Author Topic: What comes after the ACA?  (Read 386922 times)

Jrr85

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Re: What comes after the ACA?
« Reply #2550 on: June 05, 2017, 09:47:30 AM »
-EnjoyIt: I (mostly) follow your numbers but I do not understand your conclusion regarding single-payer. If we are already spending this amount on health-care in the US in all our various forms (e.g. Individual, employer, out-of-pocket, Medicare/caid etc) why would *cost* be the reason single-payer cannot work here?  Are you suggesting that a single-payer system would cause costs to increase further (seems?to be your argument regarding Medicare and its "friction and cost")?

Great question.
1) Medicaid pays less than what it costs to treat the patient. If the reimbursement rates are all Medicaid rates then this is unsustainable. This is the reason why so many providers just don't take on Medicaid patients. Medicare pays better but also very poorly to providers although it does allow for a small profit.

2) Many single payer systems in the world outsource to insurance companies to manage payments. These infact do take a profit. BTW, this practice also occurs in the US as well.

3) CMS, the guys who run Medicare/Medicaid are the ones who have created some of the rediculous regulations that are putting small practices out of business. CMS is also the reason why costs are so high in the hospital settings as well.

4) I can promise you that if tomorrow my pay got cut to just Medicaid reimbursement, I would probably just quit. Just not worth going into work. The reason why physicians take Medicare/Medicaid patients is that they hope it will also bring insured patients as well. Without the insured there just isn't a point to keeping the doors open.

5) Think about it from the physician standpoint. They graduate at about 30 years old with about $350K in debt. Very very few docs are mustachiane and buy their first home right out of residency at 3x income.  Now all of a sudden their pay is cut by 25%. For many that equals bankruptcy. Sad but true.

6) Why have insurance private or public of any kind interfere with low cost health expenditures. It is an added step, and a waste of time and money.
This is a long list of problems with our medical system, but none of it really addressed the question about why a single-payer system would not work.  The closest it comes is talking about how medicaid pays less for treatment than what doctors bill.

It's not that single payer won't work, it's that single payer may be politically impossible without addressing the cost side first.  The costs for single-payer at the prices the U.S. currently pays would be an immediate deal killer politically.  Even if you ignored the politics of getting it passed, there are a lot of fixed costs in the system (both for buildings and other capital goods and for things like student debt), that just enacting single payer and trying to use monopsony power to bring costs down to something politically acceptable would cause the healthcare industry to look like the housing industry in 2008.  It's just a big complex system and people are loss averse, so it's going to be difficult to make meaningful change. 

NESailor

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Re: What comes after the ACA?
« Reply #2551 on: June 05, 2017, 10:12:27 AM »


It's not that single payer won't work, it's that single payer may be politically impossible without addressing the cost side first.  The costs for single-payer at the prices the U.S. currently pays would be an immediate deal killer politically.  Even if you ignored the politics of getting it passed, there are a lot of fixed costs in the system (both for buildings and other capital goods and for things like student debt), that just enacting single payer and trying to use monopsony power to bring costs down to something politically acceptable would cause the healthcare industry to look like the housing industry in 2008.  It's just a big complex system and people are loss averse, so it's going to be difficult to make meaningful change.

#truth.  That's what I was saying.  Changing how we pay for healthcare still doesn't really address how much.  We first have to admit that we have a problem - that's a political non-starter.  The clowns who run the show can't be honest and expect to get elected.  Mainly because we run around pretending that somehow we can solve all the issues without any pain.  Lowering costs is abstract and sounds great.  Cutting salaries by XYZ% for everyone from the groundskeeper at a med school to a brain surgeon is a different story. 

EnjoyIt

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Re: What comes after the ACA?
« Reply #2552 on: June 05, 2017, 12:31:40 PM »
NeSailor,
You are spot on for many of the items you described in your last two posts. Just a few items that CMS (Medicare/Medicaid) have control over.  The documentary and regulatory burdens hospitals, doctors, and offices have to deal with to just even be allowed to bill CMS for the services provided is very time consuming and very expensive. The amount of people that are hired to keep up with all this costs a significant amount.  That doesn't even include the equipment and technology required to keep up with these ever changing regulations.  For example CMS has pulled out a new payment scheme called MACRA. Providers who do not comply 100% with MACRA will have a 9% cut in reimbursement by 2020 while those who do will get a 9% increase.  Despite the 9% on each side of the equation the total will be a cut in reimbursement across the board (A method to control cost.)  The people who will be hit the hardest are the small practices 1-9 providers who will be unable to easily fund the technology needed to meet MACRA's demands. This 9% cut could be the difference between staying in business or being forced to close the doors. Also, our government has had plenty of opportunity to prove that it can do a good job on paying for healthcare.  The VA is 1 example of the government doing a half ass job. Although the VA is able to control cost the care is extremely delayed, and most VA patients I work with prefer to never have to go back to the VA hospital.  The other example is CMS which has done a piss poor job of controlling costs. Because of this I am just skeptical that our government, is physically able to do a good job with the 1 payer model. I would be thrilled to be proven wrong if California could pull it off, but again I'm very skeptical and glad I do not live in California.

Just wanted to point out.  Medicare pays hospitals decently.  Not great, but definitely enough to make some profit on the transaction.  That is not the case for physicians.  For example Medicare will pay a surgeon $667 to remove an appendix.  Although this may seam like a terrific deal, let me elaborate.  The $667 covers the pre-op, surgery, as well as post op in the hospital followed by an office visit.  About 2% of appendix surgeries can have complications but that $667 is included. Also the surgeon has overhead.  They must pay the coder, the biller, the IT guy, the nurse and secretary in his/her office, also keep the lights on and the rent the surgeon must pay.  For a cumulative of about 4 hours of work the surgeon might get to keep $200-$250 pre-tax. I'm sorry but all that education including 5 years of residency plus accrued debt should pay a little more that $50-$65/hr.  Also, the average salary for physicians is about $250k/yr not $500k as you specified.

Jrr85,
I think you are 100% correct.  As long as the US population continues to expect everything regardless of cost or necessity while the actual cost is hidden through the veil of insurance, there is no hope in controlling how much we spend on healthcare.  It can only go up just like higher education.

Nereo,
You are correct I pointed out how medicaid pays very little.  You must understand that if a physician or hospital does not make even some profit they might as well close the shop and find something else to do.  Currently Medicaid pays about 80% of the cost of providing the care which means everyone involved loses money on the transaction.  For everyone to have Medicaid either the cost pf providing care must go down by 25-30% or reimbursement must go up by 30%-35% or some combination of both. You can't expect people to work for free can you?  Another interesting fact for you.  Since ACA has come out, more people have health insurance, but more people with insurance don't bother to pay their deductibles and therefor hospitals are either much less profitable or even loosing money.  Around the country hospitals are cutting costs and laying off people. Again, you can't expect a hospital to keep its doors open and loose money every year.

protostache

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Re: What comes after the ACA?
« Reply #2553 on: June 05, 2017, 01:40:49 PM »
What if we, as a society, decide to pay off all of your medical debt? I realize that this is a pie in the sky scenario, but stick with me here.

The mean medical school debt for a fresh graduate in 2014 was $180,000 (pdf). In 2015 there were 18,705 medical school gradates in the entire country. That comes to about $3.3 billion per year which would fundamentally change the calculus of how much doctors need to charge to sustain a living. I know that doesn't fundamentally change your cost structure, EnjoyIt, but it would definitely make that $65/hr more attractive, and $3.3 billion per year is a rounding error in the Federal budget.

