Author Topic: What comes after the ACA?  (Read 955322 times)

Paul der Krake

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Re: What comes after the ACA?
« Reply #5350 on: March 15, 2019, 01:47:59 PM »
Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?

ysette9

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Re: What comes after the ACA?
« Reply #5351 on: March 15, 2019, 02:11:17 PM »
Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?
I got a referral to physical therapy from my primary care doctor and she made a recommendation for a specific person she thought was good. I see for my nearest facility there is a department page for their providers. https://thrive.kaiserpermanente.org/care-near-you/northern-california/redwoodcity/departments/physical-occupational-therapy/ maybe you need to ask your doctor first?

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We have friends who bought their own Kaiser insurance on the open market rather than use a regular insurance system when she took a job that didn’t offer Kaiser. Thankfully that only lasted a year for them until one half of the couple got a new job that did offer that benefit. I hear horror stories from my friends of getting random bills in the mail up to a year after giving birth for random out of network anesthesiology fees or whatnot, and I can understand why my friends made the decision to buy their own coverage.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5352 on: March 15, 2019, 02:56:12 PM »
Serious question for you Kaiser experts: how do you see a list of physical therapists?

For example, I can find MDs and DOs for San Diego:
https://healthy.kaiserpermanente.org/southern-california/doctors-locations#/search-result?region=SCA&searchType=doctors&city_label=San%20Diego&medical_specialty_label=Physical%20Med/Rehabilitation

But where are the clinics with a bunch of physical therapists? Is there a better search tool once you are a member?
I got a referral to physical therapy from my primary care doctor and she made a recommendation for a specific person she thought was good. I see for my nearest facility there is a department page for their providers. https://thrive.kaiserpermanente.org/care-near-you/northern-california/redwoodcity/departments/physical-occupational-therapy/ maybe you need to ask your doctor first?
I should have been more clear: I'm not a Kaiser member, just trying to evaluate how far I would need to go to see a therapist should I decide to become one.

ysette9

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Re: What comes after the ACA?
« Reply #5353 on: March 15, 2019, 02:59:58 PM »
I had an appointment with my primary care doctor for an annual physical. I mentioned an ongoing issue and asked to be referred to a physical therapist. I was. My experience was pretty straight forward.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5354 on: March 15, 2019, 05:06:51 PM »
Since @EnjoyIt so enjoys arguing about healthcare, I came back around to this thread.

I just don't understand why I can't get through to you that simply going government funded healthcare is not the solution on its own...

For example the government option will cover Penicillin VK which needs to be taken 4 times a day while those who pay out of pocket can get Cefdnir twice a day.  Government option will cover Acyclovir that is taken 5 times a day, Private pay can get Valcyclovir which needs to be taken only twice a day.  Government option will fund hospital stays where you share a room with 2-4 other people.  Additional out of pocket cash will get you a private room with a better meal. Government option will fund your gall bladder surgery once a spot is available.  One can pay extra to schedule surgery next Monday.  Government option will not do chemo on a patient with little to no mental activity though a family can pay tens to hundreds of thousands if they choose to.  Government option has clinics that you can see a primary care physician but you will need to wait several hours to be seen.  You can pay extra cash to make an appointment and be seen within 20 minutes. I can go on and on.

Every single one of your examples is a current private insurance system that would be improved by offering a government backed healthcare option.  Every one.  I don't see how you could look at that paragraph you wrote and possibly conclude that we don't need a government option.  We already have the private sector side, and no one is advocating for outlawing that.  But things would be better in every case you cited if there was ANOTHER option available, funded by taxes and universally available. 

@sol, I don't think you read anything I had to say.  I am all for a public option.  We have one already called Medicare/Medicaid and we need to improve on it to be able to make it available for every American citizen and those in the US legally.  I think we need a low cost public option that is sustainable.  Current practices are unsustainable because of the massive overhead.  Public option would be free but it would include long waits, low cost generic medications, shared rooms in hospitals, low cost procedures vs cutting edge expensive ones that show little to no additional benefit, loss off ability to sue outside of malicious injury such as a surgeon carving their initials into a patient, eliminate the ridiculous complexity in documentation, billing, and compliance overhead, pay providers of healthcare a flat salary that is reasonable for the work they do (will discuss further below.) instead of a fee for service model which incentivizes waste, and I'm sure there are more cost cutting endeavors that needs to happen. 

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I know you think that Medicaid "doesn't pay enough" to cover costs but I would counter that our costs are too high, because other countries do provide the same or better medical outcomes at those lower costs.  It's hard, when it's your own industry on the chopping block, to say "people in my professions should get paid less" but that's honestly where I think we're at with medical care in America.  Our costs are too high, including overhead and insurance and yes even the salaries.  They all need to come down to be competitive with the rest of the industrialized world.

A few things we must understand about physician wages in the US compared to other more socialized models in the rest of the world.  Doctors don't pay for their training while in the US it is not uncommon to be $300k-$400 in debt once out of residence.  I personally owed a little under $350k.  So yeah, pay me back my money and pay me less for my work.  I'm OK with that.  Next, physicians in the US work way more than 40 hours a week.  It is not uncommon for some to work 60+ hours and it should make sense that those doctors make more per year as opposed to physicians working 40 hours a week.  Lastly, eliminate all the regulatory overhead that costs physicians money and remove that overhead from our wages.  I do not think anyone will complain.  Just this year alone I will be paying over $5k for certification and licensing.  Recent legislation that created a new building structure called MACRA has cost physicians 10s of thousands of dollars in compliance costs. Make it easier and less costly for us to practice medicine and we would gladly cut our wages.  Also, we need to eliminate this out of network billing where providers overcharge the insurance companies and patients. 

