals love to make the argument that to fix this issue we should make the bandwagon bigger, while conservatives like try to argue that the bandwagon is what caused the problem in the first place.

So saying that cost is our republican's only concern is a bit misleading. It is our solution to a larger problem. If an oil change cost me $1000 from my mechanic, liberals would argue that no one can afford that and the solution must be more insurance while I would argue that I could afford it if only Allstate wasn't pricing me out of the market.

Almost 44,000 people applied for admission to MD schools this year, up from 34,000 in the early 2000s (though down from the all time peak of 47,000 in the 1990s).
https://www.aamc.org/download/153708...1982to2012.pdf

Mean MCAT scores have risen fairly steadily from 26.9 in 2000 to 28.2 in 2011.
https://www.aamc.org/download/161690/data/table17.pdf

The total number of students trying to match thru NMRP has increased from under 25000 in 1990 and under 35000 in 2007 to almost 38000 in 2011.
http://www.nrmp.org/data/resultsanddata2012.pdf

It looks like many, many people still find medicine attractive.

To be fair, most of those still see specialty medicine attractive...we are already seeing medical students shy away from the lower paying primary care specialties that are the backbone of this legislation. You would be naive to think that over the long term this won't start showing up in med school applicant data. And to be fair, an increase in applicants doesn't mean much when we are also seeing an increase in college grads. The real question is what proportion of college grads ultimately apply to medical school as a percentage of total grads.

The ability to opt in and out of insurance seems to be a major objection conservatives raise, but this problem is addressed by the ACA, which:

"appropriately establishes an initial open enrollment period...as well as annual open enrollment periods in subsequent years. In an open enrollment period, people would be free to sign up for a plan or switch plans. Only in limited circumstances would people be able to enroll in or switch plans outside of an open enrollment period. This restriction is a critical feature: it ensures that individuals and families don't wait until they get sick to enroll in coverage, or switch to more comprehensive coverage when they are about to have an expensive medical procedure."
http://healthaffairs.org/blog/2011/0...itching-plans/

Since the ACA limits open enrollment periods, people can not "quickly and easily opt back into the insurance market" as you suggest. People would bear real risk if they tried to game the system like you propose

I'll concede the first point to you until I can research this more, but it isn't as damaging as you might think. As premiums rise under ACA regs you will see many employers either opt out of health insurance, pay the penalty, and give their employees cash income less the penalty or they employees will see a drop in salary. Healthier individuals are more likely to take the cash income, even if marginally so as you've said.Now these employees have the option to do whatever they wish with their income, either hop on an individual govt subsidized plan or go "naked" and take the penalty but since buying the health insurance on their own dime would amount to double taxation (their employer will have passed the tax penalty to them as well paying it with taxable income) most will opt to take the penalty and roll the dice. Of course, this isn't smart or good for health care...

Your employer likely has greatly superior bargaining power due to the number of lives it can steer to the insurer, i.e., quantity discounts. Big employers routinely negotiate much better rates for their employees than their employees could get on their own.

Moreover, what do you do about people with pre-existing conditions, perhaps the major beneficiaries of ACA? Right now, they can get employer-provided insurance without rating because their employer is delivering a whole group of insureds. Why would an insurer take on individuals with pre-existing conditions without being guaranteed a group of healthier employees?

I work for a small school district of mostly at-risk students, drop outs, teen moms, gangsters, etc...the type of under served population this bill attempts to serve. My school district has little to no bargaining power.

If you think insurers are unlikely to take a risky individual what makes you think they won't drop entire risky groups after the healthy people drop out of coverage? Does this help patients in the long run?

 

[henge]

whats the thought process on how to handle this massive influx of newly insured? more people, same amount of doctors (med schools apps/populations increasing but with same amount of residencies) and even more of those not heading to primary care?

Good question. ACA provides for reallocation of some unused residency slots and gives the government authority to create more residency slots, but the ACA does not provide funding for such new slots so Congress has to spend the money. Given the political situation, the outlook for funding new slots is, per AAMC, "pretty grim." https://www.aamc.org/newsroom/repor...sing_the_physician_shortage_under_reform.html I don't know how much it costs per year to train a resident. Guessing $150,000, it would cost $600M/yr to fund the 4000 new slots the AAMC wants to create.