Of course with this loan forgiveness plan or straight tuition subsidy there would have to be cost controls in place so colleges don't start inflating prices more than they already are, and you'd probably have to agree to work in the US for a certain number of years, but it seems like a fair trade: society pays for you to become a doctor because that means society can pay less for appendectomies.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2554 on: June 05, 2017, 04:52:04 PM »
What if we, as a society, decide to pay off all of your medical debt? I realize that this is a pie in the sky scenario, but stick with me here.

The mean medical school debt for a fresh graduate in 2014 was $180,000 (pdf). In 2015 there were 18,705 medical school gradates in the entire country. That comes to about $3.3 billion per year which would fundamentally change the calculus of how much doctors need to charge to sustain a living. I know that doesn't fundamentally change your cost structure, EnjoyIt, but it would definitely make that $65/hr more attractive, and $3.3 billion per year is a rounding error in the Federal budget.

Of course with this loan forgiveness plan or straight tuition subsidy there would have to be cost controls in place so colleges don't start inflating prices more than they already are, and you'd probably have to agree to work in the US for a certain number of years, but it seems like a fair trade: society pays for you to become a doctor because that means society can pay less for appendectomies.

That is a great question but I do not think it is reasonable because:
1) I still don't think $65/hr is worth 4 years of college, 4 years of medical school and 5 years of residency for a surgeon or really anyone else who is responsible for the life of another human being.  Especially if they take on the liability of those decisions as well.  Sorry Protostache, but for $65/hr I think I would have stuck with my other degree in college and been a programmer at 22 instead of a practicing physician at 30.
2) What about all those people that have created their lifestyles on $250k/yr are you just going to say, sorry docs sell your houses and pull your kids out of school.  Starting next year your being downgraded.
3) How about the people who are already out and paid down their debt. Do you tell them, "sucks to be you."

One of the issues plaguing physicians today is this trend in decreasing reimbursement and increasing regulations (at least that is what they/we will tell you.)  Keep in mind most physicians are horrible with money.  Because of their awesome income and job security in conjunction with banks throwing money at them, they end up creating a life for themselves that is close to paycheck to paycheck.  Eventually decreasing reimbursement hits them and their only way to respond is to just work more (remember horrible with money and not mustachian.) Then some added bureaucracy makes them work harder to accomplish the same task. This puts an incredible stress on the physician and his/her family which often leads to divorce and sometimes suicide. That is with small cuts and regulations every few years.  Can you imagine what a 50% cut would do as you propose? On top of this burned out doctors become very bad at their jobs putting lives at risk.  I have seen this scenario played out so many times over the years.

tct

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Re: What comes after the ACA?
« Reply #2555 on: June 05, 2017, 05:06:26 PM »


I'm not fully for or against a single payer system but it should only cover catastrophic health care. There is absolutely no need for even a single payer middle man for simple healthcare related transactions.  You should not have to pay $400 for a month's insurance premiums and then a $30 copay to see your GP. It should cost a flat fee with no one else involved. Same for simple imaging or lab tests.  On the other hand if someone ends up with cancer or some other expensive medical condition insurance should be able to step in and take over. Just making that change would cut the friction on much of our healthcare expenditure, and buy having transparency in prices, costs will go down for all simple outpatient care.  Emergencies are a whole other story where catastrophic insurance can come in.  I would also go so far as to say there is no need to have a prescription from your doctor for refills on your medications. Very expensive chronic conditions should also be covered by some form of insurance.  Those who can not afford it based on income or disability should get subsidies or vouchers to help pay for their care.  Subsidies/vouchers are given out on a sliding scale based on income as opposed to an all or nothing distribution ideally incentivizing employment.


EnjoyIt, i agree.. Insurance should be for catastrophic care only, not routine care.

Nightwatchman9270

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Re: What comes after the ACA?
« Reply #2556 on: June 06, 2017, 06:18:32 AM »
As another physician-member I have to agree with most of what EnjoyIt said.  At 47, I have decided to partially retire.  The profession sucks the life out of you and is bad for relationships/family as well as my own physical and mental health.  I have partners who, inexplicably are living paycheck-to-paycheck.  Unbelievable.  Fortunately for me, that has enabled me to sell off my weekend calls (at a pretty hefty premium but oh well).  If I lived the way some of my partners do, I wouldn't be able to do that.  It really has helped trmendously.

Most doctors I know have done all kinds of financial bone-head moves.  Bad investments,  multiple homes, multiple wives.  Flipping cars every other year.  Solar panels (Yes! I said it!  for 90% of folks solar panels are a stupid financial investment).

And $65/hour?  Really?  For that level of risk and responsibility and education?  If that's what it paid I would do something else.  As it is I don't really bring home much more than that when you consider I'm at the hospital 60-80 hours a week now.

My auto shop charges $75/hr for labor.  If you think your car is worth more than your life so be it, but I wouldn't want to live in a country where I had a $65/hr doctor operating on me!

NESailor

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Re: What comes after the ACA?
« Reply #2557 on: June 06, 2017, 07:50:14 AM »
Currently Medicaid pays about 80% of the cost of providing the care which means everyone involved loses money on the transaction.  For everyone to have Medicaid either the cost pf providing care must go down by 25-30% or reimbursement must go up by 30%-35% or some combination of both. You can't expect people to work for free can you?  Another interesting fact for you.  Since ACA has come out, more people have health insurance, but more people with insurance don't bother to pay their deductibles and therefor hospitals are either much less profitable or even loosing money. Around the country hospitals are cutting costs and laying off people. Again, you can't expect a hospital to keep its doors open and loose money every year.

I'm glad we agree.  I didn't repost all of it but both you and the other Doc point to a structural issue that's not really the consumer's fault.  Doctors too, have what appear to be unreasonable expectations.  I certainly value my life more than my car - but the fact that some doctor bought 3 homes and 4 cars and has 3 ex-wives is not good enough of a reason for me not to push for lower costs - that includes your salary.

You've earned it, no doubt.  Imagine that the no med school debt proposal somehow happened.  Perhaps 65/hr is not enough.  How about a 100?  And better regulations as to working hours so you DON'T have to work 60-80/week.  Maybe 40 would do.  Better work-life balance would probably see you with a higher perceived quality of life.  At a lower salary and lower total cost to the system.

Regarding the bits I quoted.  They're not general truths.  Everyone does not lose money.  As long as the provider and facility (hospital) pay 100% of their costs - all the subs make money.  It's only those who get reimbursed by Medicaid that lose money.  Not good - but not everyone loses.

The bit about ACA is not quite universal either.  My local providers estimate that the current repeal effort will hurt the bottom line by a pretty significant margin.  I'm not making these things up.  Full disclosure - I'm a CPA who sits on the board of a small mental health provider group and work in a financial management capacity at a 400 mUSD hospital network. 

Oh...and I'm aware the average physican does not make 500K.  I said they hope to make that ;)  If my physician friends took my financial advice they could all take a 20% pay cut and still be millionaires by 40.  C'est la vie.

nereo

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Re: What comes after the ACA?
« Reply #2558 on: June 06, 2017, 08:39:02 AM »
As another physician-member I have to agree with most of what EnjoyIt said.  At 47, I have decided to partially retire.  The profession sucks the life out of you and is bad for relationships/family as well as my own physical and mental health.  I have partners who, inexplicably are living paycheck-to-paycheck.  Unbelievable.  Fortunately for me, that has enabled me to sell off my weekend calls (at a pretty hefty premium but oh well).  If I lived the way some of my partners do, I wouldn't be able to do that.  It really has helped trmendously.

Most doctors I know have done all kinds of financial bone-head moves.  Bad investments,  multiple homes, multiple wives.  Flipping cars every other year.  Solar panels (Yes! I said it!  for 90% of folks solar panels are a stupid financial investment).

