"Universal" Health Coverage in California?

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OncoCaP

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Gov in CA proposed "Universal" Health Coverage. Do you think it's going to make it? Any near-term (< 10 years) impact on physicians in CA & beyond?

http://www.nytimes.com/2007/01/09/us/09calif.html?_r=1&oref=slogin

My guess is that we will see increasing taxes on businesses to pay for various state-level insurance programs. I expect that we will see increasing involvement of state government in mandating health insurance coverage for its citizens. I see this as a positive development, but it is not clear to me that the states will be able to enroll employees faster than people are losing health insurance or the growth of the adult population that never had coverage to begin with (illegal immigrants, small business workers, etc.).

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Get out while you can.

:laugh: ... I'm not headed to CA anytime soon. But seriously, the pundits are saying this is supposed to generate a lot of income for physicians and hospitals ... and this is supposed to justify the proposed 2% tax on physician income (and 4% tax on hospital revenues). Somehow I'm not sure I agree with singling out physicians and hospitals for taxes on healthcare (even if it's just a pass-thru).
 
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:laugh: ... I'm not headed to CA anytime soon. But seriously, the pundits are saying this is supposed to generate a lot of income for physicians and hospitals ... and this is supposed to justify the proposed 2% tax on physician income (and 4% tax on hospital revenues). Somehow I'm not sure I agree with singling out physicians and hospitals for taxes on healthcare (even if it's just a pass-thru).

Hey OncoCaP do you have a link to the California physician income tax story? I haven't heard of this. I know believe in Satan.
 
Hey OncoCaP do you have a link to the California physician income tax story? I haven't heard of this. I know believe in Satan.

It's in the original link story (let me know if it doesn't work). Here is the relevant quote from the article:

"The plan, which Mr. Schwarzenegger estimated would cost $12 billion, calls for many employers that do not offer health insurance to contribute to a fund that would help pay for coverage of the working uninsured. It would also require doctors to pay 2 percent and hospitals 4 percent of their revenues to help cover higher reimbursements for those who treat patients enrolled in Medi-Cal, the state’s Medicaid program.
 
:laugh: ... I'm not headed to CA anytime soon. But seriously, the pundits are saying this is supposed to generate a lot of income for physicians and hospitals ... and this is supposed to justify the proposed 2% tax on physician income (and 4% tax on hospital revenues). Somehow I'm not sure I agree with singling out physicians and hospitals for taxes on healthcare (even if it's just a pass-thru).

No sir it won't. For this reason--California is in the red. They are not going to increase anybody's income anytime soon. This is a prototype for a national Universal healthcare scheme, which will be designed on the premise that doctors are overpayed.

The Babylonians are comming.
 
"The plan, which Mr. Schwarzenegger estimated would cost $12 billion, calls for many employers that do not offer health insurance to contribute to a fund that would help pay for coverage of the working uninsured. It would also require doctors to pay 2 percent and hospitals 4 percent of their revenues to help cover higher reimbursements for those who treat patients enrolled in Medi-Cal, the state’s Medicaid program.

I know everyone on SDN is freaking out over this, but I have yet to see a real cost-benefit analysis of the effect on Cali physicians. There is an automatic presumption that physicians will get screwed by this bill, but in typical MD-fashion, it seems to be a lot of alarmism without many facts to back it up.

And I haven't even mentioned the obvious fact that, as a general principle, finding ways to provide health insurance those who cannot afford it is kind of a good thing . . .
 
No sir it won't. For this reason--California is in the red. They are not going to increase anybody's income anytime soon. This is a prototype for a national Universal healthcare scheme, which will be designed on the premise that doctors are overpayed.

The Babylonians are comming.

The idea is that CA is going to take money out of (more) CA employers pockets and "robin hood" it into health care for people who are uninsured. This supposedly will send more dollars into the healthcare system and thus increase revenues for physicians and hospitals. A big problem right now is that physicians and hospitals in certain cases are required to treat the uninsured (I realize that this is not true in every case). However, rather than then taxing doctors & hospitals, why don't they just tax business less to begin with and leave the physicians and hospitals alone (thereby avoiding taxing businesses more and then paying doctors and then taxing the doctors more). Also, what are they going to do when they find out they don't have enough doctors and hospitals to treat all these uninsured?? Shuffling the money around is just going to generate opportunities for fraud. I do like the idea that everyone should pay into the healthcare system.
 
I know everyone on SDN is freaking out over this, but I have yet to see a real cost-benefit analysis of the effect on Cali physicians. There is an automatic presumption that physicians will get screwed by this bill, but in typical MD-fashion, it seems to be a lot of alarmism without many facts to back it up.

And I haven't even mentioned the obvious fact that, as a general principle, finding ways to provide health insurance those who cannot afford it is kind of a good thing . . .

What happened to the good old days where people actually worked and took care of themselves. Do you know that for every 2% taken out of physicians' income you could probably deduct 0.02% from five thousand of those uninsured people's paychecks and it will fund this program(which benefits them). But Arnold or any other politician cannot sell tax increases to the public so they dump it on the most unsuspecting group(doctors). Why do doctors have to always be the sacrificial lambs. Is it not enough that you loose sleep, incure debt, and study for the rest of your life?
 
What happened to the good old days where people actually worked and took care of themselves. Do you know that for every 2% taken out of physicians' income you could probably deduct 0.02% from five thousand those uninsured people's paychecks and it will fund this program(which benefits them). But Arnold or any other politician cannot sell tax increases to the public so they dump it on the most unsuspecting group(doctors). Why do doctors have to always be the sacrificial lambs. Is it not enough that you loose sleep, incure debt, and study for the rest of your life?

Physicians are just going to jack their prices up 2% and hospitals 4%. They aren't going to take a cut in profits. The only reason I can think that this is being proposed is because they expect physicians and hospitals to have a large windfall (ala oil companies) as a result of having a lot more patients and maybe they want some of that money to go back into the pool (so that it can be spent again and again and again). Then again, I know nothing about CA politics (other than I expect that they have an extra allotment of politicians that are very liberal, big spenders, and pro-union -- similiar to their population, I suppose).
 
Physicians are just going to jack their prices up 2% and hospitals 4%. They aren't going to take a cut in profits. The only reason I can think that this is being proposed is because they expect physicians and hospitals to have a large windfall (ala oil companies) as a result of having a lot more patients and maybe they want some of that money to go back into the pool (so that it can be spent again and again and again). Then again, I know nothing about CA politics (other than I expect that they have an extra allotment of politicians that are very liberal, big spenders, and pro-union -- similiar to their population, I suppose).

Please tell me how they are going to do that when medicare controls payment and insurance companies base their formulas off medicare. Unless you are boutique then you really don't have any say over what you charge (vast majority of physicians).
 
Doctors are the sacrificial lamb but don't realize it until they are on the altar of residency.

Get out while you can. If you can.
 
Please tell me how they are going to do that when medicare controls payment and insurance companies base their formulas off medicare. Unless you are boutique then you really don't have any say over what you charge (vast majority of physicians).

First, let me say that I personally would be willing to pay an extra 2% tax if it meant that every person in my state now had health coverage. A healthier population is worth the money to me.

Now, to answer you question (since I'm sure most people are much more money conscious than me), there are many ways to do this. Let's just say that fundamentally from an economics standpoint, the state is asking physicians and hospitals to treat more people -- to do more work. However, it's not like they can add 100,000 more physicians in a year. That means that the demand for services will go up -- way way way up and I seriously doubt there is any capacity in CA to take all these extra people.

With all these extra patients, physicians and hospitals who are concerned about their $$ bottom line could simply do less work for the same money, become more selective about what insurance, which patients, become more selective in the kinds of procedures they offer, have limited slots for money-losing procedures. When I go to a physician nowadays, I often you'll see him or her for 10 minutes and see a bill for $100+ (what the insurance company approves). That's $600/hr. I realize there is a lot of overhead and I & my family are not the typical patient, but it is possible to make this work financially. It might also be that all this additional demand will bring in more revenue so that they extra tax is easily paid with more profits at the end of the day (I realize this is not the case in every case, but there are probably some situations where it would be true).

Yes, such a new system changes the financial equation, but I seriously doubt that physicians will be exiting CA in droves. If anything, I would expect an influx after such a law was passed to help meet the increased demand. I would also expect net compensation to increase, but there are too many variables to be sure, of course.
 