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It's unpopular to say, but I don't think doctors are special.  They are not smarter or more godly than other professionals.  As a group, they do not have more education or more responsibility or work worse hours than other similar professions that make less money.  They are just overpaid, for cultural and historical reasons supported by the AMA limiting the supply of available workers relative to the number of jobs available.  It's one of those grossly distorted markets that would provide better service at lower cost if it were less heavily regulated.

Doctors are not special they are humans like the rest of us.  They are smarter than average because the system titrates out those less capable. I discussed their wages above.  In my undergrad it seams like almost half the school said they were pre-med, but only a handful of us went to med school.  Maybe doctors have something that most of the population doesn't have.  It still doesn't make them special or godly but they are above average because they have to be.

BTW, there will always be professions that get payed better than others. Should we curtail the reimbursement to west cost engineers and programers as well?  Why should they get paid more?  What about actors and professional athletes? What about waiters in high end restaurants vs waiters in denny's  Maybe we should equalize their wages as well.  What do you think?  I am not saying doctors wages can't be cut.  They could be, but do so in a reasonable way as described above.

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I don't think the ACA is going away anytime soon, in part because the AMA and the insurance industry like it.  There are currently record profits being generated in the healthcare sector as a direct result of the ACA.  Costs are still going up, of course, but in theory costs could come down significantly and those businesses would still be profitable.  Capitalism doesn't really care about that, though.  If you have crazy high profit margins, that just means you have a successful business.

The ACA is designed to help the insurance companies.  The AMA is in bed with the insurance and pharma industry and not the physicians.  As you have requested physician pay has decreased thanks to the ACA, a little because of decreased reimbursement but cut significantly due to increased overhead and idiotic regulations that provide no benefit to the patient.  In addition current reimbursement regulations are cutting physician wages every year.

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Who would do a better job?  Some semi radical thinking has been introduced to me lately.  We have these big financial companies.  One of which is Vanguard.  Vanguard has their system setup where they are somehow owned by the people who invest in them.  They have known fees that are known to be lower.  They serve the customer who is also the owner.  Their fees are often less.  Many people on this site have pointed to Vanguard as their investment vehicle of choice.  The Vanguard people serve one master who is both the customer and the owner which seems to work out well and creates a company with greater efficiencies.

Vanguard is a socialist corporation.  Yes it provides a superior product at a lower cost than its privately owned competitors, but it does so because it does not have to pay profits to shareholders.  When it has extra profits, it just reduces costs to its customers, who ARE the shareholders.  That's like the definition of socialism, and it's kind of shocking that certain political parties don't just RAIL against vanguard as a threat to our capitalist utopia the same way they rail against socialist healthcare solutions.  Which, I agree, could also provide superior service at lower cost if they didn't have to pay profit margins to shareholders.  Just like Medicaid doesn't.

Vanguard is a public company.  It is not a socialist company.  Very different.  It does not benefit everyone, it benefits those who own a piece of Vanguard which are the people that have Vanguard funds.

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Is it better for health care administrators to serve two masters, those who wish to profit and those who are the customer?  Is it better to simply serve one customer?  The government is supposed to represent the people's interests.  I believe a public health entity would do just that. 

Wait, are you Bernie Sanders in disguise?  Don't astroturf us, Bernie.  Only a radical like you would suggest that Americans deserve a better deal than they currently get by being ripped off by private healthcare companies, when there's a proven alternative sitting right in front of us. 

Suggesting that Americans adopt socialized healthcare the same way that every other industrialized western nation has is akin to suggesting that we adopt the metric system.  It's blasphemy!  We like our stupid American system and you can pry it from our cold dead hands!

Sol,
You are a bright guy full of idealism but not looking at the whole picture.  Yelling socialized healthcare in a vacuum, yelling cut doctors wages in a vacuum, and just throwing out comments that only pander to the left accomplish nothing except maybe make you feel good about all that yelling.  We have a real problem in the US and we need the far left and the far right to come together and make progress as opposed to simple pandering.  The fact that you thought I am against a public option which I several times in this thread fully endorse just goes to show how blinded you are to those who even slightly disagree with you. 

Threshkin

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Re: What comes after the ACA?
« Reply #5355 on: March 15, 2019, 05:33:43 PM »
In some ways Kaiser is like Vanguard already in the sense that it is not-for-profit and focuses on overall well being rather than a fee-for-service model.

From wiki:

“KP's quality of care has been highly rated and attributed to a strong emphasis on preventive care, its doctors being salaried rather than paid on a fee-for-service basis, and an attempt to minimize the time patients spend in high-cost hospitals by carefully planning their stay.”

I’ll admit to being biased as I have been a happy Kaiser member for most of my life. My two babies are alive today due to Kaiser specialists and NICU doctors and nurses. I’ve has two doctors independently and completely unprompted say in my presence how glad they are to be salaried, and to not feel any pressure to make medical decisions based on cost or revenue it would bring to the HMO. I know that “Medicare for all” is a nice slogan, but honestly I’d get more excited by “Kaiser for all”.

We shifted over to Kaiser last year when we went on ACA insurance.  We are very happy with the service.

pecunia

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Re: What comes after the ACA?
« Reply #5356 on: March 15, 2019, 06:17:40 PM »
To EnjoyIt:  I just want to thank you for your input.  I'm not in the medical profession.  I do not have your perspective.  Its helpful.