And $65/hour?  Really?  For that level of risk and responsibility and education?  If that's what it paid I would do something else.  As it is I don't really bring home much more than that when you consider I'm at the hospital 60-80 hours a week now.

My auto shop charges $75/hr for labor.  If you think your car is worth more than your life so be it, but I wouldn't want to live in a country where I had a $65/hr doctor operating on me!

I come from a medial family (dad, mom, sister, grandfather are all medical professionals), and I've experienced a lot of the same regarding physicians who are barely living within their means.  When I was in HS my dad had to restructure his practice, and every doctor in the practice had to take a 8% salary reduction for 2 years.  Several of the doctors (none of whom were "new" doctors) went through bankruptcy.  His partner had been living paycheck-to-paycheck (with a salary >>$100k) for 20+ years. They were doing what you said - huge houses, 7-series BMWs (leased), tropical vacations. Growing up I kinda assumed that my dad must make much less than them since we lived in a modest house and drove to the beach for our vacation.
I think that was my first real awakening that regardless of your salary one can always get into serious financial distress in the US.

I inherently disagree about not wanting someone earning $65/hr operating on me - the amount someone is paid doesn't correlate very well with the job they do (and I think it's a huge mistake to assume more pay = better outcome).  To extend the analogy on cars, dealerships are often the most expensive but that doesn't mean they do the best job.  For physicians, I wouldn't reject a surgeon from the UK or Canada or any other developed nation, even though they earn 1/2 to 2/3 of what their US counterparts do.
"Do not confuse complexity with superiority"

Roland of Gilead

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Re: What comes after the ACA?
« Reply #2559 on: June 06, 2017, 08:44:27 AM »
Just like other professions, not all physicians are the same.

Do you know what they call you when you finish residency at backwoods medical center after graduating with a C average from po dunk U?

Doctor.

nereo

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Re: What comes after the ACA?
« Reply #2560 on: June 06, 2017, 08:57:56 AM »
Just like other professions, not all physicians are the same.

Do you know what they call you when you finish residency at backwoods medical center after graduating with a C average from po dunk U?

Doctor.
ha!
Reminds me of something a building inspector told me once:
do you know what they call buildings that are one point above "condemned"?
Up to code.
"Do not confuse complexity with superiority"

PathtoFIRE

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Re: What comes after the ACA?
« Reply #2561 on: June 06, 2017, 09:23:32 AM »
For reference, I am a physician, but admit I can't speak with any special authority on the recent issues on this thread. I'm a pathologist, and while we have seen a steady cut in reimbursement over the last 6 years that I've been practicing, our paperwork load is very minimal. And the laboratory has been a high regulatory environment since the 1980s scandals, and I don't hear any drumbeat to roll back much of that stuff on the lab/pathology side, but I can't speak for what my clinical colleagues have experienced.

Re: $65/hr physicians
This seems like something that could be easily researched. What do physicians in other developed countries make per hour. Is it similar, less, more than in the USA? I suspect it's similar to less but don't actually know. Does that affect quality in any measurable way? Do they have trouble filling medical school classes and residency spots?

Re: years and years of training
This isn't black or white. It is a special privilege to be a medical student and resident, let's not get overly dramatic and suggest that it was a tortuous living hell most of us slogged through to get out into practice, and residents/fellows do get paid. 4 years of undergrad and 4 years of medical school are unnecessary to train doctors, premed requirements encompass about 2 years, so for those who know from the start of college that they want to go into medicine, I say let them start medical school without a BS/BA. Many schools are doing in 18 months what most of use learn in the first two years of med school, and the fourth year of medical school is mostly a place filler to allow time for residency interviews, etc., so restructure that whole transition and save a year or more of time

radram

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Re: What comes after the ACA?
« Reply #2562 on: June 06, 2017, 10:08:34 AM »
I inherently disagree about not wanting someone earning $65/hr operating on me - the amount someone is paid doesn't correlate very well with the job they do (and I think it's a huge mistake to assume more pay = better outcome).  To extend the analogy on cars, dealerships are often the most expensive but that doesn't mean they do the best job.  For physicians, I wouldn't reject a surgeon from the UK or Canada or any other developed nation, even though they earn 1/2 to 2/3 of what their US counterparts do.

Completely agree. The only way I see this ending are lower salaries all around. It has already happened in so many other fields I see no reason why it will not happen in the medical field. When it is discussed that a Dr. is responsible for a human life, so is a day care provider. Look at what they are paid and how little training is required. My point here is simply that we as a society seem perfectly willing to require less qualifications if it benefits us (or even if we only THINK it benefits us).

Anytime a group has an advantage, there will be others that will work to cut them down. It is so much easier than building yourself up. Look at how union labor was attacked when they made a wage above the norm. I would contend that the main reason to attack their salaries was jealousy and nothing more. If I can't have it, you shouldn't either. They were very successful in destroying those wages.


Full disclosure. I am a FIRE former teacher, who worked through the Wisconsin cuts known as Act 10 that, in my opinion, turned the career of teaching into nothing more than a job with little room for salary growth potential. While it was very difficult to go through, it has really opened my eyes as to how people think. The state saves a TON of money, and some that might have gone into teaching might select another profession. There will never be a teacher shortage, because they will simply change the qualifications to fill the spots as needed. Before I left, there was a proposal in Wisconsin that would have allowed one of my students to take my class 1st hour, and then TEACH the class 2nd hour. It did not pass, but it is clear changes will be made to lower the requirements. Will this system be better? You need about 15 years to know for sure, but you can find tons of data to prove the point that schools are better since the changes in WI. The fact that moral when I left was in the crapper makes little difference.

I see health care moving in this direction. As long as it costs less, it is a success. For the record, I think it sucks to tear others down. But it IS very successful. I believe the health care industry is next in line for this tactic.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2563 on: June 06, 2017, 10:15:53 AM »
NEsailor,
My comments were not universal.  of coarse there are some businesses that are able to do reasonably well.  I know in my area there are several hospital systems all of which have cuts 100s of jobs and they attribute it to the very poor payer mix the ACA created.  The system I work for has dropped their margins to slightly above positive. At these margins, it is more profitable to just sell off everything and invest it in treasury bonds. 

Nereo,
I'm not condoning the physician who is a financial moron, just as I don't condone the $35k/yr secretary who has a new cell phone every year leasing the latest 3 series.  As for the $65/hr.  I am not the best doctor in the world, but I am damn good (based on the responses from my colleagues.) If I knew going into med school I would only make $65/hr, I would never have gone that route.  Just not worth it and the US would be out, me.  I'm sure other very bright people would choose other pathways as well.  The best way to attract the brightest people is to pay them a reasonable wage for the work provided. And yes, reasonable is a loose term.  Look at Apple and Google paying top dollar to get the best and brightest.  The same is in regards to medicine.  And although other countries may pay their physicians less, it definitely is more than $65/hr and also requires less time and no debt to get there.  BTW, some of the brightest docs in the world come to the US to practice. The not so bright ones are not accepted and stay in their lower wage jobs.  Yes, there are always exceptions and nothing is absolute.

PathtoFIRE, may have a decent solution by cutting the required time for education by a few years. It would be nice to be out practicing by the time you are 25 instead of 30.  It would also be nice to have some restrictions on hours and to get rid of the regulations that decrease efficiency allowing us to be more productive with our limited time.  BTW, residency is not hell, but working 60-80 hours a week for 3-6 years straight is very difficult, even if you get paid for it.  And BTW, I'm not sure when you went through residency, but there were plenty of weeks I worked closer to 100hrs despite the 80 hour rule.   Either way, by allowing us to start earlier with lower debt and allow us to be more productive per per patient delivered can therefor allow for cuts in reimbursement without affecting pay since more patients are treated in the same span of time.