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First, let me say that I personally would be willing to pay an extra 2% tax if it meant that every person in my state now had health coverage. A healthier population is worth the money to me.

Now, to answer you question (since I'm sure most people are much more money conscious than me), there are many ways to do this. Let's just say that fundamentally from an economics standpoint, the state is asking physicians and hospitals to treat more people -- to do more work. However, it's not like they can add 100,000 more physicians in a year. That means that the demand for services will go up -- way way way up and I seriously doubt there is any capacity in CA to take all these extra people.

With all these extra patients, physicians and hospitals who are concerned about their $$ bottom line could simply do less work for the same money, become more selective about what insurance, which patients, become more selective in the kinds of procedures they offer, have limited slots for money-losing procedures. When I go to a physician nowadays, I often you'll see him or her for 10 minutes and see a bill for $100+ (what the insurance company approves). That's $600/hr. I realize there is a lot of overhead and I & my family are not the typical patient, but it is possible to make this work financially. It might also be that all this additional demand will bring in more revenue so that they extra tax is easily paid with more profits at the end of the day (I realize this is not the case in every case, but there are probably some situations where it would be true).

Yes, such a new system changes the financial equation, but I seriously doubt that physicians will be exiting CA in droves. If anything, I would expect an influx after such a law was passed to help meet the increased demand. I would also expect net compensation to increase, but there are too many variables to be sure, of course.

only problem is that everyone will not be covered. Just like every "hand me" social program, it will be exploited and bankrupted.
 
only problem is that everyone will not be covered. Just like every "hand me" social program, it will be exploited and bankrupted.

Why do you think not everyone will be covered?

The proposed system basically just forces businesses to either provide health insurance to all their employees or to pay for the government to do it with a tax.

I agree that there will be problems with it ... similiar perhaps to the public school system. Even so, public education is available to everyone (at varying levels of quality, of course). People will still be able to buy their own health insurance if they want to.

What is happening now is that we all pay for the uninsured anyway (although their services are being throttled ... which might actually increase the total cost). A certain amount in every "paid" healthcare bill pays for someone who didn't pay their bill. Also, governements are already taxing citizens to fund public hospitals. The new system might actually be more effective and efficient.

I'm not trying to trivialize the difficulty of this task. However, this represents an important opportunity. Anything can be messed up, whether we're talking about a medical education, a patient's treatment, a marriage, a car repair -- whatever. There will always be problems. There are similiarly opportunities to make improvements and this might just be one of those....

I could see this proposed system making it into other states as well.
 
only problem is that everyone will not be covered. Just like every "hand me" social program, it will be exploited and bankrupted.

Therefore we should never attempt to help our fellow citizens who are in need.. Thanks for clearing that up.

While we're at it, let's disband the military. If all these lazy citizens want protection from foreign aggressors, let 'em buy a couple guns and stand up for themselves . . .
 
what will be really funny is when someone making $100K/year will get this free healthcare. Why not, just refuse to buy health insurance. Whats the penalty of not paying for health insurance, either way it will be taken care of so let someone else foot the bill.


What happened to the menality of sacking up and taking care of YOURSELF.:idea:

Granted there are rare occurrances where someone is SOL and needs some help but otherwise it's all about priorities. Do you buy a new $20k car or get yourself/family health insurance? If I was in California right now I'd have to worry about making space in my garage :laugh:
 
what will be really funny is when someone making $100K/year will get this free healthcare. Why not, just refuse to buy health insurance. Whats the penalty of not paying for health insurance, either way it will be taken care of so let someone else foot the bill.


What happened to the menality of sacking up and taking care of YOURSELF.:idea:

Granted there are rare occurrances where someone is SOL and needs some help but otherwise it's all about priorities. Do you buy a new $20k car or get yourself/family health insurance? If I was in California right now I'd have to worry about making space in my garage :laugh:

We could say the same thing about public education and, like Tired said, the military. Everyone should just go buy their own private education or guns or asphalt paver ... let's not provide these things through gov't administration anymore. Heck, let's be totally capitalistic about this and just eliminate medical licensing and the FDA altogether and just make it a "buyer is responsible" system.

Clearly most people would not agree with these extreme and silly examples. Similarly there are smaller adjustments to the system that we could explore. The fact that we have millions of people running around without health insurance creates a problem for our country. If nothing else, uninsured people who are sick must wait well past the optimal treatment time, and then we have no choice but to treat them (major surgery, expensive drugs, expensive care for the disabled) because we are not willing to just let sick people die without treatment.

It probably makes sense to deal with people the way that they are rather than hope they will take responsibility (which many people don't). This means that the gov't steps in on certain critical issues, and healthcare is certainly one of those. So rather than waiting for a diabetic's health to get so bad that the person becomes disabled and we can only amputate and provide expensive care, let's provide more care up front to prevent the expensive problems that cost all of us in the end with higher taxes anyway. I would rather pay less up front in taxes. Again, I'm not pretending that this is going to be easy to do right. It's hard work, but it doesn't mean that we should just give up.
 
only problem is that everyone will not be covered. Just like every "hand me" social program, it will be exploited and bankrupted.

Correct, more people would sign up for this free insurance(even those that could afford private insurance). The volume of reimbursements will overwhelm the government, and they will respond by cutting reimbursements. In the end you will work more for less.
 
Correct, more people would sign up for this free insurance(even those that could afford private insurance). The volume of reimbursements will overwhelm the government, and they will respond by cutting reimbursements. In the end you will work more for less.

While we will always have a certain number of people who exploit anything we do, do you think there are incentives that could be put into place to prevent employers from just dumping their health insurance in favor of a government program? For example, perhaps the taxes that a business without health insurance is charged could be more than what it would cost the business to just get health insurance on its own? If businesses have a way to save money and cut their costs, they will often do it. Thus, if the tax is less than the health insurance, employers could very well drop their private insurance. However, if they can pay less taxes by getting their own insurance, they will. It depends the amount of the non-compliance tax.

Really, all California would need to do is tax the dickens out of any business that doesn't offer the minimum health insurance to their employees, and every business will be rushing to get private health insurance. Those few "unwise" businesses might be paying 20% more for health insurance than they would otherwise. It's hard to tell if this proposal will pass or what it will look like when it finally comes out. It might only cover all children.

If you are saying that physicians and hospitals don't have enough political power to prevent socialization of medicine so that they earn less and work more, you may be right. Maybe physicians will be earning as much as school teachers by the time this is over with. However, I would be surprised if this happens.
 
While we will always have a certain number of people who exploit anything we do, do you think there are incentives that could be put into place to prevent employers from just dumping their health insurance in favor of a government program? For example, perhaps the taxes that a business without health insurance is charged could be more than what it would cost the business to just get health insurance on its own? If businesses have a way to save money and cut their costs, they will often do it. Thus, if the tax is less than the health insurance, employers could very well drop their private insurance. However, if they can pay less taxes by getting their own insurance, they will. It depends the amount of the non-compliance tax.

Really, all California would need to do is tax the dickens out of any business that doesn't offer the minimum health insurance to their employees, and every business will be rushing to get private health insurance. Those few "unwise" businesses might be paying 20% more for health insurance than they would otherwise. It's hard to tell if this proposal will pass or what it will look like when it finally comes out. It might only cover all children.

If you are saying that physicians and hospitals don't have enough political power to prevent socialization of medicine so that they earn less and work more, you may be right. Maybe physicians will be earning as much as school teachers by the time this is over with. However, I would be surprised if this happens.