If sufficient government GME funding is not forthcoming: 1) More responsibility for nurses, techs, etc. (many SDN posts on this); 2) Replacement/enhancement of productivity thru technological changes (lots of SDN posts on this); 3) Waiting. And speculating wildly and wholly without support: 1) Sources other than the government fund residencies in order to lock in docs (with earn out provisions so if the doc leaves employ, they have to pay back some of the dollars they earned as residents) or to further charitable missions (the Gates Foundation endowed residency in X); 2) accepting credentials from other select countries; 3) shortening some residencies, perhaps only for some FMG who had training abroad.

 

[henge]

If an oil change cost me $1000 from my mechanic, liberals would argue that no one can afford that and the solution must be more insurance while I would argue that I could afford it if only Allstate wasn't pricing me out of the market.

No liberals I know would make that argument and the car analogy tends to trivialize the position of liberals.

Why would Allstate agree to pay $1000 for an oil change? If they pay $30, they add $970 to their bottom line. As a profit maximizing entity, they have an incentive to cut costs just like you do.

To be fair, most of those still see specialty medicine attractive...we are already seeing medical students shy away from the lower paying primary care specialties that are the backbone of this legislation.

No surprise that students gravitate to higher paying specialties. Is that new? I'll check historical match data when I get a chance. At any rate, there are only so many GME slots to go around, and to the extent slots are reallocated they will be allocated to primary care.

You would be naive to think that over the long term this won't start showing up in med school applicant data.

It hasn't yet and ACA has been on the books for 2 years. I think people making this argument underestimate the appeal of a job with secure employment (lots of data on shortages of docs), good pay (I'm not going to rehash arguments that have been made ad nauseum on this site) and high prestige http://www.usnews.com/usnews/biztech/articles/070802/2prestige.htm

And to be fair, an increase in applicants doesn't mean much when we are also seeing an increase in college grads. The real question is what proportion of college grads ultimately apply to medical school as a percentage of total grads.

Why is this relevant, much less the "real question"? If the percentage of the population graduating from college doubles, do you think the need for doctors also doubles?

I work for a small school district of mostly at-risk students, drop outs, teen moms, gangsters, etc...the type of under served population this bill attempts to serve. My school district has little to no bargaining power.

You are a group of one. They still have a bigger group than you. And most groups are larger and more powerful than yours apparently is.

I'll concede the first point to you until I can research this more.[/QUOTE]

 

[Dave89]

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

But after making such comments, better make sure nobody slips on a banana peel in your hospital

The discussion of cost gets lost in translation between the reps and dems. Right now we have an health market that is essentially split between govt/privately insured and uninsured. Now the govt/privately insured buyers exert so much market influence and have so little incentive to conserve resources that they have priced everyone else out of the market so that no one can afford health care unless they hop on the govt/private insurance bandwagon. Now liberals love to make the argument that to fix this issue we should make the bandwagon bigger, while conservatives like try to argue that the bandwagon is what caused the problem in the first place.


If you think insurers are unlikely to take a risky individual what makes you think they won't drop entire risky groups after the healthy people drop out of coverage? Does this help patients in the long run?

The US has the worst of both worlds when it comes to healthcare - oppressive government regulation and private insurance. The mix of public and private, i.e. corporatism, is often worse than purely public/govt-run sytems, and far worse than essentially private or free market systems.

 

[sean842]

The US has the worst of both worlds when it comes to healthcare - oppressive government regulation and private insurance. The mix of public and private, i.e. corporatism, is often worse than purely public/govt-run sytems, and far worse than essentially private or free market systems.

Why does someone who appears to favor larger government over free enterprise have a Milton Freedman sig?

I do agree though, the mix of public and private is awful. It has to be one or the other or we all get screwed and the house of cards comes falling down. I prefer private.

 

[Dave89]

Why does someone who appears to favor larger government over free enterprise have a Milton Freedman sig?

I do agree though, the mix of public and private is awful. It has to be one or the other or we all get screwed and the house of cards comes falling down. I prefer private.

No, no, I said govt-run is worse than free-market.

But I think corporatist systems are worse than purely govt-run in some ways, as you'll have "private" prices (as opposed to artificially low socialist ones) but "government quality" (crap). And lobbying, not quality, determines the company's success.

 

[sean842]

No liberals I know would make that argument and the car analogy tends to trivialize the position of liberals.

Why would Allstate agree to pay $1000 for an oil change? If they pay $30, they add $970 to their bottom line. As a profit maximizing entity, they have an incentive to cut costs just like you do.