Radram,
Reimbursement rates have been decreasing for years.  The cuts are here and still more on its way.  I would suspect by 2030 the average income of physicians will be down by 10-20%.  its why I make hay now while the sun is still shining and why I am content with a few more years syndrome just to be sure.  Every few years CMS makes cuts into a specialty.  I'm sure my specialty will get its cuts soon enough.

brooklynguy

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Re: What comes after the ACA?
« Reply #2564 on: June 06, 2017, 10:53:04 AM »
Seems like the gravity of just how far Washington is from an actual law on the AHCA is finally sinking in. I will not be surprised at all if they inevitably end up having to abandon the AHCA and work to improve the existing framework of the ACA.

That would almost be funny, given that, in the meantime, they're doing such an excellent job of sabotaging the existing framework.

I just have a feeling that this is where we're going to end up, which wouldn't necessarily be a bad thing if there wasn't all the sabotage in the middle. I would love to see how they'll explain that away without losing votes.

The likelihood of this outcome (total abandonment of the GOP's repeal/repeal and replace campaign) appears to be steadily increasing.  There have been various reports that, if it comes to it, Senate GOP leaders may even intentionally force a vote they know will fail just to provide closure and move on to other issues on the agenda.  I like the colorful imagery conjured up by the lobbyist source behind this Vox article, which describes the rationale behind that potential approach as the need to "show the electorate a body" before abandoning the repeal efforts.  Of course, the House already produced a body once in their first go-round earlier this year (at which time Paul Ryan had declared, with premature conclusiveness, that the ACA will remain "the law of the land for the foreseeable future") only to then reanimate the corpse upon subsequent pressure from Trump, but a legislative death in the Senate would, I expect, have more finality.

Lagom

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Re: What comes after the ACA?
« Reply #2565 on: June 06, 2017, 11:08:14 AM »
NEsailor,
My comments were not universal.  of coarse there are some businesses that are able to do reasonably well.  I know in my area there are several hospital systems all of which have cuts 100s of jobs and they attribute it to the very poor payer mix the ACA created.  The system I work for has dropped their margins to slightly above positive. At these margins, it is more profitable to just sell off everything and invest it in treasury bonds. 

Nereo,
I'm not condoning the physician who is a financial moron, just as I don't condone the $35k/yr secretary who has a new cell phone every year leasing the latest 3 series.  As for the $65/hr.  I am not the best doctor in the world, but I am damn good (based on the responses from my colleagues.) If I knew going into med school I would only make $65/hr, I would never have gone that route.  Just not worth it and the US would be out, me.  I'm sure other very bright people would choose other pathways as well.  The best way to attract the brightest people is to pay them a reasonable wage for the work provided. And yes, reasonable is a loose term.  Look at Apple and Google paying top dollar to get the best and brightest.  The same is in regards to medicine.  And although other countries may pay their physicians less, it definitely is more than $65/hr and also requires less time and no debt to get there.  BTW, some of the brightest docs in the world come to the US to practice. The not so bright ones are not accepted and stay in their lower wage jobs.  Yes, there are always exceptions and nothing is absolute.

I mean, I'm sure this is true, but I would wager many of the subpar doctors also chose the profession because it's high paying, if you see what I mean. While I think doctors should definitely be paid a good wage (say top 5-10%?), I don't think (in theory) that moving the $300-400k doctors to ~$200k or whatever would necessarily result in a bunch of shitty doctors. Lots of brilliant people who went through similar amounts of schooling work for waaaaay less (e.g. research scientists in many disciplines). I do think we can't just cut doctor wages and still demand 60-80 hour weeks. It sounds like the educational requirements have some fat that could be trimmed too. But there does appear to be a path that would still leave medicine as a highly desirable and lucrative career path, even if the pure $$$ chasers no longer care to pursue it. I bet lots of people think $150-200k/year (+/- depending on COL) with reasonable hours and highly impactful work outcomes would sound pretty sweet.

sol

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Re: What comes after the ACA?
« Reply #2566 on: June 06, 2017, 11:12:02 AM »
The likelihood of this outcome (total abandonment of the GOP's repeal/repeal and replace campaign) appears to be steadily increasing.  There have been various reports that, if it comes to it, Senate GOP leaders may even intentionally force a vote they know will fail just to provide closure and move on to other issues on the agenda.  I like the colorful imagery conjured up by the lobbyist source behind this Vox article, which describes the rationale behind that potential approach as the need to "show the electorate a body" before abandoning the repeal efforts.  Of course, the House already produced a body once in their first go-round earlier this year (at which time Paul Ryan had declared, with premature conclusiveness, that the ACA will remain "the law of the land for the foreseeable future") only to then reanimate the corpse upon subsequent pressure from Trump, but a legislative death in the Senate would, I expect, have more finality.

You don't post often enough, BG, but when you do you always bring me such happy news.

I agree that it looks like the Senate is preparing to abandon the GOP push to ruin the American healthcare system by repealing the ACA, but I'm not seeing any evidence of their intention to abandon the effort to ruin the American healthcare system by undermining and sabotaging the ACA.

So they still want to fuck over the country's poor and elderly population, but they want to do so quietly and without any publicity instead of dramatically with blaring headlines and trumpets.  I mean, I'm thrilled the immediate shittiness appears to be passing, but I'm not really optimistic about the nation's future if the new republican plan is to dismantle the republic discretely from the inside.  Attempted coups generate useful opposition (e.g. Trump) when done in public, but they are harder to oppose when executed quietly behind closed doors of power.

Can we please just all go back to political gridlock while the president's Twitter feed paralyzes the nation into maintaining the status quo?  I'll consider it a victory if Trump can continue to be enough of chaos agent to prevent any significant legislative accomplishments that further undermine the American social contract.

Midwest

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Re: What comes after the ACA?
« Reply #2567 on: June 06, 2017, 11:25:10 AM »
NEsailor,
My comments were not universal.  of coarse there are some businesses that are able to do reasonably well.  I know in my area there are several hospital systems all of which have cuts 100s of jobs and they attribute it to the very poor payer mix the ACA created.  The system I work for has dropped their margins to slightly above positive. At these margins, it is more profitable to just sell off everything and invest it in treasury bonds.

You mention your hospital system has cut it's margins.  I have been of the opinion it's the hospital systems that are one of the problems.  We have 2 local hospital systems that have huge capital expenditures (despite a stable population) and administrators making much more than providers.  Do you see similar trends?

The insane bills I have received for medical care have always been from the hospitals.



I'm not condoning the physician who is a financial moron, just as I don't condone the $35k/yr secretary who has a new cell phone every year leasing the latest 3 series.  As for the $65/hr.  I am not the best doctor in the world, but I am damn good (based on the responses from my colleagues.)

I don't know why anyone in their right mind would become a doctor in the US for that kind of money.  There are simply too many other opportunities for smart people to make more money than that.

Jrr85

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Re: What comes after the ACA?
« Reply #2568 on: June 06, 2017, 12:07:54 PM »

Anytime a group has an advantage, there will be others that will work to cut them down. It is so much easier than building yourself up. Look at how union labor was attacked when they made a wage above the norm. I would contend that the main reason to attack their salaries was jealousy and nothing more. If I can't have it, you shouldn't either. They were very successful in destroying those wages.

That's a little rich.  You think the people having to pay for the higher wages/benefits don't support the unions because of jealousy?  I don't think the vast majority of buyers even know if the products/services they buy are produced/provided by union workers are not.  They just go with the best perceived value.