I won't.
 
just read an article about this that incensed me. The part that really made me mad was the 2% tax on physicians. WTF?! it's not enough that we spend the best years of our lives slaving away in libraries and hospitals, income is dropping every year and pay 30-40% in taxes AND we pay, depending on specialty, up to $100,000 / year in malpractice insurance....but they want us to give even more of our income away for a public insurance plan?! Why do they feel the need to penalize doctors? why not stockbrokers, or entrepreneurs, or businesspeople?

some small businesses just do not have the money to pay for insurance for their employees. if this does go through, small business will be hurt, it will be a brain drain on californias physicians as they seek work elsewhere where their sacrafices are valued, and it will increase insurance prices for everyone (as insurance companies have to insure sicker people who would have been uninsurable in the past).
 
just read an article about this that incensed me. The part that really made me mad was the 2% tax on physicians. WTF?! it's not enough that we spend the best years of our lives slaving away in libraries and hospitals, income is dropping every year and pay 30-40% in taxes AND we pay, depending on specialty, up to $100,000 / year in malpractice insurance....but they want us to give even more of our income away for a public insurance plan?! Why do they feel the need to penalize doctors? why not stockbrokers, or entrepreneurs, or businesspeople?
some small businesses just do not have the money to pay for insurance for their employees. if this does go through, small business will be hurt, it will be a brain drain on californias physicians as they seek work elsewhere where their sacrafices are valued, and it will increase insurance prices for everyone (as insurance companies have to insure sicker people who would have been uninsurable in the past).

This is a good question.
 
Therefore we should never attempt to help our fellow citizens who are in need.. Thanks for clearing that up.

While we're at it, let's disband the military. If all these lazy citizens want protection from foreign aggressors, let 'em buy a couple guns and stand up for themselves . . .

YES!!!! The government should NEVER steal money from one person and give it to another person "in need." This is called stealing, and the government is supposed to exist to stop people from doing this. Giving should be personal, and no person should be exploited based on someone else's opinion on how much they give to charity.
 
some small businesses just do not have the money to pay for insurance for their employees. if this does go through, small business will be hurt, it will be a brain drain on californias physicians as they seek work elsewhere where their sacrafices are valued, and it will increase insurance prices for everyone (as insurance companies have to insure sicker people who would have been uninsurable in the past).

Government schemes almost always hurt small business to the benefit of large politically connected companies.
 
just read an article about this that incensed me. The part that really made me mad was the 2% tax on physicians. WTF?! it's not enough that we spend the best years of our lives slaving away in libraries and hospitals, income is dropping every year and pay 30-40% in taxes AND we pay, depending on specialty, up to $100,000 / year in malpractice insurance....but they want us to give even more of our income away for a public insurance plan?! Why do they feel the need to penalize doctors? why not stockbrokers, or entrepreneurs, or businesspeople?

some small businesses just do not have the money to pay for insurance for their employees. if this does go through, small business will be hurt, it will be a brain drain on californias physicians as they seek work elsewhere where their sacrafices are valued, and it will increase insurance prices for everyone (as insurance companies have to insure sicker people who would have been uninsurable in the past).

I think OncoCaP may have touched on it earlier. With all of the variables, I don't think anyone can say for sure what would happen. It seems to me, though, that a sudden increase in people who previously could not access the healthcare system would occur, and without a likewise sudden explosion of physicians and hospitals, demand would go up. You could charge more and selectively choose who you care for. In this way, physicians and hospitals are seen to benefit from this new plan, and no doubt it is a very expensive plan, so they are trying to fund it any way they can.
 
There are probably only two paths out of the current state of healthcare funding: complete socialization where the gov't controls all (already in process with Medicare/Medicaid) or removal of 3rd party pay systems (let market dynamics adjust prices rather than insurance companies/gov't). The problem is we are stuck in between the two systems. It looks like California has started taking one more step toward the former.

In either system, physician pay would go down. We had better get used to it. Our nation apparently can't afford the current price of physicians any longer (or maybe it's the price of hospital and insurance company CEOs more than that?). Bummer for us because we drop at least $150 grand on med school, but that would probably adjust itself down too. I don't care because I'm not doing it for the money. If I can get out of the debt in a reasonable amount of time, that will be enough for me.

I do think that everyone needs access to affordable health care, but I don't have the solution. If I did, I would run for president. :D
 
There are probably only two paths out of the current state of healthcare funding: complete socialization where the gov't controls all (already in process with Medicare/Medicaid) or removal of 3rd party pay systems (let market dynamics adjust prices rather than insurance companies/gov't). The problem is we are stuck in between the two systems. It looks like California has started taking one more step toward the former.

In either system, physician pay would go down. We had better get used to it. Our nation apparently can't afford the current price of physicians any longer (or maybe it's the price of hospital and insurance company CEOs more than that?). Bummer for us because we drop at least $150 grand on med school, but that would probably adjust itself down too. I don't care because I'm not doing it for the money. If I can get out of the debt in a reasonable amount of time, that will be enough for me.

I do think that everyone needs access to affordable health care, but I don't have the solution. If I did, I would run for president. :D

It is the cost of healthcare not "the price of physicians" that is responsible for our expensive healthcare. A surgeon makes about $700 dollars from a $12,000 surgery, so what if he takes a 50% pay cut, you still have to account for the remaining $11,650. Meanwhile nobody has evaluated how much defensive medicine is costing the country either.
I am glad you are not "doing it for the money", but don't forget that as a doctor you are a pseudo-businessman(contractor) and profit/loss dynamics will affect your ability to practice, so don't be too nonchalant about a loss when you see one.
 
YES!!!! The government should NEVER steal money from one person and give it to another person "in need." This is called stealing, and the government is supposed to exist to stop people from doing this. Giving should be personal, and no person should be exploited based on someone else's opinion on how much they give to charity.

This is where the argument should end. Unfortunately, most people ignore this basic truth and it sickens me.
 
Therefore we should never attempt to help our fellow citizens who are in need.. Thanks for clearing that up.

While we're at it, let's disband the military. If all these lazy citizens want protection from foreign aggressors, let 'em buy a couple guns and stand up for themselves . . .

Seriously I feel like i wandered into a meeting at the Heritage Foundation. Look, both left-wing and right-wing idealogues will not provide us with any realistic public solutions. The program in California is modeled after the one Massachusettes which for whatever your political leanings is the cumulative realization that we are headed for healthcare disaster if we don't bolster up the public infrastructure. The reality is that we end up paying for those who don't take care of themselves. The question is how do we manage that problem with cost-effective strategies. The California Plan that the governor put forth splits the burden to as many parties as will gain, physicians and citizens who will barely be able to pay included.
Someone referred to the "good old days when people took care of themselves"....what kind of bland, uninsightful historiography is that. Save it for meathead Archie we've got real public problems on our hands.
The AMA's militant and isolationist stance of pay for service long beyond its sustainibility is as much responsible for the emergence of costly para-medical industries that burden us as anything else. So you can thank the old dudes in robes that grace the halls of your medical school for that.

I feel for the plight of plummeting doctor's salaries and long hours, but this is the downward sloping portion of the medical professional arc, and its best to be realistic and studious rather than dogmatic about why that is happening.
If you're really that upset about it there is much to gain from the upheavel if one is so inclined as the sample of this thread indicates. Might I suggest botique medicine and business and investment aspects of medicine as robust venues for your disdain for common folk.
 
I am glad you are not "doing it for the money", but don't forget that as a doctor you are a pseudo-businessman(contractor) and profit/loss dynamics will affect your ability to practice, so don't be too nonchalant about a loss when you see one.

My point was that there are market forces (either gov't driven or free market driven) that will drive down the cost of health care because they see it as too expensive. The market (gov't driven) is now merely trying to readjust for the continually rising costs. This will entail decreases in gross reimbursement and along with that, if businesses are mismanaged, physician net income.

If the medical market weren't so profitable (regardless of who gets the profits in the end: Drs, CEOs, corporations) there wouldn't be so many people wanting to get into this field. RNs are able to negotiate salaries that were previously unheard of because there is a nursing shortage, and the hospitals are still making a killing (figuratively, not literally). :) This will eventually level back out, but don't expect the hospitals to decrease prices unless the market forces them to.

The cost of medical equipment is so high because the companies that build this equipment know that the services that will be performed can acceptably be billed at high rates (under the current system). It is a vicious cycle for the end healthcare consumer.

As businesspersons our job is to maximize our profitability within the market, not try to manipulate the market to our advantage through lobbying or legislation (although these do have their place). This means that the medical profession as a whole, rather than compaining about decreased reimbursement or increased taxes, needs to learn how to deliver our services in new and better ways to minimize cost and maximize utilization. If this is done properly, in the end, our net profits are the same (or greater) and more people have better health.
 