Classical_Liberal

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Re: What comes after the ACA?
« Reply #5357 on: March 15, 2019, 09:35:47 PM »
To EnjoyIt:  I just want to thank you for your input.  I'm not in the medical profession.  I do not have your perspective.  Its helpful.

+1, Except I am in the medical profession. I've been following this thread for a long time (off and on) and rarely participate because I don't have the time or energy to put in the effort @EnjoyIt does to try an explain from an insiders POV what is wrong with the system. 

sol

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Re: What comes after the ACA?
« Reply #5358 on: March 15, 2019, 10:15:29 PM »
I don't think you read anything I had to say.  I am all for a public option.  We have one already called Medicare/Medicaid and we need to improve on it to be able to make it available for every American citizen and those in the US legally.  I think we need a low cost public option that is sustainable.

Okay, then it sounds like we don't actually disagree very much.  You kept saying things like "going government funded healthcare is not the solution" and "government funded insurance is not the solution" now you're saying that these things ARE the solution.  I understand that you also want additional changes to the system, and I don't oppose any of that.  I just think it's silly that so many people are still adamantly opposed to step 1, which is providing universally available government-funded healthcare to every American citizen.  All by itself, that would improve virtually every aspect of our broken system.

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It still doesn't make them special or godly but they are above average because they have to be.

I think that's true of lots of professionals.  Nuclear engineers are also above average, and they have more required education, work worse hours, have more responsibility and liability for mistakes, and they still don't make as much as doctors to.  Half the population is above average and I would wager most doctors are in that upper half.  That doesn't mean they should make $400k/year, though.

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BTW, there will always be professions that get payed better than others. Should we curtail the reimbursement to west cost engineers and programers as well? 

I'm not suggesting that we curtail doctor wages, I'm suggesting that we do away with the artificial barriers to entry that keep the labor supply artificially low.  Let the marketplace set a fair wage, with willing buyers meeting willing sellers.  Doctors are arguably the world's most strictly regulated and labor-constrained professional organization, for no good reason.  They should definitely be certified, by why aren't they certified the same way lawyers are?  Or vets?  Why all the extra hoops?

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What about actors and professional athletes? What about waiters in high end restaurants vs waiters in denny's  Maybe we should equalize their wages as well.  What do you think?

We're not talking about nationalizing the industry to enforce equal pay, we're talking about deregulating a horribly corrupt system to allow people more freedom to get the required training and certifications they need in order to fill the labor shortage.  Some doctors will still make more than others and that's fine. 

Since you mentioned professional athletes, the analogous situation for NFL players would be if each D1 college football program was only allowed to grant one NFL union card every other year.  The league needs to hire hundreds of new recruits per year, and they would still be able to get some, but they would pay much higher salaries to those rookie athletes because they would need to attract one of only a very few available college players.  With more open jobs than applicants, wages rise.  That's basically what I think we've seen with doctors.  Not enough union cards.

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Vanguard is a public company.  It is not a socialist company.  Very different.  It does not benefit everyone, it benefits those who own a piece of Vanguard which are the people that have Vanguard funds.

I thought the joke was clear, by maybe not?  All companies with shareholders are public, the difference at places like Vanguard is that the shareholders are also the customers.  That's how communism works, in theory, everyone communally owns the resources and industry and so they work to everyone's benefit, instead of the benefit of a handful of wealthy owners.  Instead of the industry enriching the few by exploiting the masses, it's supposed to enrich everyone equally. 

There's not really any such thing as a socialist company.  We sometimes call them "employee-owned" or "non-profit" but the general idea is that they exist for the benefit of the people they serve, instead of the benefit of a third party who has interests not aligned with those of the customers.  All government agencies are theoretically "employee owned" in the sense that they serve the citizens of the country, and can do their best to help those citizens without worrying about making the owner rich.  Wouldn't it be nice if the government could provide health insurance and/or healthcare with that same mentality, of actually trying to help our citizens instead of making the owner rich?

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Yelling socialized healthcare in a vacuum, yelling cut doctors wages in a vacuum, and just throwing out comments that only pander to the left accomplish nothing except maybe make you feel good about all that yelling. 

I didn't think I was yelling, and besides you seem to agree with me on the need for government-backed healthcare.  I didn't suggest cutting doctor wages, I lamented the artificially high wages that doctors can command because they self-regulate the supply of new doctors.  And I definitely wasn't trying to pander to anyone, I was trying to say that we should demand our elected representatives get serious about making some fundamental changes to the way the American healthcare system operates.  A good first step would be to cut out the profit-seeking middlemen who complicate it, and let people vote for a system that better serves them.

Bateaux

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Re: What comes after the ACA?
« Reply #5359 on: March 16, 2019, 09:19:02 AM »
Most doctors these days are just glorified auto mechanics.  As we learn more and more about the body and what makes it malfunction, the role of doctors will become more and more diluted.  We'll all become virtual  doctors some day.   We'll have an onboard computer that analyses all our systems, just like cars do now.   We'll have predictive maintenance just like cars do.  The medical field is ripe for an artificial intelligence overhaul.  Going to SEE the doctor is some archaic shit in the 21st century.   Most of what ails us could be treated at home or remotely, by a much cheaper human doctor in China or India.  How long can they keep technology under wraps?  I guess as long as the lawmakers help them. 

pecunia

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Re: What comes after the ACA?
« Reply #5360 on: March 16, 2019, 10:08:46 AM »
Most doctors these days are just glorified auto mechanics.  As we learn more and more about the body and what makes it malfunction, the role of doctors will become more and more diluted.  We'll all become virtual  doctors some day.   We'll have an onboard computer that analyses all our systems, just like cars do now.   We'll have predictive maintenance just like cars do.  The medical field is ripe for an artificial intelligence overhaul.  Going to SEE the doctor is some archaic shit in the 21st century.   Most of what ails us could be treated at home or remotely, by a much cheaper human doctor in China or India.  How long can they keep technology under wraps?  I guess as long as the lawmakers help them.