And of course for public employee unions, the benefits to union members are completely disconnected from the value they provide, and are just determined by who can produce voter turnout.   

 

Roland of Gilead

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Re: What comes after the ACA?
« Reply #2569 on: June 06, 2017, 02:48:39 PM »
I don't know why anyone in their right mind would become a doctor in the US for that kind of money.  There are simply too many other opportunities for smart people to make more money than that.

It can't only be about the money otherwise everyone would go into software engineering.  Four years of school then get a job for $80k working your way up to about $250k after 15 years or so.  When my wife left the industry she was doing a bit better than even that.

geekette

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Re: What comes after the ACA?
« Reply #2570 on: June 06, 2017, 04:19:50 PM »
NEsailor,
My comments were not universal.  of coarse there are some businesses that are able to do reasonably well.  I know in my area there are several hospital systems all of which have cuts 100s of jobs and they attribute it to the very poor payer mix the ACA created.  The system I work for has dropped their margins to slightly above positive. At these margins, it is more profitable to just sell off everything and invest it in treasury bonds.

You mention your hospital system has cut it's margins.  I have been of the opinion it's the hospital systems that are one of the problems.  We have 2 local hospital systems that have huge capital expenditures (despite a stable population) and administrators making much more than providers.  Do you see similar trends?

The insane bills I have received for medical care have always been from the hospitals.


Per the NY Times, administrators are making more than physicians.

Quote
The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctorsí salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

nereo

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Re: What comes after the ACA?
« Reply #2571 on: June 06, 2017, 04:43:27 PM »
Nereo,
I'm not condoning the physician who is a financial moron, just as I don't condone the $35k/yr secretary who has a new cell phone every year leasing the latest 3 series.  As for the $65/hr.  I am not the best doctor in the world, but I am damn good (based on the responses from my colleagues.) If I knew going into med school I would only make $65/hr, I would never have gone that route.  Just not worth it and the US would be out, me.  I'm sure other very bright people would choose other pathways as well.  The best way to attract the brightest people is to pay them a reasonable wage for the work provided. And yes, reasonable is a loose term.  Look at Apple and Google paying top dollar to get the best and brightest.  The same is in regards to medicine.  And although other countries may pay their physicians less, it definitely is more than $65/hr and also requires less time and no debt to get there.  BTW, some of the brightest docs in the world come to the US to practice. The not so bright ones are not accepted and stay in their lower wage jobs.  Yes, there are always exceptions and nothing is absolute.

Would you feel the same way if you could have graduated from medical school with no more than, say, $50k in student loan debt?
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Luck12

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Re: What comes after the ACA?
« Reply #2572 on: June 06, 2017, 04:51:55 PM »
Medicaid for all in Nevada:

Still needs to be signed by their Republican governor and don't know what kind of deductibles, co-pays, etc there would be. 

http://nymag.com/daily/intelligencer/2017/06/nevada-is-considering-a-revolutionary-health-care-experiment.html

Midwest

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Re: What comes after the ACA?
« Reply #2573 on: June 06, 2017, 06:19:25 PM »
I don't know why anyone in their right mind would become a doctor in the US for that kind of money.  There are simply too many other opportunities for smart people to make more money than that.

It can't only be about the money otherwise everyone would go into software engineering.  Four years of school then get a job for $80k working your way up to about $250k after 15 years or so.  When my wife left the industry she was doing a bit better than even that.

I don't think most docs are only in it for the money, but given the responsibilities $65 an hour wouldn't be worth it to many docs. 

Focusing on doc comp is misguided in my opinion.  I would start with hospitals, regulations and insurance.

sol

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Re: What comes after the ACA?
« Reply #2574 on: June 06, 2017, 07:02:48 PM »
The likelihood of this outcome (total abandonment of the GOP's repeal/repeal and replace campaign) appears to be steadily increasing.  There have been various reports that, if it comes to it, Senate GOP leaders may even intentionally force a vote they know will fail just to provide closure and move on to other issues on the agenda.

Today's news suggests they've revised their pessimistic outlook since yesterday, and expect to offer a republican ACA replacement plan to the CBO by this Friday June 9th.  Details are publicly sparse, but it sounds like a slightly watered down version of the ACA instead of anything like the House's monstrosity of a bill.

http://www.politico.com/story/2017/06/06/senate-republicans-obamacare-repeal-timing-239186
« Last Edit: June 06, 2017, 07:06:05 PM by sol »

jim555

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Re: What comes after the ACA?
« Reply #2575 on: June 06, 2017, 07:03:42 PM »
Medicaid for all in Nevada:

Still needs to be signed by their Republican governor and don't know what kind of deductibles, co-pays, etc there would be. 

http://nymag.com/daily/intelligencer/2017/06/nevada-is-considering-a-revolutionary-health-care-experiment.html
They would allow a Medicaid buy-in at cost.

NESailor

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Re: What comes after the ACA?
« Reply #2576 on: June 07, 2017, 07:01:32 AM »


Per the NY Times, administrators are making more than physicians.

Quote
The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctorsí salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.

Not quite.  Of course the CEO is going to make a lot of money.  But that's one person overseeingeasily several thousand employees and tens or hundreds of millions in revenue/expenses.  1 CEO can oversee an operation of several hundred MD's on the admin side.  Sure, that 1 gal may make more than the average MD but that's not a blanket "administrators make more money than doctors".  At our place, there are exactly 4 administrators who make more money than the average doc...and all of them sit in the C-suite and work their butts off and are no less brilliant than the average doc.  In fact, one of them IS a doc turned administrator (Chief Medical Officer).  There are still docs who make more than these guys - just not the overall average which includes new hires straight out of residency and people doing all sorts of part time schedules etc.

brooklynguy

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Re: What comes after the ACA?
« Reply #2577 on: June 07, 2017, 07:31:46 AM »
Details are publicly sparse, but it sounds like a slightly watered down version of the ACA instead of anything like the House's monstrosity of a bill.

I don't know, I'm now starting to get the impression it might look more like the House's monstrosity with a fresh coat of lipstick.  Republican moderates are starting to signal that they'll settle for the gutting of Medicaid as long as it's implemented at a slower pace.  What else would it take to thread the needle across all GOP factions?  Water down the states' opt-out rights, beef up the subsidies and call it a day?  Guess we'll find out soon. 

talltexan

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Re: What comes after the ACA?
« Reply #2578 on: June 07, 2017, 07:54:16 AM »
even if the Senate passes something substantially different from the House Bill, the negotiations to unite the two bills could pull it back toward the House version. They have to placate the Freedom Caucus enough to pass *something*.

stoaX

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Re: What comes after the ACA?
« Reply #2579 on: June 07, 2017, 10:20:55 AM »
even if the Senate passes something substantially different from the House Bill, the negotiations to unite the two bills could pull it back toward the House version. They have to placate the Freedom Caucus enough to pass *something*.

and then HHS needs to re-do their regulations, lawsuits will occur and the court decisions will influence how this all goes.  It could be a while before we have stability in this marketplace and know how it effects early retirement. 

tyort1

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Re: What comes after the ACA?
« Reply #2580 on: June 07, 2017, 10:27:36 AM »
This crap makes me glad I'm about 13 years from retirement.
Frugalite in training.

jim555

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Re: What comes after the ACA?
« Reply #2581 on: June 08, 2017, 07:03:39 AM »
"Anthem, one of the country's big five public health insurers, announced that it is pulling out of Ohio's Affordable Care Act individual insurance marketplace for the 2018 plan year on Tuesday."

https://finance.yahoo.com/news/could-tidal-wave-terrible-news-042100491.html

The Repubs effort to destabilize the ACA are bearing fruit.  Now they can blame Obama.  The morons will all believe it, see the comments.

nereo

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Re: What comes after the ACA?
« Reply #2582 on: June 08, 2017, 07:26:45 AM »
"Anthem, one of the country's big five public health insurers, announced that it is pulling out of Ohio's Affordable Care Act individual insurance marketplace for the 2018 plan year on Tuesday."

https://finance.yahoo.com/news/could-tidal-wave-terrible-news-042100491.html

The Repubs effort to destabilize the ACA are bearing fruit.  Now they can blame Obama.  The morons will all believe it, see the comments.