That's precisely my point, you're making an argument to move health care away from market incentives on the basis that corporations are profit maximizing and rational and would respond to market incentives. Given a free market, we would never see costs this high. It is the absence of a free market that has allowed such a ballooning in costs. So why would the solution to this problem be to further remove ourselves from the market incentives that would solve things?

No surprise that students gravitate to higher paying specialties. Is that new? I'll check historical match data when I get a chance. At any rate, there are only so many GME slots to go around, and to the extent slots are reallocated they will be allocated to primary care.

Just because you have historical precedence doesn't mean this is an efficient allocation of resources. Are you arguing that there isn't a primary care shortage?

It hasn't yet and ACA has been on the books for 2 years. I think people making this argument underestimate the appeal of a job with secure employment (lots of data on shortages of docs), good pay (I'm not going to rehash arguments that have been made ad nauseum on this site) and high prestige http://www.usnews.com/usnews/biztech/articles/070802/2prestige.htm

This isn't the kind of trend that shows up in two years. It is the kind of trend that shows up in 30.

Why is this relevant, much less the "real question"? If the percentage of the population graduating from college doubles, do you think the need for doctors also doubles?

It is relevant because quoting an increase in applicant numbers means nothing when you consider the increase in college grads. Considering the percentage of college grads is a more appropriate way to gauge student interest in medicine. If the percentage of college grads interested in medicine drops then we have reason to be concerned about our ability to care for an aging population.

If you don't like measuring it that way then fine, consider the proportion of high school grads that ultimately become docs, but quotes like "applicant numbers have increased" mean nothing unless we correct for increases in population.

 

[ronaldo23]

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

 

[MaraCeles]

Translation: You're mad you didn't get into med school so you had to settle for law.

Listen buddy, the value of a lawyer compared to that of a doctor is analogous to the nutritional value of dog turd compared to a four course meal.

AHAHAHAHA WINNING! Tasteless, but winning!

 

[startoverat40]

I completely agree with you, I tend to fear unchecked government power. I also recognize that most private insurance companies are greedy leeches. We agree on both of those points. However, given the right market greedy leeches can do a lot of good.

no, leeches cannot be trusted with people's health.

I love my smartphone, but I'm not naive enough to think that andriod made it because they were altruistic, they are just greedy and they had their greed satisfied because I thought they made a useful product. Blackberry on the other hand is just as greedy, and they are probably kicking themselves because they kind of suck and now no one buys their product.

making arguments about consumer goods is irrelevant. you can make a choice to buy a phone or not buy a phone. but you can't make a choice about living or dying. you wouldn't want to make that choice. that's why "free market" arguments are nonsensical when it comes to healthcare.

Good things can come from markets if given the right market conditions.

not when it comes to healthcare.

For one, terrible products don't last. If blue cross blue shield were as cavalier with reimbursements in a truly competitive market they wouldn't last a week. I think we can all agree that would be a good thing to see a few insurance companies go down.

the perfect insurance company would be one that doesn't add anything over and beyond what the doctor charges. insurance companies are superfluous. they are a 0 added-benefit intermediary. they should be cut out completely.

Because I'm not free to switch health care providers the "greedy leeches" are basically given a blank check to screw me over. I'm on the same page with you, but lets not incorrectly assume that the solution is government intervention. Plenty of companies with greedy CEO's provide useful services.

government run health systems are not out to make a profit, so they don't add much cost over the actual cost of healthcare. the VA system is doing just fine.

The philosophical part of me dislikes treating patients as a commodity just as much as you, but lets not get caught up majoring in the minor leagues here. It should be our ultimate goal to improve the delivery of health care and not satisfy our philosophical egos. If treating a patient like a commidity in the broader economic sense (no, don't do this when you are actually with a patient!) lends itself to more effecient delivery of care and better health outcomes then we should all swallow our pride and get over the fact that it feels kind of "icky."

the delivery of care under the VA is just fine.

Probably so, our govt is very dysfunctional and itself tends to behave as the oligopoly that we all seek to avoid. Do you really think ACA for the dems or patriot act for the reps would have passed if their were 15+ parties represented in our govt? No, but since their are 2 they tend to exert oligopolostic effects.

If you take away the ability for a health insurance company to make a profit on basic health care, the natural progression will be to have medical professionals that are very good at doing nose jobs but piss poor at treating a cold.

obviously you are wrong because this is not happening in Switzerland.

This is a loaded stat. Medicaid/care has such low overhead because it really just wites checks, their is no admin cost devoted to deturning fraud or checking claims, etc...

fraud protection efforts still don't add up to the 400 billion which would be saved with single payer.