Seriously I feel like i wandered into a meeting at the Heritage Foundation. Look, both left-wing and right-wing idealogues will not provide us with any realistic public solutions. The program in California is modeled after the one Massachusettes which for whatever your political leanings is the cumulative realization that we are headed for healthcare disaster if we don't bolster up the public infrastructure. The reality is that we end up paying for those who don't take care of themselves. The question is how do we manage that problem with cost-effective strategies. The California Plan that the governor put forth splits the burden to as many parties as will gain, physicians and citizens who will barely be able to pay included.
Someone referred to the "good old days when people took care of themselves"....what kind of bland, uninsightful historiography is that. Save it for meathead Archie we've got real public problems on our hands.
The AMA's militant and isolationist stance of pay for service long beyond its sustainibility is as much responsible for the emergence of costly para-medical industries that burden us as anything else. So you can thank the old dudes in robes that grace the halls of your medical school for that.

I'm not sure that you can discount an entire statement by simply stating that it is "bland unsightful historiography." How about some evidence. Please state an example of how the progressive government intervention into the medical marketplace has improved access. It seems that the cost of healthcare and the number of uninsured KEEP RISING. You CANNOT provide infinite amounts of healthcare to everyoen. It cannot be done. The more people you cover at the same level, the lower the quality of that level. If you want examples, feel free to refer to my blog.

I feel for the plight of plummeting doctor's salaries and long hours, but this is the downward sloping portion of the medical professional arc, and its best to be realistic and studious rather than dogmatic about why that is happening.
If you're really that upset about it there is much to gain from the upheavel if one is so inclined as the sample of this thread indicates. Might I suggest botique medicine and business and investment aspects of medicine as robust venues for your disdain for common folk.
How does expecting people to pay for services and wanting to not be taxed more count as having disdain for the common folk? Your post is full of inflammatory attacks with NO evidence. Common folk usually work for money, expect to be paid, and don't want to pay more in taxes. I think that my stance makes me much more common than yours.
 
My point was that there are market forces (either gov't driven or free market driven) that will drive down the cost of health care because they see it as too expensive. The market (gov't driven) is now merely trying to readjust for the continually rising costs. This will entail decreases in gross reimbursement and along with that, if businesses are mismanaged, physician net income.

If the medical market weren't so profitable (regardless of who gets the profits in the end: Drs, CEOs, corporations) there wouldn't be so many people wanting to get into this field. RNs are able to negotiate salaries that were previously unheard of because there is a nursing shortage, and the hospitals are still making a killing (figuratively, not literally). :) This will eventually level back out, but don't expect the hospitals to decrease prices unless the market forces them to.

The cost of medical equipment is so high because the companies that build this equipment know that the services that will be performed can acceptably be billed at high rates (under the current system). It is a vicious cycle for the end healthcare consumer.

As businesspersons our job is to maximize our profitability within the market, not try to manipulate the market to our advantage through lobbying or legislation (although these do have their place). This means that the medical profession as a whole, rather than compaining about decreased reimbursement or increased taxes, needs to learn how to deliver our services in new and better ways to minimize cost and maximize utilization. If this is done properly, in the end, our net profits are the same (or greater) and more people have better health.


This is what happens in a free market. It works in reverse when the government controls the market. Everyone tries to provide the most expensive services possible, in order to get a larger share of the government pie. Please refer to any beauracracy as an example. If medical service prices dropped, pay would drop. The incentive is inverted in a government controlled market.
 
YES!!!! The government should NEVER steal money from one person and give it to another person "in need." This is called stealing, and the government is supposed to exist to stop people from doing this. Giving should be personal, and no person should be exploited based on someone else's opinion on how much they give to charity.

How typical. The priveleged professional complaining about his taxes, all the while ignoring all the benefits he receives from his own government. You're just an Ayn Rand wannabe without the vocabulary.

1) Providing for the underclass provides benefits to all classes. An unstable, hungry underclass will necessarily cause social unrest in the form of riots and crime. Governments prevent social upheaval by assisting the underclass with basic needs they cannot provide for themselves, including health care.

2) Government is not some overarching entity operating independently of the populace. Government is representative. If the public did not want taxes to fund social welfare programs, there would be no liberals in the halls of power. Fixing the healthcare crisis, and figuring out how to get health care to the lower classes, is consistently ranked as a serious concern in most polls.

3) Taxation is not stealing. Taxation is what allows the government to function, and government is integral to the continued functioning of society at large. Police & fire protection, public infrastructure, military, these are all basic needs that government provides to its citizens, utilizing tax dollars.

4) Physicians (like corporations) are licensed at the discretion of the state. This both ensures adequate qualifications of practicing physicians, and allows docs to maintain their quasi-monopoly on the delivery of health care. This situation is what allows doctors to earn such large (relative to the average American) salaries.

5) Taxation and Health Care are already intimately related. Medicare constitutes well over 15% of the Federal budget. Federal dollars in the form of research funding and direct compensation to hospitals and providers are a major source of revenue in health care. No provider or facility could stay in business without Federal dollars, nor could most medical schools. This is why "Medicare Exclusion" is the most serious penalty providers and hospitals can face, perhaps even more severe than losing a licensce.

So please, feel free spout off about "socialism" and "stealing", as is your right as an American. But understand that, like the underclasses you so abhor, a big part of your paycheck already comes from my tax dollars. You're taking just as much of a "hand out" as the poor are.
 
Miami Med,

My point was directed at the fly by comments deploring the laziness of the working poor while singling out the 2% tax on physicians as if that were the entire premise of new plan in California. I am reading over your blog now. It's well witten and argued. I don't necesarily disagree with alot of your ideas. But fundamentally, like Tired, i don't see taxation as stealing but as funding a society that we can all derive satisfaction from living in.
As to your call for evidence for social controls on medicine and how they have enabled increasing access to the otherwise uncared for....without data at this time it seems a matter of common sense and dignity that for our elderly on fixed incomes medicare allows for them to be treated whereas in a fee for service, free market system they might not be. It's one thing to talk about Jeffersonian philosophy of 200 years ago and quite another to turn somebody away who can't afford care. The generation that created the medicare system was the same generation that survived the depression and defeated global fascism. They saw the injustice of untreated and preventable diseases causing human suffering on a scale that is hard for us to imagine.
I'm not minimizing or "Straw-manning" your arguments as inhumane. But I have a hard time imagining a free market system solving public health problems like the epidemics of infectious diseases of the last century that seem likely to reemerge upon us. Its important to note that these counter measures were publicly funded efforts.
On the other hand your first couple of blog entries brought home some serious problems about consumer expectations for high cost end of life issues. Working in healthcare I've often thought some of those very same things as extensive measures were executed on patients--whom if that were me--I would just rather check-out. It's not the discourse of your blog that
I object to its the idealogical pandering of sound bites that solve nothing.
 
I found this on the LA Times website. So far, it is the only proposal that has made sense to me...unfortunately it was not part of the governor's plan. Does anyone find any flaws in the reasoning here? I honestly think this is the way to go.



Make health insurers play fair
Any plan to reform healthcare must tackle the biggest obstacle to insuring everyone -- private insurers.
By Jamie Court and Judy Dugan
January 5, 2007

WHEN Gov. Arnold Schwarzenegger, on crutches, unveils his expected grand redesign of the state's health insurance system Monday, he must tackle the biggest obstacle to insuring the uninsured: insurance companies.

The governor said recently that California's high number of uninsured residents — about one in five — acts as a hidden tax on the insured by forcing them to pay higher premiums, deductibles and co-pays. He has strongly hinted that he favors a system requiring individuals to buy health insurance, as well as assuring coverage for all children in the state (who constitute about 12% of the uninsured).

But he's said nothing about reforming insurance companies or HMOs.

Schwarzenegger's experience with health insurers is not your average citizen's. Anyone as rich as he is doesn't have to worry about medical expenses. He and his surgeon surely didn't have to seek permission for treatment. They didn't have to argue with a cost-control center demanding something cheaper — such as outpatient surgery. The governor won't fear that his insurer will retroactively cancel his policy or double his premiums because of the surgery.

Not only is Schwarzenegger immune to most people's struggles with insurers, he's also enjoyed nearly $1 million in direct political contributions from them, according to public contribution reports.

It is this political relationship that should worry Californians hoping for real healthcare reform. Insurance companies, after all, will spend whatever it takes and call in every favor they're owed to stop reforms that restrict their profits, curb their extravagant overhead or limit what they can pay their chief executives.