I'm beginning to believe this could be an effective, long-term strategy.  Convince millions of people that health-care is unsustainable by forcing the ACA to fail.  "See - we tried it and it was an enormous disaster!"

Then it's open season on gutting Medicare/Medicaid.... a massive reduction in entitlement spending... Ryan and others might still get their dream. And it'll probably be great for anyone that's not poor, middle-class, old or chronically ill.
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DavidAnnArbor

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Re: What comes after the ACA?
« Reply #2583 on: June 08, 2017, 07:52:41 AM »
The ACA is definitely not working in more rural counties with smaller populations. That's probably why a public option was needed in those areas.

EnjoyIt

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Re: What comes after the ACA?
« Reply #2584 on: June 08, 2017, 08:51:04 AM »
You mention your hospital system has cut it's margins.  I have been of the opinion it's the hospital systems that are one of the problems.  We have 2 local hospital systems that have huge capital expenditures (despite a stable population) and administrators making much more than providers.  Do you see similar trends?

The insane bills I have received for medical care have always been from the hospitals.

Everyone wants to make a profit.  If the stock market can return 5% or more, then any business wants profit margins better than the stock market, otherwise why even invest in the company.  Just sell it off and buy index funds.  The huge bills you are seeing from hospitals is because hospitals are very expensive to run.  A large chunk of hospital expenditures are from over priced medications, supplies personnel who involved with regulatory compliance, billing, and coding. Hospitals have a huge overheard and patients foot the bill.

I don't think most docs are only in it for the money, but given the responsibilities $65 an hour wouldn't be worth it to many docs. 

Focusing on doc comp is misguided in my opinion.  I would start with hospitals, regulations and insurance.

I would agree, we are not in it for only the money.  Those who go into medicine just for the money realize there are easier ways to make that much cash and tend to be pretty bad docs who are miserable throughout their residency and career.  But, most docs expect decent money and likely would have chosen other career paths if money was not an issue. This is a study asking 630,000 physicians if they would retire today if they had the money.  60% of them said they would.
https://www.whitecoatinvestor.com/60-of-doctors-would-retire-now-if-they-could/

That just proves to me that despite not being in it for the money, money is very important.

Would you feel the same way if you could have graduated from medical school with no more than, say, $50k in student loan debt?

No.  If I am going to take on all that risk and liability as well as time, I would want to be paid for it.  I get it, plenty of phd grads work pretty damn hard and make a lot less money than physicians.  But we all made out choices hopefully understanding the pay structure. If someone told me physicians only make $65/hr I would have made the choice to not be a physician.


EnjoyIt

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Re: What comes after the ACA?
« Reply #2585 on: June 08, 2017, 09:34:16 AM »

So they still want to fuck over the country's poor and elderly population, but they want to do so quietly and without any publicity instead of dramatically with blaring headlines and trumpets.  I mean, I'm thrilled the immediate shittiness appears to be passing, but I'm not really optimistic about the nation's future if the new republican plan is to dismantle the republic discretely from the inside.  Attempted coups generate useful opposition (e.g. Trump) when done in public, but they are harder to oppose when executed quietly behind closed doors of power.

Sol, I am going to call you out on the bolded comment. Being a liberal that comment makes complete sense and another liberal could read it and completely agree with you. But is the comment reality or just a liberal perception that fits the world they/you understand.  Allow me to diverge for a second and explain with an example.  Cathy Griffith posted pictures of a decapitated Donald Trump.  To do so she had to have a group of like minded people design everything necessary to take such photos and then post them. In their view of the world, Donald Trump is a monster that should be decapitated, ISIS style. They must have truly believed in their minds and in their hearts that what they were doing is right, and the rest of the US agrees with how they view Donald Trump.  It turns out their perception was wrong.  A very large portion of people believe what Cathy Griffith did was a horrible atrocious act.  How is it possible? How could Cathy Griffith and her like minded friends be so wrong when their intellectual views of the world "must be accurate?" Maybe what they believe and how they feel is not the complete reality, but by being around a bunch of people with similar views their reality seams like it might be the truth as everyone around them reiterates similar thinking over and over again.  To them, Donald Trump is evil and something must be done.

Back to your comment Sol.  It is a fact that the older one gets, the more likely they go vote for their public officials. If Seniors are so likely to vote, do you really believe that there is a single candidate willing to destroy their largest base of voters? How would they possibly get elected?  Maybe the seniors and older population that votes conservative does not see the world through the same lens that you do. Maybe you are wrong and maybe the goal of conservatives is not to "fuck over the elderly."  Equally there is a large percentage of poor people who vote conservative.  They also don't think their elected officials are trying to fuck them over.  These people might truly believe that going too liberal will turn our country into communist Russia and everyone will be screwed. Some use terms like "class warfare" to describe the liberal movement.  Are the conservative voters just stupid?  Okay, maybe a few percent on average have a lower education level based on a study, but the difference is not that big and these conservatives, like you believe they are making intelligent well thought out decisions at the ballot box.

So who is right? Is your view of the world accurate or is it the conservative view? I don't know that answer as I have my own perceptions of the world that may be equally flawed. Personally I believe it is somewhere in between these two extremes. What I do know is when we use such blatant comments as "fuck over the poor" or "class warfare" all it shows is that we are stuck in an echo chamber of like minded individuals who may be estranged from reality and the possibility that our perceptions may be flawed.

Look back at Cathy Griffith who now says that Donald Trump ruined her life when in reality it was her choices and her choices alone that caused her own demise. 

Midwest

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Re: What comes after the ACA?
« Reply #2586 on: June 08, 2017, 09:59:00 AM »
You mention your hospital system has cut it's margins.  I have been of the opinion it's the hospital systems that are one of the problems.  We have 2 local hospital systems that have huge capital expenditures (despite a stable population) and administrators making much more than providers.  Do you see similar trends?

The insane bills I have received for medical care have always been from the hospitals.

Everyone wants to make a profit.  If the stock market can return 5% or more, then any business wants profit margins better than the stock market, otherwise why even invest in the company.  Just sell it off and buy index funds.  The huge bills you are seeing from hospitals is because hospitals are very expensive to run.  A large chunk of hospital expenditures are from over priced medications, supplies personnel who involved with regulatory compliance, billing, and coding. Hospitals have a huge overheard and patients foot the bill.

Many hospital systems are non-profit.  Theoretically, this should remove the profit motive.  We have 2 major systems in our area both are non-profit.  Interestingly, I find costs at the "non-profit" hospitals are often higher than their for profit alternatives on many things (MRI's for example).  Meanwhile, the executives in those non-profit systems are taking home compensation packages in the millions. 

I realize hospitals are expensive to run, but there has to be a method of reducing the cost curve.  To my local example, we have a flat population.  Despite that, the hospitals have made enormous expenditures (billions) in expanding their facilities over the past 10 years.  I contend at least some of those capital expenditures were unnecessary and wouldn't have happened if their ability to raise price had been curtailed.  I suspect this situation is similar in many areas of the country.