 

[sean842]

no, leeches cannot be trusted with people's health.
making arguments about consumer goods is irrelevant. you can make a choice to buy a phone or not buy a phone. but you can't make a choice about living or dying. you wouldn't want to make that choice. that's why "free market" arguments are nonsensical when it comes to healthcare.


not when it comes to healthcare.

the perfect insurance company would be one that doesn't add anything over and beyond what the doctor charges. insurance companies are superfluous. they are a 0 added-benefit intermediary. they should be cut out completely.


government run health systems are not out to make a profit, so they don't add much cost over the actual cost of healthcare. the VA system is doing just fine.

the delivery of care under the VA is just fine.



obviously you are wrong because this is not happening in Switzerland.

fraud protection efforts still don't add up to the 400 billion which would be saved with single payer.

These are just statements, you have argued nothing. Sources?

 

[startoverat40]

if i have a surgery and the doctor charges 10k, i want all 10k to go to him/her. i don't want any insurance leech taking any of that money.

 

[DrOwnage]

First of all, I don't think we should even call this bill Obamacare. Only ignorant layman could possibly think that President Obama is the sole proprietor of this bill. I would like people to stop giving him credit for it.

I am very curious to see how malpractice insurance will be affected by the decision to "tax" the American people with healthcare. It would be nice to see people who slam doctors for being greedy have to pay for malpractice insurance pooled into a government subsidy. I am not sure with the current health care laws how a doctor could be charged by a single plaintiff, if they are getting the service paid for them by the government.

Another thing that people are failing to address is the fact that we already have organized branches of "socialized" healthcare: they are called medicare and medicaid. People don't realize that medicare and medicaid were enacted for the same exact reason that this bill is being inaugurated today. Except those two cater to a very small market comparable to the Affordable Healthcare Act. Medicare has cost the government FAR more than was ever estimated back in 1965. Albeit it was 1965, but it says a lot... especially with the Obama's administrations history with spending considerably more than was promised with diminishing outcomes.

Because the federal government is legally obligated to provide Medicare benefits to older and disabled Americans, it cannot cut costs by restricting eligibility or benefits, except by going through a difficult legislative process (since most of them have chronic conditions). Although I personally believe that the government CAN and WILL cut costs by restricting eligibility to younger people under the new act.

Also, a small medicaid study of 10,000 individuals showed that when offered federal insurance: hospital utilization increased by 30% for those with insurance, with the length of hospital stays increasing by 30% and the number of procedures increasing by 45% for the population with insurance.

I will be attending my first year in medical school starting in August. I recently just applied to the Air Force for a 3 year medical scholarship. I believe that getting any of your loans covered without having the unsubsidized compounded interest will pay off a lot. I urge anyone going into medical school these days to do that same if you're out of state (I hate people in Texas because it costs them like 12,000 a year for medical school). With this bill, I am increasingly unsure of how much I will be earning in 8-10 years. In fact, if government reimbursements prove to be horrific, I might just practice in the Air Force and have malpractice paid for with a steady government salary and guaranteed pension.

I might sound like a hate the bill, but I don't entirely. I believe that everyone should have access to health care, except I entirely hate the idea of our government taxing a commodity (that's what health care is).

Also, people on this thread who are going to be going to medical school should realize that there are approximately 300 people for every doctor in the United States. That ratio will only increase in the next 10 years. You have to ask yourself the question: Do I really agree with working for the government? Because this is more about the current and prospective physicians than it is about the people receiving the care since we are in the minority by far.

Epic analogy time. If Taco Bell decides to give everyone free Doritos Locos tacos on Tuesdays (which are awesome), everything sounds good. But what about the business? You have to think about the extra strain put on the supplier, the quality of the tacos being made, what if they run out of doritos taco shells and start making them with the horrible regular ones (god help us if this happens).

As doctors we have to know what we are getting into. Honestly, I don't. But people who shrug this bill off like they are still going to have a comfortable income should think twice. You would never think about performing a procedure and simply not getting paid, but it already happens with medicare and medicaid and those are smaller programs compared to the new one.

People should watch this short Youtube video on a doctor's view of the Act:

http://www.youtube.com/watch?v=jwae822Sw-4

Opinions?

 

[Amnipotem]

.

 

[Wolverines83]

Exuding class. If you want me to be honest with you, no offense, kid, but I majored in math at HYPMSC for undergrad and went to a top 5 law school. So odds are, I'm probably smarter than you.