For health coverage truly to be affordable and accessible, the governor and Legislature must force insurers to accept the following rules of fairness:

• A "take-all-comers" rule. Insurers today can deny a health policy to individual buyers in California for almost any reason. In Massachusetts, which recently required all citizens to carry health insurance, insurers have to take all patients, regardless of preexisting conditions. California insurers should be required to do the same.

• Charges set by community, not condition. California health insurers want to insure the healthy, not the sick, so they charge individuals who even might become sick astronomical premiums. Those who do become ill can see their premiums skyrocket or their policies canceled. It's the opposite of Massachusetts and other states where health insurers must base premiums on broad characteristics such as age and regional healthcare costs — not on a buyer's specific medical condition. The purpose of insurance, after all, is to spread the risk.

• Regulation of health premiums like auto premiums. California auto insurers must show that their profits are reasonable and ask permission of state regulators before raising premiums. The system has saved motorists tens of billions of dollars on their auto insurance since it was adopted in 1988. It's the least the state should demand of health insurers, who now face little to no scrutiny of their profits or bloated administrative costs. As a result, health insurers that sell to individuals spend as little as 50 cents of every premium dollar on actual medical care.

• A ban on health insurance policies that set no limits on what patients can pay. A policy that pays only $300 a day for a hospital stay that costs as much as $10,000 a day may cost a lot less than comprehensive policies, but it is hardly worth the paper it is printed on. Fringe insurers have been held accountable in California courts for such "junk insurance," but traditional insurers are moving toward similar "mini-policies." All policies should have an out-of-pocket maximum. If you're left with half a million dollars in medical bills, as one California patient was recently after her husband's death from cancer, then you're not really covered.

• A "California Health Plan" offering universal access to public officials' health coverage. The state employees' retirement and benefits fund, CalPERS, has used its size and clout to cut drug costs and provide care without paying for insurers' profit and overhead. Hundreds of thousands of state employees, including legislators and gubernatorial aides, have access to this directly state-funded system. If all Californians had access to this well-run, low-overhead plan, private insurers would be forced to drop prices and reduce overhead and profits if they wanted to compete.

California insurers won't like these proposals, and won't be shy in reminding the governor and Legislature about favors owed. Whether our elected officials respond to the desires of insurers or the needs of California will determine everything about healthcare reform.
 
How typical. The priveleged professional complaining about his taxes, all the while ignoring all the benefits he receives from his own government. You're just an Ayn Rand wannabe without the vocabulary.

I'm actually not a true objectovist, but I am a staunch libertarian. In that sense, I am only part an Ayn Rand wannabe. I'm not sure why you feel the need to criticize my vocabulary. I think that it has been perfectly sufficient to get my points across. In terms of privelege, I'm sure that the years of work, the multiple jobs and business ventures that I engaged in to put myself through college, and the loans that I now take to fund my education don't count. I worked hard. I still work hard. I intend to be rewarded for it at the level that my service is worth. You are more than welcome to sell YOURSELF for whatever you want.

1) Providing for the underclass provides benefits to all classes. An unstable, hungry underclass will necessarily cause social unrest in the form of riots and crime. Governments prevent social upheaval by assisting the underclass with basic needs they cannot provide for themselves, including health care.
This is just a touch insulting isn't it? If we don't take things from rich people and give them to poor people, the poor will attack everyone. I don't think that being poor equals being violent. This is like arguing that we should kill ourselves prophylactically in order to prevent someone from killing us.

2) Government is not some overarching entity operating independently of the populace. Government is representative. If the public did not want taxes to fund social welfare programs, there would be no liberals in the halls of power. Fixing the healthcare crisis, and figuring out how to get health care to the lower classes, is consistently ranked as a serious concern in most polls.
False, concensus and majority doesn't equal moral superiority. We'll conveniently ignore the fact that most national elections are choices between members of two monopoly parties who come from the same "evil" wealth class that you decry. If a majority vote that we should kill someone, should we? If a majority think that we should seize all of your assets and give them to me, should we?
3) Taxation is not stealing. Taxation is what allows the government to function, and government is integral to the continued functioning of society at large. Police & fire protection, public infrastructure, military, these are all basic needs that government provides to its citizens, utilizing tax dollars.
Taking money from someone who doesn't want to give it to you is stealing. Even our founding fathers argued that the government collected taxes as part of a social contract through voluntary association. This was at a time when secession was possible and individuals could take their property and leave the fragile union. If I declared my property independent today, I would be taken at gun point to prison. Therefore, my taxes are not voluntary, the social contract is void, and taxation is stealing.
4) Physicians (like corporations) are licensed at the discretion of the state. This both ensures adequate qualifications of practicing physicians, and allows docs to maintain their quasi-monopoly on the delivery of health care. This situation is what allows doctors to earn such large (relative to the average American) salaries.
I'd be happy to give up this monopoly. It would create new, innovative, and cheaper ways to provide medical training. I could skip my $30k classes on feeling my patient's pain.
5) Taxation and Health Care are already intimately related. Medicare constitutes well over 15% of the Federal budget. Federal dollars in the form of research funding and direct compensation to hospitals and providers are a major source of revenue in health care. No provider or facility could stay in business without Federal dollars, nor could most medical schools. This is why "Medicare Exclusion" is the most serious penalty providers and hospitals can face, perhaps even more severe than losing a licensce.
Except that they all did before Medicare came into existance in the 60s. Healthcare has evolved independently of market forces for the last 40 years, and we can follow the progression of the disaster. I think we should phase out these programs, take away hospital pseudo-monopoly status imposed in jurisdictions and free up healthcare to market forces. Medicare exclusion is feared because that is the coverage that patients have. If it didn't exist, the system would be different.
So please, feel free spout off about "socialism" and "stealing", as is your right as an American. But understand that, like the underclasses you so abhor, a big part of your paycheck already comes from my tax dollars. You're taking just as much of a "hand out" as the poor are.

You'll have to explain this one to me. I don't even understand what you are trying to say. Government drives up medical school prices by giving them an accreditation monopoly. Government then negotiates favorable bank rates to loan money to me to pay for obscene tuition. I then pay money back, + income taxes that are annually greater than all money paid in my benefit. Seems like a racket to me.

Also, I am really getting annoyed with your accusation of my hatred for the underclass. I believe that the "underclass" are people that have the same priveleges and responsibilities as the "overclass." I believe that they are equal. You are the one who argues that this is a "class" prone to spontaneous bouts of violence and incapable of self-preservation. That IS insulting.
 
Miami Med,

My point was directed at the fly by comments deploring the laziness of the working poor while singling out the 2% tax on physicians as if that were the entire premise of new plan in California. I am reading over your blog now. It's well witten and argued. I don't necesarily disagree with alot of your ideas. But fundamentally, like Tired, i don't see taxation as stealing but as funding a society that we can all derive satisfaction from living in.
As to your call for evidence for social controls on medicine and how they have enabled increasing access to the otherwise uncared for....without data at this time it seems a matter of common sense and dignity that for our elderly on fixed incomes medicare allows for them to be treated whereas in a fee for service, free market system they might not be. It's one thing to talk about Jeffersonian philosophy of 200 years ago and quite another to turn somebody away who can't afford care. The generation that created the medicare system was the same generation that survived the depression and defeated global fascism. They saw the injustice of untreated and preventable diseases causing human suffering on a scale that is hard for us to imagine.
I'm not minimizing or "Straw-manning" your arguments as inhumane. But I have a hard time imagining a free market system solving public health problems like the epidemics of infectious diseases of the last century that seem likely to reemerge upon us. Its important to note that these counter measures were publicly funded efforts.
On the other hand your first couple of blog entries brought home some serious problems about consumer expectations for high cost end of life issues. Working in healthcare I've often thought some of those very same things as extensive measures were executed on patients--whom if that were me--I would just rather check-out. It's not the discourse of your blog that
I object to its the idealogical pandering of sound bites that solve nothing.


#1: Jeffersonian philosophy (and Lockean) is the basis of American government. You can't divorce America from Jefferson.