To your point on overhead, wouldn't streamlining regulations help reduce these costs?
For example, providers are mandated to do their own charting via EMR (correct me if I'm wrong).  None of the doc's I work with feels this increases efficiency or outcomes but is required by regulation.

As to what is a fair or reasonable cost.  I recently had a 1 hour surgery at an outpatient hospital.  I was at the facility for less than 6 hours.  My insurance and I paid over $20,000 for the surgery.  Seems like there has to be some fat in that number.

I don't think most docs are only in it for the money, but given the responsibilities $65 an hour wouldn't be worth it to many docs. 

Focusing on doc comp is misguided in my opinion.  I would start with hospitals, regulations and insurance.

I would agree, we are not in it for only the money. /

That just proves to me that despite not being in it for the money, money is very important.

If it wasn't clear from my earlier statements, I have no beef with doctor comp.  Doc's pay has been under pressure while costs increase to the patient.  My issue is the other sources of costs.
« Last Edit: June 08, 2017, 10:02:17 AM by Midwest »

Lagom

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Re: What comes after the ACA?
« Reply #2587 on: June 08, 2017, 10:14:54 AM »
No.  If I am going to take on all that risk and liability as well as time, I would want to be paid for it.  I get it, plenty of phd grads work pretty damn hard and make a lot less money than physicians.  But we all made out choices hopefully understanding the pay structure. If someone told me physicians only make $65/hr I would have made the choice to not be a physician.

Sure, but again, many bad physicians also might have chosen not to enter the profession if it paid less, so your reluctance isn't really indicative that this would inherently dilute the talent pool. Additionally, there is no reason in our theorizing we couldn't also add in some sort of government sponsored liability protection (either statutory reform or perhaps baked into nationalized healthcare). Just spitballing here, but the point is none of this is black or white regardless of the direction you're coming from.

sol

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Re: What comes after the ACA?
« Reply #2588 on: June 08, 2017, 10:28:10 AM »
Cathy Griffith posted pictures of a decapitated Donald Trump.  To do so she had to have a group of like minded people design everything necessary to take such photos and then post them. In their view of the world, Donald Trump is a monster that should be decapitated, ISIS style. They must have truly believed in their minds and in their hearts that what they were doing is right, and the rest of the US agrees with how they view Donald Trump.

I don't buy that interpretation of events for a second.  Griffin is a comedian who has made herself rich and famous by being deliberately inflammatory.  She partnered with an artist/photographer who is even more inflammatory. Tyler Shields's previous work has focused on graphic depictions of violence and sex, often involving stand-ins for US presidents and other celebrities.  Look him up, the guy's a real piece of shit.  His only goal life is to offend.

So no, I don't think that he thought for one minute that this photo shoot was okay.  He knew it was obscene, and that was the whole point.

Quote
It turns out their perception was wrong.  A very large portion of people believe what Cathy Griffith did was a horrible atrocious act.  How is it possible?

His perception was exactly right.  He knew people would be outraged, and that's the reaction he was hoping for.  That's how he stays "famous".  Like I said, he's a piece of shit.

Quote
If Seniors are so likely to vote, do you really believe that there is a single candidate willing to destroy their largest base of voters?

I think you've confused the party's voters with the party's constituency. 

The Republican party represents wealthy business interests.  They promote lower taxes on rich people, higher taxes on poor people, and less regulation on what businesses can and can't do.  They want more law enforcement of poor black communities but less law enforcement of white collar crime.  They preach a gospel of individual liberty, unless you are a woman, or gay, or unintentionally pregnant, or brown.  They want fewer restrictions on gun ownership, except in inner cities.

In order to further these interests, they need voters.  In order to get voters, they need money to buy allegiance.  They aren't trying to sway elections by proposing ideas that are important to their voters, they are trying to sway elections by telling their voters which ideas should be important to them.  That strategy requires newspapers and tv networks, AM radio talk show hosts, and elected representatives who can be bought off enough to parrot their lies.  It needs money.  Money comes from wealthy business owners, not voters. 

The Republican health care plan is a giant fuck-you to senior citizens.  Compared to the ACA, their premiums would skyrocket and their coverage would be skimpier.  The GOP health care plan takes healthcare away from millions of poor and elderly Americans in order to pay for a tax cut for the wealthiest Americans.  Who do you think is the real constituency here?

They're not worried about losing the votes of senior citizens.  Those votes can be bought back with enough Fox News coverage about how our seniors made a noble sacrifice to save the country from ruin.  They're only worried about keeping the money flowing, and that means appeasing the Kochs and Adelsons of the world.

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Maybe you are wrong and maybe the goal of conservatives is not to "fuck over the elderly."

I used to spend more time and effort trying to give them the benefit of the doubt.  I thought long and hard about why the GOP could possibly think supply side economics would work this time, when it never has before.  Why they thought taking health insurance from tens of millions of Americans would fulfill their campaign promise of coverage for everyone.  About why they think the way to improve public education is to gut its funding, why they think the way to deal with climate change is to make it worse, why they think the way to fight terrorism is to start wars.  The only unifying theme that I found in all of these ideas is (and maybe you're catching on enough that this won't be a surprise at this point) is that all of these seemingly asinine ideas are good for business.  They make even more money for the wealthiest Americans, at the expense of average Americans.  They promote the wealth inequality that is the very foundation of the Republican party.

I'm open to hearing other ideas, if you have any genius suggestions for what alternative unifying theme might motivate such a seemingly disparate array of republican policy positions.

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Equally there is a large percentage of poor people who vote conservative.  They also don't think their elected officials are trying to fuck them over.

They've been deceived.  Many poor people who vote republican have been tricked into that support with seductive advertising about "personal responsibility" and "individual liberty" even though our wealthiest citizens don't really believe in any of that.  Trump inherited his fortune and appears to lack a moral compass, how personally responsible is he?  Individual liberty sounds great, unless you're black or gay or muslim, in which case it usually rings a little hollow as the republican party systematically deprives you of your individual liberties.

Poor rural white Americans sometimes support the republican party platform of enhancing wealth inequality.  Not because they actually support a system that keeps them poor while enriching the born Trumps of the world, but because they have been deceived into believing that their systematic economic oppression is a necessary part of their perceived economic opportunity.  They want to believe that they too can become rich like Trump, if they just support enough crony capitalist politicians who further enhance wealth inequality, without realizing that their support of those politicians is the very thing preventing them from rising out of poverty.  You think the Trumps of the world give a rat's ass about poor people? 

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Some use terms like "class warfare" to describe the liberal movement.  Are the conservative voters just stupid? 

It absolutely IS class warfare, but they'e got the wrong party.  The Democratic party has spent three generations fighting for the rights of blue collar workers, while Republicans further divide America into the haves and the have-nots.  It's Republicans like Trump who are conducting class warfare, by using a calculated public performance of success and wealth to inspire our poorest citizens to self-destructively support further social and economic inequality.  They're like 1850s plantation slaves pressed into service to hunt down runaway slaves with the argument that runaways make it harder for the slaves left behind.

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What I do know is when we use such blatant comments as "fuck over the poor" or "class warfare" all it shows is that we are stuck in an echo chamber of like minded individuals who may be estranged from reality and the possibility that our perceptions may be flawed.

I don't feel like I'm in an echo chamber, I feel like I'm shouting into the void.  All three branches of US government currently parrot the Trump/Ryan philosophy of America, which I find repulsive.  Everyone around me says the only way to save America is to destroy everything we have built together, and I feel like the one lone rational voice left in a sea of lies, stupidity, and complicity.