I've had health insurance from a couple of employers recently as well as have purchased it from the marketplace.  They are getting quite close to what you suggest.  One insurer had nurses that you could call 24 hours a day and the other had phone and online contact with physicians.  The service was free.  It offers convenience and saves the insurance company money.  Fortunately, I have found no need to avail myself of such services.  I have found WebMD to be helpful on several occasions.

I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5361 on: March 16, 2019, 10:32:04 AM »
I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.
Overpaid west coast programmer here.

We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

katsiki

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Re: What comes after the ACA?
« Reply #5362 on: March 16, 2019, 03:11:57 PM »
I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.
Overpaid west coast programmer here.

We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

+1   :)

I do think tele-medicine and its ilk will become more common.

pecunia

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Re: What comes after the ACA?
« Reply #5363 on: March 16, 2019, 03:12:19 PM »
I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.
Overpaid west coast programmer here.

We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

Yes - and with a relatively high degree of certainty.  They may not be perfect to start out, but think of Moore's Law.  Think of most any invention.  Look at the automobiles of 1910 vs today.  Think of the computers of the 1960s vs today.  Nobody talks about Univac any more.  Much of the technology is there now but separated.  Heart rate, respiration, blood pressure, blood sampling and a long series of questions is to be answered for machine input.  A doctor can spend maybe 15 minutes with you during a checkup and obtains limited information.  This machine will be able to obtain more data which will reduce uncertainty.

With the "shortage" of medical personal, it's time for technological solutions to work around these folks.  It's probably happening already.  The high cost of medicine would certainly make insurance companies your ally.  Predictive / preventive devices would save a lot of treatment cost and save a lot of cost for the insurance company.  It would behoove them to give you a discount on your premium for the use of such a device.  It would prevent health issues in the same way as being a non- smoker prevents health issues.

The initial machines would probably be high priced and would be placed in clinics and pharmacies in much the same manner as self blood pressure instrumentation.  With the economy of scale, the price would come down and they would end up in folk's bathrooms.  The machine would trend records from all users and either store the information locally or in a central database.

With the high cost of medicine and the sometimes difficult nature of obtaining such service, I would think there would be a ready market for such a device.  It would be an easy sale as health is a major concern.  It is not just a US market.  People could use these world-wide.  There would be a secondary market for disposable needles, filters, required chemicals, etc.  The market is easily in the billions of dollars.

Paul - I suggest you head on over to Frys Electronics, get some stuff from the scrap bin and concoct this gadget.  Let someone else worry about the websites.  It's those on the cutting edge who made the big computer business on the West Coast.  Find some old retired engineer from Hewlett Packard to help you put this one together.

You could be like Norman Borlaug and save a billion lives.

AnswerIs42

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Re: What comes after the ACA?
« Reply #5364 on: March 16, 2019, 05:29:58 PM »
We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

I'm reminded of this classic XKCD cartoon:


EnjoyIt

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Re: What comes after the ACA?
« Reply #5365 on: March 17, 2019, 01:50:22 PM »
I don't think you read anything I had to say.  I am all for a public option.  We have one already called Medicare/Medicaid and we need to improve on it to be able to make it available for every American citizen and those in the US legally.  I think we need a low cost public option that is sustainable.

Okay, then it sounds like we don't actually disagree very much.  You kept saying things like "going government funded healthcare is not the solution" and "government funded insurance is not the solution" now you're saying that these things ARE the solution.  I understand that you also want additional changes to the system, and I don't oppose any of that.  I just think it's silly that so many people are still adamantly opposed to step 1, which is providing universally available government-funded healthcare to every American citizen.  All by itself, that would improve virtually every aspect of our broken system.

We agree on much more than you seem to think and I am fiscally conservative.  We as Americans are already paying for a lot of people's healthcare in one way or another.  We pay through taxes and we pay through high insurance premiums and increase cost of delivery.  My qualm with universal healthcare is that it alone is not the fix.  We can't just switch everyone over and expect all will be well. As it stands the cost of delivery is too expensive to provide what the entire population needs and expects.  We need to change expectations similar to what other countries have and we need to decrease the overhead of delivery.  That will provide adequate funding for a public option.  As I said, before as it stands, the reimbursement for Medicaid generally does not cover the cost of delivery.  Medicare does, but medicare is not free. If all else is held equal and the entire population was on Medicaid, the whole system would crumble.  Therefor we need a path that can provide for the basic healthcare needs of every person in America who is in the US legally.


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It still doesn't make them special or godly but they are above average because they have to be.

I think that's true of lots of professionals.  Nuclear engineers are also above average, and they have more required education, work worse hours, have more responsibility and liability for mistakes, and they still don't make as much as doctors to.  Half the population is above average and I would wager most doctors are in that upper half.  That doesn't mean they should make $400k/year, though.