Most smart science students don't go to med school. They get PhDs. All of my science major friends who did well in undergrad got PhDs and did not go to med school. As one of my friends eloquently put it, "only idiot science majors go to med school." And since many low ranked medical schools accept people who are poor standardized test takers, you clearly don't need to be smart to go to medical school. I mean, how do you think you got into medical school?

Thanks to Obamacare, now you will be paid what you are actually intellectually worth. So I guess the world is coming around and putting people like you in your place. I hope you enjoy the dregs of the paid professions, or should I say underpaid professions.

ZING! You're a clown but that was a good one, lol. Maybe law school payed off; you can argue well.

EDIT: I swear I'm not on SDN at 11 on a Friday night....

 

[nosleep]

Exuding class. If you want me to be honest with you, no offense, kid, but I majored in math at HYPMSC for undergrad and went to a top 5 law school. So odds are, I'm probably smarter than you.

Most smart science students don't go to med school. They get PhDs. All of my science major friends who did well in undergrad got PhDs and did not go to med school. As one of my friends eloquently put it, "only idiot science majors go to med school." And since many low ranked medical schools accept people who are poor standardized test takers, you clearly don't need to be smart to go to medical school. I mean, how do you think you got into medical school?

Thanks to Obamacare, now you will be paid what you are actually intellectually worth. So I guess the world is coming around and putting people like you in your place. I hope you enjoy the dregs of the paid, or should I say unpaid, professions.

Bravo bravo, lawyer man in here dropping such impressively unverifiable high status bombs. But with all that you still couldn't get into medical school. It's ok, not everyone can be a winner. You're a classic case of the participation trophy generation. You were never really good at anything so your mom bought you a 10 dollar participation trophy to make you feel like a "winner." Now whenever you fail (like not getting into med school), instead of improving yourself you hate on those that succeeded aka the rest of us here. Does using the word physician bother you? You can say you're a doctor with a JD but never call yourself a physician. You should really get your inferiority complex sorted out with a psychiatrist, who by the way is a physician.

physician physician physician

 

[henge]

That's precisely my point, you're making an argument to move health care away from market incentives on the basis that corporations are profit maximizing and rational and would respond to market incentives. Given a free market, we would never see costs this high. It is the absence of a free market that has allowed such a ballooning in costs. So why would the solution to this problem be to further remove ourselves from the market incentives that would solve things?

Read back to the post I was responding to. We are talking past one another. Under the ACA mandate, people buy insurance from private insurers. Those insurers have a market incentive to pay as little for services as they can, just like you do. They want to make a profit; if they pay too much fro services they won't make a profit. They have market clout and can get better deals from providers than you can individually. The non-market condition exists when people without insurance get care they can't pay for.

Just because you have historical precedence doesn't mean this is an efficient allocation of resources. Are you arguing that there isn't a primary care shortage?

Many studies indicate there is a shortage of primary care physicians. ACA takes steps to increase the supply of primary care physicians.

This isn't the kind of trend that shows up in two years. It is the kind of trend that shows up in 30.

I agree stuff like this takes a while to show up. But in my post I was responding to a claim that medicine was becoming less attractive as a career. If you are correct that these trends take decades to reveal themselves, then, just as there is no basis for saying medicine is not becoming less attractive (your point), there is also no basis for saying that medicine is becoming less attractive (sort of my point). It is all assumption and bias with little data. There will be all sorts of mini-trends over the next 30 years, as when med school apps went up in the mid 90s, down in the early 00s and then back up. We are two very short inconclusive years into it, but things are holding up for now.

It is relevant because quoting an increase in applicant numbers means nothing when you consider the increase in college grads. Considering the percentage of college grads is a more appropriate way to gauge student interest in medicine. If the percentage of college grads interested in medicine drops then we have reason to be concerned about our ability to care for an aging population..."applicant numbers have increased" mean nothing unless we correct for increases in population.

I didn't quote just an increase in number of applicants, I also quoted an increase in MCAT scores and an increase in match applicants, which may have something to do with FMGs wanting to practice in the US (I didn't track the numbers of FMGs over time). MCAT have gone up, indicating applicant quality is still high.

I was looking at the issue from the point of view of whether there were large numbers of students of high caliber (high MCAT) who wanted to go to med school. There are. You are looking at it from the point of view of whether a large percentage of students find med school attractive, with a dropping percentage indicating that medicine is becoming less sought after. I see your point, but if you can still fill a class with people who have skill (MCAT),does it really matter if more people choose Wall Street than medicine?