#2: I have always argued in previous posts (read them if you like), that infectious disease is the ONE exception in which the government should become involved. This is not for the protection of the sick patient but for the protection of innocent civilians. This is like the existance of the military, a protectionist force to prevent aggression (in this case from microbes). This argument doesn't apply to cancer, CHF, diabetes, etc....

#3: In terms of providing care to those that can't afford it. Tired called me an Ayn Rand wannabe, so I'll use an Ayn Rand reference. In the book "The Fountainhead," Howard Roark, an architect accepts a job to design a building. As the building is rising, he realizes that he has made a mistake. Rather than allow the building to be completed, he redesigns the building and fixes it at a net cost to himself that he can ill afford. He just couldn't stand to see it being done wrong.
For me, that is my problem with healthcare. I just want the system to work. I've done my share of charity work, and I enjoy doing it. I don't want people to die unnecessarily, and I try to prevent it as much for my own benefit as for theirs. I think that a free market will in time lead to the best care for everyone, and wealth is the natural reward for quality provision of a service. As with Roark in the book however, wealth shouldn't be obtained for insufficient work. This "charitable" serivce that I choose to give however, is revokable and not a right. There are people who genuinely live parasitically, and I feel no obligation to slave away in the name of an individual who refuses to try and help himself.


I apologize if I misunderstood the intention of your post. I mean no ill will, and we will probably agree to disagree. I'm always willing to engage in a civil discourse that refrains from name calling and accusations without evidence. I think that I just misunderstood what you were trying to say and to whom your accusations were aimed. Feel free to PM me or continue the debate at any time.
 
... In terms of privelege, I'm sure that the years of work, the multiple jobs and business ventures that I engaged in to put myself through college, and the loans that I now take to fund my education don't count. I worked hard. I still work hard. I intend to be rewarded for it at the level that my service is worth. You are more than welcome to sell YOURSELF for whatever you want.

I agree that you should be rewarded for your efforts. You can participate in a hopeless effort to abolish taxation if you want. At the same time, I also wish people took more responsibility and that people who repeatedly refuse to take even minimal steps on their health should face some kind of consequence. Even so, I realize the political realities and avoid hopeless causes unless it's a job requirement I can't get out of.

...
Taking money from someone who doesn't want to give it to you is stealing. Even our founding fathers argued that the government collected taxes as part of a social contract through voluntary association. This was at a time when secession was possible and individuals could take their property and leave the fragile union. If I declared my property independent today, I would be taken at gun point to prison. Therefore, my taxes are not voluntary, the social contract is void, and taxation is stealing.

Why do you choose to live in a country that steals from its citizens? Why not move somewhere where the government does not tax its citizens (a lawless place, say, Somalia, for example). The reality is your ideas are not practical or you would have a country that doesn't have taxes to where you could move. The most liveable places have taxes ... usually very high income taxes and a great deal of redistribution of wealth.

I'd be happy to give up this monopoly. It would create new, innovative, and cheaper ways to provide medical training. I could skip my $30k classes on feeling my patient's pain.

If you gave up this monopoly, you would be earning about $50 to $100K as a physician. There are plenty of snake-oil salesmen out there who could convince members of the public that they have a cure for cancer (http://www.quackwatch.org/01QuackeryRelatedTopics/cancer.html) and probably drive legitimate physicians largely out of business. Medical education would need to change radically to accommodate the elimination of licensing, and medicine would be like the old days (eons ago) when you could learn medicine "on the job" without even a college education. If every herbalist and accupuncturist who could provide the same medical services as an MD, you can bet wages for physicians will be sub $100K (except for the billionaire snake-oil salesmen, of course).


#2: I have always argued in previous posts (read them if you like), that infectious disease is the ONE exception in which the government should become involved. This is not for the protection of the sick patient but for the protection of innocent civilians. This is like the existance of the military, a protectionist force to prevent aggression (in this case from microbes). This argument doesn't apply to cancer, CHF, diabetes, etc....

So ... stealing (taxing to pay for infectious disease programs, military spending, etc.) would be ok if it was for a good cause? It seems like you're in a difficult spot on this point of the discussion. Trying to justify military spending while eliminating medicare would be a political no-go.
 
I apologize if I misunderstood the intention of your post. I mean no ill will, and we will probably agree to disagree. I'm always willing to engage in a civil discourse that refrains from name calling and accusations without evidence. I think that I just misunderstood what you were trying to say and to whom your accusations were aimed. Feel free to PM me or continue the debate at any time.[/QUOTE]

On the contrary my friend, you bring dignity and intelligence to bear on some serious problems we face as a society and perhaps more keenly as future physicians (although I'm still a pre-med hopeful). I am becoming increasingly interested in economics and entreprenuerial activities and your insights are more than appreciated as I know next to nothing of either. I have shifted from the radical left fringe to a more independent less ideological position as my experience has informed me of some of the things you discuss in your blog and here. To use a quote from Panda Bear's blog..."Starbuck's...the graveyard of [liberal idealism].." has rung true with my own experience.
I am really not interested in debate so much much as knowledge and benefitting from the wisdom born of experience in the lives of others. I am curious about your plans in medicine but I can PM you, perhaps at a later time when medicine becomes a reality for me.

P.S. with regard to the inseparability of Jefferson and American history. I agree. Gore Vidal is one of my favorite authors along these lines.
 
This is just a touch insulting isn't it? If we don't take things from rich people and give them to poor people, the poor will attack everyone. I don't think that being poor equals being violent. This is like arguing that we should kill ourselves prophylactically in order to prevent someone from killing us.

It's hardly insulting to point out a historical fact. The rise of communism/socialism throughout the world was fueled precisely by this phenomenon. Being poor does not equal being violent. But being hungry does. Providing basic needs for those who cannot provide them for themselves is a mechanism of societal protection.

False, concensus and majority doesn't equal moral superiority. We'll conveniently ignore the fact that most national elections are choices between members of two monopoly parties who come from the same "evil" wealth class that you decry. If a majority vote that we should kill someone, should we? If a majority think that we should seize all of your assets and give them to me, should we?

Consensus doesn't equal moral superiority, but consensus does fuel action in a representative democracy. I am highly skeptical of the two party system, but thus far we seem to be functioning fairly well with it, and it certainly preferable to the traditional alternatives of fascism/oligarchy/monarchy.

And for the record, yes, if the majority votes to seize all my assets and give them to you, it will happen. It is, of course, not moral, but in the presence of overriding social benefit, it is at least justifiable. Hence our concept of imminent domain.

Taking money from someone who doesn't want to give it to you is stealing. Even our founding fathers argued that the government collected taxes as part of a social contract through voluntary association. This was at a time when secession was possible and individuals could take their property and leave the fragile union. If I declared my property independent today, I would be taken at gun point to prison. Therefore, my taxes are not voluntary, the social contract is void, and taxation is stealing.

Taxation has a firm basis in both legislation and judicial decisions. You are making the specious arguments of the Tax Protester. This issue has been settled repeatedly. I am suprised that any reasonable person could put any stock in this nonsense. Hopefully you don't practice what you preach, or you won't be in business long.

Except that they all did before Medicare came into existance in the 60s. Healthcare has evolved independently of market forces for the last 40 years, and we can follow the progression of the disaster. I think we should phase out these programs, take away hospital pseudo-monopoly status imposed in jurisdictions and free up healthcare to market forces. Medicare exclusion is feared because that is the coverage that patients have. If it didn't exist, the system would be different.

Despite your obvious education in history, you are conveniently ignoring it. Prior to the 1960s when Medicare came into being, medical practice was relatively low-tech, consisting mainly of a limited pharmacopeia, some surgery, and xrays. The rise of technology has greatly expanded our diagnostic/therapeutic interventions, and also drastically increased our costs. Fifty years ago people could easily pay for the available medical treatments, but in an age of MRI/CT, interventional radiology, plethora of blood tests, etc this is simply no longer feasible. On a cash basis, it would be impossible for anyone but the richest to pay for these things. Hence our implementation of Medicare and rise of health insurance (the health paying for the sick).

"A healthcare system subject to market forces" sounds fantastic, but is simply not feasible due to the costs involved. It is analgous to requiring individuals to pay for their own police/fire/military protection. While you might be comfortable turning down high-tech medical care to those who cannot pay, most of us are not. That is why we will continue to seek ways to provide health issurance to the underinsured.