Most doctors do not make $400k a year.  There are a few specialties that make that and even more.  Some very specialized neurosurgeons make over $1 million a year while most physicians are in the $200k a year range which is not that far from top engineers and software developers in the US.Majority of the doctors in the US are internal medicine, family practice, pediatrics and hospitalists.  According to this Forbes article:
https://www.forbes.com/sites/jacquelynsmith/2012/07/20/the-best-and-worst-paying-jobs-for-doctors-2/#7d714ce0a2a3
And this doesn't include all the licensing fees and costs of having the privilege to practice medicine that engineers and developers don't have to fork over. they don't have ever changing compliance costs, and they rarely risk getting sued personally.

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BTW, there will always be professions that get payed better than others. Should we curtail the reimbursement to west cost engineers and programers as well? 

I'm not suggesting that we curtail doctor wages, I'm suggesting that we do away with the artificial barriers to entry that keep the labor supply artificially low.  Let the marketplace set a fair wage, with willing buyers meeting willing sellers.  Doctors are arguably the world's most strictly regulated and labor-constrained professional organization, for no good reason.  They should definitely be certified, by why aren't they certified the same way lawyers are?  Or vets?  Why all the extra hoops?

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What about actors and professional athletes? What about waiters in high end restaurants vs waiters in denny's  Maybe we should equalize their wages as well.  What do you think?

We're not talking about nationalizing the industry to enforce equal pay, we're talking about deregulating a horribly corrupt system to allow people more freedom to get the required training and certifications they need in order to fill the labor shortage.  Some doctors will still make more than others and that's fine. 

Since you mentioned professional athletes, the analogous situation for NFL players would be if each D1 college football program was only allowed to grant one NFL union card every other year.  The league needs to hire hundreds of new recruits per year, and they would still be able to get some, but they would pay much higher salaries to those rookie athletes because they would need to attract one of only a very few available college players.  With more open jobs than applicants, wages rise.  That's basically what I think we've seen with doctors.  Not enough union cards.


I think you have a misunderstanding on where the bottleneck is.  It is not at the schools.  There are plenty of schools MD and DO as well as a few out of country affiliate schools.  What we lack is residencies.  So how do we get more residencies? CMS needs to approve them therefor CMS is creating the shortage and not the AMA (which I despise for other reasons.)  BTW back when I was a resident, it cost CMS $100,000 per year per resident for training which may be the reason why CMS does not want to open the flood gates for more doctors as I'm sure it costs well over $100k today. I'm sure there are other reasons I am not aware of but making doctors is not cheap.

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Vanguard is a public company.  It is not a socialist company.  Very different.  It does not benefit everyone, it benefits those who own a piece of Vanguard which are the people that have Vanguard funds.

I thought the joke was clear, by maybe not?  All companies with shareholders are public, the difference at places like Vanguard is that the shareholders are also the customers.  That's how communism works, in theory, everyone communally owns the resources and industry and so they work to everyone's benefit, instead of the benefit of a handful of wealthy owners.  Instead of the industry enriching the few by exploiting the masses, it's supposed to enrich everyone equally. 

There's not really any such thing as a socialist company.  We sometimes call them "employee-owned" or "non-profit" but the general idea is that they exist for the benefit of the people they serve, instead of the benefit of a third party who has interests not aligned with those of the customers.  All government agencies are theoretically "employee owned" in the sense that they serve the citizens of the country, and can do their best to help those citizens without worrying about making the owner rich.  Wouldn't it be nice if the government could provide health insurance and/or healthcare with that same mentality, of actually trying to help our citizens instead of making the owner rich?

Speaking of socialism, there has yet in history been a socialist system that stood the passage of time.  So far they either all collapse or the people have significant misery.  There is one young exception today, Norway backed by massive oil reserves they have been able to fund a rich social backbone.  I wish all Norwegians the best and hope their country continues to flourish.  On the other side, the US was built on a capitalist system, and despite all its flaws, the US economy is the envy of most of the world.  This statement is proven because the US is about 50% of the world economy and people from all over the world invest in our government through bonds.  Let's not destroy what has made America what it is but make calculated adjustments that improve life for everyone. Personally I am vehemently against the socialist movement.  I have lived in it, I have suffered in it, and I have escaped it. People who want socialism don't fully understand what it really is.  They hide behind the word democratic socialism thinking the outcome will somehow be different.  It won't and people as usual will suffer. 

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Yelling socialized healthcare in a vacuum, yelling cut doctors wages in a vacuum, and just throwing out comments that only pander to the left accomplish nothing except maybe make you feel good about all that yelling. 

I didn't think I was yelling, and besides you seem to agree with me on the need for government-backed healthcare.  I didn't suggest cutting doctor wages, I lamented the artificially high wages that doctors can command because they self-regulate the supply of new doctors.  And I definitely wasn't trying to pander to anyone, I was trying to say that we should demand our elected representatives get serious about making some fundamental changes to the way the American healthcare system operates.  A good first step would be to cut out the profit-seeking middlemen who complicate it, and let people vote for a system that better serves them.

Although I agree that the insurance industry is a leach on the system, I do not believe it is the first step especially since those same companies manage Medicare and Medicaid in certain areas and populations.  You can't just turn on the Universal Healthcare switch and think all will be well.  Honestly, that is kind of ignorant. We need to cut the cost of delivery first and foremost, and as these cuts occur, implement a bare bones public option for all people who are legally in the US.