I choose to use inflammatory language to describe the destruction of the American ethos because I find it a deeply inflammatory development.  I'm always open to having my views changed, if I find an argument that relies on rationality and history and makes a compelling case, but so far that hasn't described anything the GOP has done in the past few cycles.
« Last Edit: June 08, 2017, 10:47:26 AM by sol »

protostache

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Re: What comes after the ACA?
« Reply #2589 on: June 08, 2017, 10:29:39 AM »
...Cathy Griffith...

Kathy Griffin

Sorry. It just really bugs me when people repeatedly mis-speak others' names.

Lagom

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Re: What comes after the ACA?
« Reply #2590 on: June 08, 2017, 10:43:51 AM »
Excellent post Sol, as usual. My only personal point of disagreement regards the claim that Dems have been fighting for blue collar workers. Some have. Many haven't. And the party as a whole has done a pretty shit job for them for some time now, with plenty of corporate shilling to go around, not that there is a good alternative party on that front, of course. ETA - but on healthcare, Dems definitely are serving the working class lightyears better, as the AHCA makes abundantly clear.
« Last Edit: June 08, 2017, 11:48:38 AM by Lagom »

nereo

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Re: What comes after the ACA?
« Reply #2591 on: June 08, 2017, 11:34:14 AM »
...Cathy Griffith...

Kathy Griffin

Sorry. It just really bugs me when people repeatedly mis-speak others' names.
Thanks, that was really bugging me too.
I'd just add to the comments that it's absurd to compare a PR stunt done by a comedian to the actions of elected officials, particularly POTUS. There is no illusion that the Griffin represents only herself, while the latter group are inherently representing all citizens.
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tyort1

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Re: What comes after the ACA?
« Reply #2592 on: June 08, 2017, 12:15:12 PM »
Re: the damage the repubs are doing - one simple solution for the left (of which I am a part) - VOTE.  To quote Obama "Don't boo... VOTE".  Especially in mid terms.  And at the state level and every other level.  If we vote, we win.  There's no freaking reason the Repubs should have strangleholds on the legislative houses like they do.

Hopefully all this sound and fury will get people off their butts and to the voting polls in 2018. 
Frugalite in training.

dividendman

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Re: What comes after the ACA?
« Reply #2593 on: June 08, 2017, 12:54:33 PM »
Re: the damage the repubs are doing - one simple solution for the left (of which I am a part) - VOTE.  To quote Obama "Don't boo... VOTE".  Especially in mid terms.  And at the state level and every other level.  If we vote, we win.  There's no freaking reason the Repubs should have strangleholds on the legislative houses like they do.

Hopefully all this sound and fury will get people off their butts and to the voting polls in 2018.

I really hope, and I know it's bad, that the Congress and President pass their entire legislative agenda. What this will do is devolve a bunch of responsibilities onto the states. The crappy/poor (read: Red) states will suck even more and the good/rich (read:Blue) states will have a windfall of tax money (as they can increase their state taxes and not increase the overall tax burden) and programs to help their people.

Yes, I realize by doing this half the country is getting thrown under the bus.... but they WANT to be thrown under the bus, why are people always trying to stop em?


DavidAnnArbor

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Re: What comes after the ACA?
« Reply #2594 on: June 08, 2017, 01:31:58 PM »

I really hope, and I know it's bad, that the Congress and President pass their entire legislative agenda. What this will do is devolve a bunch of responsibilities onto the states. The crappy/poor (read: Red) states will suck even more and the good/rich (read:Blue) states will have a windfall of tax money (as they can increase their state taxes and not increase the overall tax burden) and programs to help their people.

Yes, I realize by doing this half the country is getting thrown under the bus.... but they WANT to be thrown under the bus, why are people always trying to stop em?


Just like I wouldn't want half the country to continue to allow slavery, I wouldn't want half the country to continue to disenfranchise huge swaths of the population from accessing healthcare. The little children that are born don't have a choice, and yet they're the ones that end up bearing the awful burden of the failed Republican policies that would cause at least 23 million to lose their health care insurance for themselves and their families. Presumably, Medicaid and CHIP would still be around for children but I'm not sure how effectively these disempowered people would be to enroll their children.

sol

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Re: What comes after the ACA?
« Reply #2595 on: June 08, 2017, 01:48:57 PM »
they WANT to be thrown under the bus, why are people always trying to stop em?

I ask myself this question almost daily. 

But, as I've outlined above, the answer is that the people who are voting in self-destrutive ways because they have been lied to.  As an American, I want each and every one of my fellow citizens to have the privilege of voting for what they think is best, but I also want them to be as well informed as possible so that no one is inadvertently exploited by the oligarchy. 

Right now, I think a lot of Trump voters are having second thoughts as they realize that he's not following through on the things he promised them, and maybe the Democrats had a point in highlighting that a silver spoon NY billionaire egomaniac reality tv star with no relevant experience was not the best choice for the job. 

talltexan

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Re: What comes after the ACA?
« Reply #2596 on: June 08, 2017, 02:51:57 PM »
they WANT to be thrown under the bus, why are people always trying to stop em?

I ask myself this question almost daily. 

But, as I've outlined above, the answer is that the people who are voting in self-destrutive ways because they have been lied to.  As an American, I want each and every one of my fellow citizens to have the privilege of voting for what they think is best, but I also want them to be as well informed as possible so that no one is inadvertently exploited by the oligarchy. 

Right now, I think a lot of Trump voters are having second thoughts as they realize that he's not following through on the things he promised them, and maybe the Democrats had a point in highlighting that a silver spoon NY billionaire egomaniac reality tv star with no relevant experience was not the best choice for the job.

I disagree. Every person who's admitted to voting for Trump (I live in a state Trump carried) seems to like how things are going.

One word: Gorsuch.

dividendman

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Re: What comes after the ACA?
« Reply #2597 on: June 08, 2017, 03:24:33 PM »
they WANT to be thrown under the bus, why are people always trying to stop em?

I ask myself this question almost daily. 

But, as I've outlined above, the answer is that the people who are voting in self-destrutive ways because they have been lied to.  As an American, I want each and every one of my fellow citizens to have the privilege of voting for what they think is best, but I also want them to be as well informed as possible so that no one is inadvertently exploited by the oligarchy. 

Right now, I think a lot of Trump voters are having second thoughts as they realize that he's not following through on the things he promised them, and maybe the Democrats had a point in highlighting that a silver spoon NY billionaire egomaniac reality tv star with no relevant experience was not the best choice for the job.

I disagree. Every person who's admitted to voting for Trump (I live in a state Trump carried) seems to like how things are going.

One word: Gorsuch.

Yeah, I figured the Trump supporters would like everything that's happening, so give them the rest - all that juicy legislation that will impact their lives very quickly.

scottish

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Re: What comes after the ACA?
« Reply #2598 on: June 08, 2017, 03:36:05 PM »
They seem to be blaming other people for Trump's inability to deliver on his promises.    "Trump would have done this but the federal court wouldn't let him.   D**m courts, who do they think they are".   Maybe one day he can attend a presidential debate and explain why he did nothing.  (I can't find the article right now, but I'll post it if it comes back.)

nereo

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Re: What comes after the ACA?
« Reply #2599 on: June 08, 2017, 04:32:15 PM »
They seem to be blaming other people for Trump's inability to deliver on his promises.    "Trump would have done this but the federal court wouldn't let him.   D**m courts, who do they think they are".   Maybe one day he can attend a presidential debate and explain why he did nothing.  (I can't find the article right now, but I'll post it if it comes back.)

I've listened to numerous people go through elaborate cognitive contortions to claim that the courts are not the arbitrators of what is constitutional whenever they or their side disagrees with the outcome. The latest example is DJT's stalled EOs, but this is not limited to this presidency or the GOP.
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