Also, I am really getting annoyed with your accusation of my hatred for the underclass. I believe that the "underclass" are people that have the same priveleges and responsibilities as the "overclass." I believe that they are equal. You are the one who argues that this is a "class" prone to spontaneous bouts of violence and incapable of self-preservation. That IS insulting.

You make the typical Libertarian argument that 'providing help' = contempt. No one buys it, which is why Libertarians are consistently rejected in the electoral process. In truth, you want to protect your own interests, even if that means children don't get medicine and the injured don't get cared for. The theme of Objectivism/Libertarianism/Natural Selection runs deep throughout all your posts. I am suprised you don't just embrace it, rather than taking accurate descriptions of your tone as an "insult".

I'm sure that what really burns you up about all of this, is that it is the public who voted for these representatives who are instituting health care reform. Clearly America rejects your viewpoint, even if you can find a few self-interested SDN posters who agree with you
 
If you gave up this monopoly, you would be earning about $50 to $100K as a physician.

If that is the true market value for a physician, why should we keep salaries falsely elevated at the expense of our nation's health?

Both my wife and I independently make money in this range (she actually makes more than me), and together we have a pretty comfortable life. I am definitely not looking forward to med school draining my bank account and destroying my current leisure (I start in the fall), but I have a hard time thinking that any one person provides $350K in value to our society regardless of the cost of their education (especially CEOs but that is for another post). The president of the US only makes $400K and he's the president!

I wonder how many would pursue a career in medicine if the financial benefit weren't there. Perhaps I should start a new thread...
 
If that is the true market value for a physician, why should we keep salaries falsely elevated at the expense of our nation's health?

Both my wife and I independently make money in this range (she actually makes more than me), and together we have a pretty comfortable life. I am definitely not looking forward to med school draining my bank account and destroying my current leisure (I start in the fall), but I have a hard time thinking that any one person provides $350K in value to our society regardless of the cost of their education (especially CEOs but that is for another post). The president of the US only makes $400K and he's the president!

I wonder how many would pursue a career in medicine if the financial benefit weren't there. Perhaps I should start a new thread...

Medical licensing and oversight by the Government (which costs money and requires tax dollars) is necessary. Without such oversight and licensing, we would have unqualified people flooding into the medical field (to some extent this is already happening, but not to the extent that it would without the FDA and medical licensing boards). We live in a country where salesmen can sell "special" salt -- plain NaCl really -- for $25 a vial and claim it cures everything from diabetes to pimples ... and people really believe it works.

Having licensed and thoroughly trained physicians (with an imperfect system, I agree) raises the costs of such experts, and such a higher wage is justified because we benefit from competent physicians. One way to reduce the wages might be to let in more foreign-trained medical students into residencies and by increasing the number of residencies. This does raises the issue of quality of physicians.

There are things that we can do to reduce the cost of health care starting with a mandated standardized system for billing and insurance, electronic health records on par with electronic banking records, and better compensation for primary care. Also, we're paying for the uninsured to get health care now (by charging more to those who can pay and with tax funding of hospitals). Let's admit that and then figure out what the best way to raise and spend money on the uninsured. Simply making sure that everyone has health insurance so that they can go to the doctor or get meds when the "problem" is relatively cheap would improve health and reduce costs.

Outside of healthcare, I could see having a special tax on fast food, alcohol, and donor-cycles to help pay for the health problems that such foods, beverages, and activities cause. It would give people the option to buy, consume, and use unhealthy things but also provide the funding to treat them for their errors when the time comes.
 
oncocap and others....

What do you think of the Kaiser model?

I disagree with the common HMO as evil empire scoop. I think for those of us in the camp who see cost control mechanisms and fair distribution of basic healthcare to as many as possible this model has to be taken seriously. A non-profit organization that has cut out the non-medical industry middle men in a closed-loop system with a motivation for keeping people healthy while attracting and retaining its members.

Of course any system can be criticized but I think you'd be hard pressed to produce a parallel example of success. They negotiate pure physician autonomy which has evidence of over prescriptive downsides with spreading the cost equally among its members with the unique motive of general preventative health which is in turn enormously more effective both in health and in business. What do all you smart people think about the Kaiser model.
 
It's hardly insulting to point out a historical fact. The rise of communism/socialism throughout the world was fueled precisely by this phenomenon. Being poor does not equal being violent. But being hungry does. Providing basic needs for those who cannot provide them for themselves is a mechanism of societal protection.



Consensus doesn't equal moral superiority, but consensus does fuel action in a representative democracy. I am highly skeptical of the two party system, but thus far we seem to be functioning fairly well with it, and it certainly preferable to the traditional alternatives of fascism/oligarchy/monarchy.

And for the record, yes, if the majority votes to seize all my assets and give them to you, it will happen. It is, of course, not moral, but in the presence of overriding social benefit, it is at least justifiable. Hence our concept of imminent domain.



Taxation has a firm basis in both legislation and judicial decisions. You are making the specious arguments of the Tax Protester. This issue has been settled repeatedly. I am suprised that any reasonable person could put any stock in this nonsense. Hopefully you don't practice what you preach, or you won't be in business long.



Despite your obvious education in history, you are conveniently ignoring it. Prior to the 1960s when Medicare came into being, medical practice was relatively low-tech, consisting mainly of a limited pharmacopeia, some surgery, and xrays. The rise of technology has greatly expanded our diagnostic/therapeutic interventions, and also drastically increased our costs. Fifty years ago people could easily pay for the available medical treatments, but in an age of MRI/CT, interventional radiology, plethora of blood tests, etc this is simply no longer feasible. On a cash basis, it would be impossible for anyone but the richest to pay for these things. Hence our implementation of Medicare and rise of health insurance (the health paying for the sick).

"A healthcare system subject to market forces" sounds fantastic, but is simply not feasible due to the costs involved. It is analgous to requiring individuals to pay for their own police/fire/military protection. While you might be comfortable turning down high-tech medical care to those who cannot pay, most of us are not. That is why we will continue to seek ways to provide health issurance to the underinsured.



You make the typical Libertarian argument that 'providing help' = contempt. No one buys it, which is why Libertarians are consistently rejected in the electoral process. In truth, you want to protect your own interests, even if that means children don't get medicine and the injured don't get cared for. The theme of Objectivism/Libertarianism/Natural Selection runs deep throughout all your posts. I am suprised you don't just embrace it, rather than taking accurate descriptions of your tone as an "insult".

I'm sure that what really burns you up about all of this, is that it is the public who voted for these representatives who are instituting health care reform. Clearly America rejects your viewpoint, even if you can find a few self-interested SDN posters who agree with you


It's been a long night for me, so I won't respond to all of this. I will respond to a couple of points though. I don't think that proivding help=contempt. I believe that stealing money from someone who earns it legitimately and giving it to someone else for any reason is wrong. I think that providing help is good, when it is VOLUNTARY.

What a free market does is find a way to divide scarce resources in a way that has high efficiency and allows individuals to make decisions about resource allocation for themselves based on the value of the work that they have put into the system. Your high tech medicine argument is flawed, because it assumes that the modern way of providing medical care is the best way. It also divorces medicine from the economy as a whole. Is it worth it to spend 20% of GDP on healthcare? How about 100%? How much should the government seize to give to US? There is SOME number that is correct. The market can determine this. If you care to read my blog, one of the articles deals with the excessive sums spent to keep people alive for a few months. Medicine doesn't HAVE to be as expensive as it is. I am not ignoring history at all. I said that the last 40 years have lead to a disaster, with a little bit of good leading to all sorts of bad.

In truth, you want to protect your own interests, even if that means children don't get medicine and the injured don't get cared for. The theme of Objectivism/Libertarianism/Natural Selection runs deep throughout all your posts. I am suprised you don't just embrace it, rather than taking accurate descriptions of your tone as an "insult".

As I've said, I am a Libertarian. I am not a true objectivist, and as a scientist, I assume that you understand that natural selection is a scientific principle as opposed to a personal ideal. You persistently ignore market scarcity in your arguments. I was also not insulted by you calling me an Ayn Rand wannabe, though the tone was unnecessary. I thought your derision of my vocabulary unnecessary.

Taxation has a firm basis in both legislation and judicial decisions. You are making the specious arguments of the Tax Protester. This issue has been settled repeatedly. I am suprised that any reasonable person could put any stock in this nonsense. Hopefully you don't practice what you preach, or you won't be in business long.