And yes you do pander, by throwing ridicule at a population that does not agree with you 100%.  You use terms that rile up the far left as opposed to creating arguments that bring people together.  All that does is alienate any good intentions you may have.  Just because someone has conservative views does not make them racist. Just because some voted for Trump does not mean they agree with him100%.  Guess what, I think Trump is not a great human being, but all in all, I am happy with the majority of what he has accomplished while displeased with certain aspects of his presidency. As it currently stands I very well may vote for him in 2020.  And believe me, I am no racist or uneducated trash that you seem to believe those who vote conservative are. I would also like to point out that I am not a republican.

Those of us who are vocal and give a damn need to use arguments and rhetoric that brings both sides together otherwise we add to the divisiveness and accomplish nothing.

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Re: What comes after the ACA?
« Reply #5366 on: March 17, 2019, 02:08:01 PM »
I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.
Overpaid west coast programmer here.

We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

People have such a wonderful idealistic view of the world but have no clue on the logistics of how to implement their idealism. 

Hey tech guy.  Next week make a computer that can follow a medical algorithm, do it accurately with no mistakes and....lets have it by 2021.  I'm waiting!

I do agree that much of medicine follows an algorithm and we can likely implement software to assist us. But, let us look a little closer.   What do we do if the algorithm chosen isn't right or if the algorithm got a response the puts it in the wrong direction?  I see this happen all the time in real life and I will share it with 2 examples: 

1) Experienced nurses have watched these algorithms take place over and over and over again.  Over time they learn these algorithms and even ready to implement them without the doctor.  But, because the nurses don't understand all the physiology and all the non standard outcomes when something does not fit the classic pattern they fail and risk poor outcomes to the patient.  Some other failsafe is necessary.  Some nurses may argue with that comment thinking they are amazing nurses and that is not them, but my comment is reinforced when I see those same amazing nurses going for their nurse practitioner license and finally realize how much they did not know or understand.

2) There are some amazing nurse practitioners (NPs) and physician assistants (PAs) that know medicine as well if not better than physicians.  These people are honestly rare gems and need to be cherished if you are lucky to have someone in your practice.  But, most NPs and PAs follow a protocol, do it well and tend to have excellent outcomes.  But, I on a regular basis I see these same practitioners miss things that potentially add risk to a patient.  Unfortunately humans do not follow protocols, it takes some nuance, it takes an ability to interpret all the details and information and come up with the right decision which simply does not follow a strict protocol.  I swear, I have pulled an unorthodox pathway from what seems to be out of my ass which deemed to be the correct course of action. I can only attribute that decisions making as experience and knowledge driving me outside of a standard pathway. Those patients are fortunate this has happened as a standard protocol would have resulted in significant morbidity or death.

So I ask you, if today's protocols have so many issues that can potentially lead to mistakes how willing are you to take that risk for yourself and your loved ones?  Are you willing to take a 1 in 50 chance?  What about 1 in 20?

Instead of replacing humans, let us use technology to help make them more efficient and better practitioners that way we have superior outcomes.

pecunia

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Re: What comes after the ACA?
« Reply #5367 on: March 17, 2019, 05:50:34 PM »
"So I ask you, if today's protocols have so many issues that can potentially lead to mistakes how willing are you to take that risk for yourself and your loved ones?  Are you willing to take a 1 in 50 chance?  What about 1 in 20?"

Soooo - What's the probability of the doctor making a mistake?  It seems like I've had a lot of conversations with people who have taken various medicines that the doctor is "trying" on them to see how well they work.   

Any new development will need the bugs eliminated.  I do not have the experience of performing the tasks.  However, I believe the knowledge can be assembled coupled with the right instrumentation to give a very good shot at a diagnosis.  Since the machine doesn't exist, I can't say what probability of success would be achieved, but I would certainly expect that given time the probability of failure would constantly lessen.  Many human tasks have been performed more successfully with machinery and I doubt medicine will prove to be the exception.

In the past the world was running out of kerosene for lamps.  This gave birth to the oil industry which provided an alternative.  A need was there and had to be met.  There is a need for medical service that must be met.  Many people have stated that the needs are not being met with the current system.

This need is like a vacuum.  It will eventually pull alternatives in to replace / augment this failing system.  I was merely suggesting that technology may be at least a partial solution to this problem.  I believe this will happen, but can't say when.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5368 on: March 17, 2019, 06:12:42 PM »
"So I ask you, if today's protocols have so many issues that can potentially lead to mistakes how willing are you to take that risk for yourself and your loved ones?  Are you willing to take a 1 in 50 chance?  What about 1 in 20?"

Soooo - What's the probability of the doctor making a mistake?  It seems like I've had a lot of conversations with people who have taken various medicines that the doctor is "trying" on them to see how well they work.   

Any new development will need the bugs eliminated.  I do not have the experience of performing the tasks.  However, I believe the knowledge can be assembled coupled with the right instrumentation to give a very good shot at a diagnosis.  Since the machine doesn't exist, I can't say what probability of success would be achieved, but I would certainly expect that given time the probability of failure would constantly lessen.  Many human tasks have been performed more successfully with machinery and I doubt medicine will prove to be the exception.

In the past the world was running out of kerosene for lamps.  This gave birth to the oil industry which provided an alternative.  A need was there and had to be met.  There is a need for medical service that must be met.  Many people have stated that the needs are not being met with the current system.

This need is like a vacuum.  It will eventually pull alternatives in to replace / augment this failing system.  I was merely suggesting that technology may be at least a partial solution to this problem.  I believe this will happen, but can't say when.