Moreover, I am not convinced that med school apps have dropped as a percentage of college grads. The data is out there, but I haven't found it. Though, as you say, short-term data may not mean much, and we don't have long term data yet, so even looking at recent changes in percentages really does not reveal much.

This has been interesting, but I have other stuff to do. There are a lot of little ideas swirling around in this discussion, but my basic point was this. When markets work, they can allocate resources efficiently. The pre-ACA individual health insurance market is not a well-functioning market. Conservatives seem to think that if you eliminate the tax advantages for employer provided insurance and require that insureds keep skin in the game, the inefficient individual markets will become efficient.

I disagree. If you do those two things, and only those two things, you will throw literally millions of individuals with high risk/pre-exisiting conditions into a market that does not like to provide insurance to people with high risk/pre-existing conditions or, importantly, for people who the insurers think might have high risk/pre-exsiting conditions. Insurers know less about insureds' health than do the insureds, so insurers reasonably believe that the people who want insurance are the people who need insurance, so they have to charge more to cover that risk. The economist Kenneth Arrow won his Nobel for illuminating how asymmetric information and similar market failures are an unavoidable aspect of the insurance market; even one without government subsidies for employer-provided health insurance or by low deductibles. So, if you just throw the high risk to the necessarily inefficient individual insurance market, they will suffer.

And you can't avoid this by having the insureds keep skin in the game. High deductible policies are fine, but people will need insurance to cover big risks, and it is the big expensive problems that eat up most of the health care dollars. If it makes you feel better, have everyone pay for their own routine treatments, but don't expect to cut a lot off the health care bill. The people with extensive cancer treatments, long-term expensive illnesses and such will still eat up your dollars.

If you want an individual insurance market that actually functions, you have to take steps to create it. Because of the market failures Arrow articulated, an efficient market will not spontaneously generate. I guess that may be our biggest difference in viewpoint. You would want to eliminate the insurers' incentive to discriminate based on health status, such as pre-existing conditions, since that moots some of the information asymmetry problem, as well as a lot of transaction costs. If insurers can't discriminate on this basis, they have to compete on price and service, not underwriting ability, which is now a huge part of their game in the individual market. You also make it easier for insureds to shop around since they don't have to get physicals or wait for ratings results. And of course, people with pre-existing conditions can get insurance, which will help alleviate their suffering. But if you do this, then policies may get more expensive since high risk folks will be the first in line for insurance. So, to get every one in the pool, including the young invulnerables, you need a mandate.

I know you won't accept that. But, all politics aside, if you are even considering dumping your employer provided policy for an individual (non-ACA) policy, I would strongly recommend that you learn about what rights you have in your state to renew your policy. You might end up with the insurer dumping you after you get sick, or maybe "just" increasing your premium by multiples. It is a very serious matter to lose your group coverage rights. Bottom line: I stand by my statement that you should do your utmost to avoid having to get coverage under a pre-ACA individual policies (as opposed to a group policy), and if ACA should get repealed, and the Reps don't put ACA-like protections in place in the individual market, you should avoid the individual market then as well.

 

[xf3rn4nd3sx]

if i have a surgery and the doctor charges 10k, i want all 10k to go to him/her. i don't want any insurance leech taking any of that money.

Government are the leeches. I'm a surgeon so I know. If I charge 10k for a surgery, Medicaid/Medicare NEVER pays the full amount. On average I get 10% of what I charge and it takes tons of paperwork and months to finally receive payment. Losing money on a Medicaid patient is very common and that is why you see many doctors stating that they no longer treat these patients. Its much less of a headache to just take patients with private insurance as we know we'll get paid.

 

[xf3rn4nd3sx]

Exuding class. If you want me to be honest with you, no offense, kid, but I majored in math at HYPMSC for undergrad and went to a top 5 law school. So odds are, I'm probably smarter than you.

Most smart science students don't go to med school. They get PhDs. All of my science major friends who did well in undergrad got PhDs and did not go to med school. As one of my friends eloquently put it, "only idiot science majors go to med school." And since many low ranked medical schools accept people who are poor standardized test takers, you clearly don't need to be smart to go to medical school. I mean, how do you think you got into medical school?

Thanks to Obamacare, now you will be paid what you are actually intellectually worth. So I guess the world is coming around and putting people like you in your place. I hope you enjoy the dregs of the paid, or should I say unpaid, professions.

Edit: I'm deleting this post. Amnipotent deleted his comment, so my response no longer has purpose.