I've always paid my taxes, and I always will. I have no choice. The IRS has a gun pointed at me. I just know enough to see that I am being exploited.

I'll hit the other points some other time.
 
Really, all California would need to do is tax the dickens out of any business that doesn't offer the minimum health insurance to their employees, and every business will be rushing to get private health insurance.

Its people who type things like this that should not be debating economic policy. They tax the dickens out of business the businesses run to the insurance companies, the insurance companies jack thier prices up so its JUST BARELY enough to make it worthwhile to switch to private insurance. HMO CEOs get richer (thats where your 2%/4% doc/hospital tax goes).
 
oncocap and others....

What do you think of the Kaiser model?

I disagree with the common HMO as evil empire scoop. I think for those of us in the camp who see cost control mechanisms and fair distribution of basic healthcare to as many as possible this model has to be taken seriously. A non-profit organization that has cut out the non-medical industry middle men in a closed-loop system with a motivation for keeping people healthy while attracting and retaining its members.

Of course any system can be criticized but I think you'd be hard pressed to produce a parallel example of success. They negotiate pure physician autonomy which has evidence of over prescriptive downsides with spreading the cost equally among its members with the unique motive of general preventative health which is in turn enormously more effective both in health and in business. What do all you smart people think about the Kaiser model.

From what little I know about it, it looks like a great model. Other models could work well also if they were well designed and faced reality, such as the fact that we have a lot of people who are not getting the care that they need and it costs more in the end for everyone.

http://www.berkeley.edu/news/media/releases/2003/03/07_medicare.shtml

http://www.consumerwatchdog.org/nw/?postId=487&pageTitle=OFFICIALS+SAY+KAISER+PHYSICIANS+ACCESSIBLE
 
Medical licensing and oversight by the Government (which costs money and requires tax dollars) is necessary. Without such oversight and licensing, we would have unqualified people flooding into the medical field (to some extent this is already happening, but not to the extent that it would without the FDA and medical licensing boards). We live in a country where salesmen can sell "special" salt -- plain NaCl really -- for $25 a vial and claim it cures everything from diabetes to pimples ... and people really believe it works.

Having licensed and thoroughly trained physicians (with an imperfect system, I agree) raises the costs of such experts, and such a higher wage is justified because we benefit from competent physicians. One way to reduce the wages might be to let in more foreign-trained medical students into residencies and by increasing the number of residencies. This does raises the issue of quality of physicians.

There are things that we can do to reduce the cost of health care starting with a mandated standardized system for billing and insurance, electronic health records on par with electronic banking records, and better compensation for primary care. Also, we're paying for the uninsured to get health care now (by charging more to those who can pay and with tax funding of hospitals). Let's admit that and then figure out what the best way to raise and spend money on the uninsured. Simply making sure that everyone has health insurance so that they can go to the doctor or get meds when the "problem" is relatively cheap would improve health and reduce costs.

Outside of healthcare, I could see having a special tax on fast food, alcohol, and donor-cycles to help pay for the health problems that such foods, beverages, and activities cause. It would give people the option to buy, consume, and use unhealthy things but also provide the funding to treat them for their errors when the time comes.


There are already unqualified people all over the market place. My mom insists on seeing a quack pharmacist that gives her random crap and charges her a fortune. Like most regulation, legitimate providers have to deal with all sorts of crap, while the snake-oil salesman go underground and make a fortune. I just want to be able to compete with these guys AS a legitimate provider. Just go on the internet if you doubt this.

I agree that we treat the uninsured now. It is a complete disaster. EMTALA is destroying emergency medicine. Yet, your solutions are more government market interventions (like mandatory EHR). In a free market, if this is the most efficient solution, the guy who provides it first will outperform his competitors, take market share, and it will become the standard. It can also be tried competitively. Right now, no one can say for sure whether EHR is the answer, because there is no free market in medicine. My problem is not everyone having insurance. My problem is taking money by force to give it to them.

If we don't give healthcare away for free, and people are responsible for their own actions, there is no need for taxes on alcohol or motorcycles. These people will be responsible to pay for their own mistakes.

As a final point, there is NO reason why the current residency system has to be the way that it is. Highly trained professionals in many other fields learn on the job for much higher salaries with more job flexibility. Residency, in its current form, is a relic that has failed to keep up with the times due to its ingraining in legislation. It's not that it can't exist, but mandating that everyone go through it just creates another pseudo-monopoly that this time screws you.
 
Medical licensing and oversight by the Government (which costs money and requires tax dollars) is necessary.

I wasn't suggesting that we get rid of medical licensing, merely that if we as physicians have kept our salaries falsely elevated (for whatever reasons we might give) compared to what the market would normally pay, we should let market forces readjust them for the good of the health of the nation.

I am currently an engineer (from other posts I believe you are too, OncoCap), and we as engineers have professional licensing tests and boards, and yet engineers make in the aforementioned pay range. Why? We don't have a bogus screening process for engineering degrees; we let people self select (and self deselect through failure) throughout the curriculum. (And don't anyone give me any smack about how doctors can kill people if they aren't competent, because engineers can kill them just as easily if they aren't competent either: think big building or bridge falling, cars randomly crashing, etc.) Medicine could do the same by teaching the non-lab basic sciences (or maybe even the labs too) at the much cheaper undergrad level, and those who could hack it make it to the next level with the labs and clinicals. This would at least decrease the cost of medical education and give us one less excuse for falsely elevated salaries, but what do I know, I'm a stupid engineer. ;)
 
I agree that you should be rewarded for your efforts. You can participate in a hopeless effort to abolish taxation if you want. At the same time, I also wish people took more responsibility and that people who repeatedly refuse to take even minimal steps on their health should face some kind of consequence. Even so, I realize the political realities and avoid hopeless causes unless it's a job requirement I can't get out of.

Why do you choose to live in a country that steals from its citizens? Why not move somewhere where the government does not tax its citizens (a lawless place, say, Somalia, for example). The reality is your ideas are not practical or you would have a country that doesn't have taxes to where you could move. The most liveable places have taxes ... usually very high income taxes and a great deal of redistribution of wealth.

I am not an anarchist. I believe in freedom of association. The just role of government is to provide for defense internally and externally. Somalia is often in anarchy, and that is not what I mean at all. I believe that if a government engages in its rightful role, and an individual has the right to take his property and leave both the protection and fees of that government, then taxes are a contract. Your reference to livable places is backwards. Most highly Livable places developed their original wealth under capitalism first, and then imposed high taxes on a still somewhat functioning capitalist system that continues to feed the monster. The taxes are not what makes them livable. Most of Latin America has tax rates higher than the US, and many people in those countries are in less than ideal conditions. I stay in the US, because it still most closely resembles my ideals of any developed country, though many people would like to change that.


If you gave up this monopoly, you would be earning about $50 to $100K as a physician. There are plenty of snake-oil salesmen out there who could convince members of the public that they have a cure for cancer (http://www.quackwatch.org/01QuackeryRelatedTopics/cancer.html) and probably drive legitimate physicians largely out of business. Medical education would need to change radically to accommodate the elimination of licensing, and medicine would be like the old days (eons ago) when you could learn medicine "on the job" without even a college education. If every herbalist and accupuncturist who could provide the same medical services as an MD, you can bet wages for physicians will be sub $100K (except for the billionaire snake-oil salesmen, of course).

OK, then that's what I'll make. I believe that I can do better than that, but atleast all of my earnings will be for what I'm actually worth (This statement may drive some up a wall). I do not want to steal or manipulate the market to my benefit.


So ... stealing (taxing to pay for infectious disease programs, military spending, etc.) would be ok if it was for a good cause? It seems like you're in a difficult spot on this point of the discussion. Trying to justify military spending while eliminating medicare would be a political no-go.

As the saying goes: "what is right is not always popular, and what is popular is not always right." The constitution mentions the common defense, but it makes no mention of universal healthcare. The 10th amendment specifically bars the federal government from doing ANYTHING that it has not been specifically given power to do by the constitution. At the state level, the politics are tricky. Of course, I could always move to New Hampshire. At the Federal Level, the popular argument might go against me, but the actual constitution agrees with me fully.
 
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