That is kind of it, medicine has protocols but the science is not 100% which requires trial and error as well as sometimes thinking outside the box. For example the text book heart attack presentation is chest pain radiating to the left arm, sweating, shortness of breath, and a feeling of doom.
I can not remember the last time I saw someone fitting the mold precisely.

I don’t know if you ever heard of IBM’s Watson, a learning computer that IBM currently has going to medical school. Let’s see how Watson does. I’m all for improving technology and helping all of us lead better healthier lives. Tech has been replacing humans in every aspect of industry, I’m sure in time tech will do similar to medicine. We aren’t there yet but it is coming eventually. Recent imaging technology has made immense improvement in diagnosis decreasing unnecessary procedures, and decreasing risk. Tech will continue in assistance us as it has in the past. I’m sure the roles of physicians will need to be flexible with the incoming technology.

pecunia

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Re: What comes after the ACA?
« Reply #5369 on: March 18, 2019, 05:58:09 AM »

- SNIP -

I don’t know if you ever heard of IBM’s Watson, a learning computer that IBM currently has going to medical school. Let’s see how Watson does. I’m all for improving technology and helping all of us lead better healthier lives. Tech has been replacing humans in every aspect of industry, I’m sure in time tech will do similar to medicine. We aren’t there yet but it is coming eventually. Recent imaging technology has made immense improvement in diagnosis decreasing unnecessary procedures, and decreasing risk. Tech will continue in assistance us as it has in the past. I’m sure the roles of physicians will need to be flexible with the incoming technology.

Like the weavers of centuries past, they will have no choice.  Automation will be upon them and benefit the majority.

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Re: What comes after the ACA?
« Reply #5370 on: March 18, 2019, 07:03:35 AM »
That is kind of it, medicine has protocols but the science is not 100% which requires trial and error as well as sometimes thinking outside the box. For example the text book heart attack presentation is chest pain radiating to the left arm, sweating, shortness of breath, and a feeling of doom.
I can not remember the last time I saw someone fitting the mold precisely.

You don't have to fit the mold precisely though.  You just need to build up a certain degree of confidence to provide an answer . . . and then if treatment doesn't seem to be helping the symptoms, modify the treatment.  This is how a typical MD performs right now, isn't it?

Anything that can be broken down into a logical set of repeatable steps to come to an answer can be automated.  The automation may be complex, it may require significant input, but it can be done.  Unless doctors are guessing what to prescribe as treatments, rather than following a standard diagnostic and treatment method their work is certainly automatable.  Automation has a great many benefits over a person doing diagnosis  . . . in that the automation can be kept up to date with the best information much more easily than a population of aging physicians with decaying knowledge.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5371 on: March 18, 2019, 09:16:19 AM »
That is kind of it, medicine has protocols but the science is not 100% which requires trial and error as well as sometimes thinking outside the box. For example the text book heart attack presentation is chest pain radiating to the left arm, sweating, shortness of breath, and a feeling of doom.
I can not remember the last time I saw someone fitting the mold precisely.

You don't have to fit the mold precisely though.  You just need to build up a certain degree of confidence to provide an answer . . . and then if treatment doesn't seem to be helping the symptoms, modify the treatment.  This is how a typical MD performs right now, isn't it?

Anything that can be broken down into a logical set of repeatable steps to come to an answer can be automated.  The automation may be complex, it may require significant input, but it can be done.  Unless doctors are guessing what to prescribe as treatments, rather than following a standard diagnostic and treatment method their work is certainly automatable.  Automation has a great many benefits over a person doing diagnosis  . . . in that the automation can be kept up to date with the best information much more easily than a population of aging physicians with decaying knowledge.

I can not argue with the above. In time technology will replace many jobs around the world. Medicine is not immune to progress.

Interestingly, over the last few decades progress has caused an increase in the cost of delivering medicine. New diagnostic and treatment modalities have not been cheap. The past does not predict the future so who knows how it will turn out.

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Re: What comes after the ACA?
« Reply #5372 on: March 18, 2019, 10:13:25 AM »
I certainly do like the idea of predictive maintenance.  Your analogy to a car mechanic brings the automotive analyzer to mind.  It seems like there would a ready market for a body analyzer to be created by those overpaid West Coast engineers and programmers.  (or elsewhere.)  This would be a product with real value.  It should be created where it would not require an MD to operate it.
Overpaid west coast programmer here.

We can barely keep our own websites running, but you think we can make body devices that accurately diagnose the sick?

+1   :)

I do think tele-medicine and its ilk will become more common.

Way back in the late '80s I installed video conferencing systems.  One of the hot (hyped) uses was tele-medicine.  Aside for some specialized applications it has never really taken off.  I am not holding my breath.

rantk81

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Re: What comes after the ACA?
« Reply #5373 on: March 18, 2019, 12:08:22 PM »
That is kind of it, medicine has protocols but the science is not 100% which requires trial and error as well as sometimes thinking outside the box. For example the text book heart attack presentation is chest pain radiating to the left arm, sweating, shortness of breath, and a feeling of doom.
I can not remember the last time I saw someone fitting the mold precisely.

You don't have to fit the mold precisely though.  You just need to build up a certain degree of confidence to provide an answer . . . and then if treatment doesn't seem to be helping the symptoms, modify the treatment.  This is how a typical MD performs right now, isn't it?

Anything that can be broken down into a logical set of repeatable steps to come to an answer can be automated.  The automation may be complex, it may require significant input, but it can be done.  Unless doctors are guessing what to prescribe as treatments, rather than following a standard diagnostic and treatment method their work is certainly automatable.  Automation has a great many benefits over a person doing diagnosis  . . . in that the automation can be kept up to date with the best information much more easily than a population of aging physicians with decaying knowledge.

I can not argue with the above. In time technology will replace many jobs around the world. Medicine is not immune to progress.

Interestingly, over the last few decades progress has caused an increase in the cost of delivering medicine. New diagnostic and treatment modalities have not been cheap. The past does not predict the future so who knows how it will turn out.

I just hope for the day where we all can just get a series of blood tests, have comprehensive photos taken of our bodies, potentially imaging/ultrasonic data, and input any complaints/symptoms we have ---> And then just input that whole combination of data into an expert/AI system, which uses millions and millions of previously-known data-points (on other patients) to accurately figure out what is wrong and what to do about it (with confidence intervals.)

(Side Note: I suppose we are a long way off from that, as long we are still getting recommendations from doctors and the American Diabetes Association that folks with insulin resistance should be consuming things that spike insulin response, like "whole grains" and fruit juices.... Or liberally prescribing statins when there hasn't been any causal link between high LDL and heart disease,....)
« Last Edit: March 18, 2019, 12:16:04 PM by rantk81 »

katsiki

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Re: What comes after the ACA?
« Reply #5374 on: March 18, 2019, 08:19:23 PM »
I do think tele-medicine and its ilk will become more common.

Way back in the late '80s I installed video conferencing systems.  One of the hot (hyped) uses was tele-medicine.  Aside for some specialized applications it has never really taken off.  I am not holding my breath.

Maybe you are referring to a different type of tele-medicine..  perhaps video specifically.  Tele-medicine is already here and has been for a while.  In my not advanced state (ha!), we have it with most major insurers.  I also have it through my PCP.  A few years back, we had it through a third-party service.  They could do anything non-emergency in terms of PCP or basic physician duties.

I would love to see insurers and govt programs leverage this to reduce costs for everyone.  Why go see a doctor and create a big administrative burden for a common cold, etc?  Complete waste of time and money for everyone involved.  Diagnose over the phone, call in a pill and you're done.

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Re: What comes after the ACA?
« Reply #5375 on: March 18, 2019, 08:44:53 PM »
I feel like Kaiser does a good job of this already with their advice nurse line. Or at least that is my first line of defense when I have questions about my kiddos. For myself I usually email a doctor and wait a day or two for a response. For regular meds I can get refills in the mail, which rocks. I will say, I felt a bit strange emailing the pediatrician a photo of a particularly bad bout of diaper rash. I cropped that photo down to the point that it could have been a rash anywhere and you would have never known, but I was still grateful for the separate secure medical email versus my regular gmail or whatnot.

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Re: What comes after the ACA?
« Reply #5376 on: March 19, 2019, 10:58:25 PM »
I feel like Kaiser does a good job of this already with their advice nurse line. Or at least that is my first line of defense when I have questions about my kiddos. For myself I usually email a doctor and wait a day or two for a response. For regular meds I can get refills in the mail, which rocks. I will say, I felt a bit strange emailing the pediatrician a photo of a particularly bad bout of diaper rash. I cropped that photo down to the point that it could have been a rash anywhere and you would have never known, but I was still grateful for the separate secure medical email versus my regular gmail or whatnot.

Kaiser has done a great job at keeping patients out of expensive emergency rooms.  They also request any patient admitted outside of a Kaiser hospital, if stable to be transferred to a Kaiser facility to keep costs down.  Compared to other models Kaiser pays providers significantly less, but they have very nice benefits and quality of life which plenty of physicians are willing to make the trade.  This is a great example proving that plenty of docs will be happy to cut their pay if their work life balance was improved as well. 

Threshkin

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Re: What comes after the ACA?
« Reply #5377 on: March 20, 2019, 12:43:56 PM »
I do think tele-medicine and its ilk will become more common.

Way back in the late '80s I installed video conferencing systems.  One of the hot (hyped) uses was tele-medicine.  Aside for some specialized applications it has never really taken off.  I am not holding my breath.

Maybe you are referring to a different type of tele-medicine..  perhaps video specifically.  Tele-medicine is already here and has been for a while.  In my not advanced state (ha!), we have it with most major insurers.  I also have it through my PCP.  A few years back, we had it through a third-party service.  They could do anything non-emergency in terms of PCP or basic physician duties.

I would love to see insurers and govt programs leverage this to reduce costs for everyone.  Why go see a doctor and create a big administrative burden for a common cold, etc?  Complete waste of time and money for everyone involved.  Diagnose over the phone, call in a pill and you're done.
Yes, at that time the concept was enabling doctors and specialists to interact with people in remote locations where the population was insufficient to support a local doctor.  One of the big problems was that in most cases these small population centers did not have enough money to buy the videoconferencing, bandwidth to make the video usable, technical expertise to keep the system running or all of the above.

The only places where this use of video conferencing was marginally successful were locations where money or ROI didn't matter much.  Mainly remote military bases or heavily subsidized communities.     

pecunia

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Re: What comes after the ACA?
« Reply #5378 on: March 26, 2019, 05:42:36 PM »
That orange haired wonder doesn't give up.  Why he doesn't give up is a wonder.  It's got to be based on money for himself and his buds.

https://www.denverpost.com/2019/03/25/trump-administration-obama-affordable-care-act/


Trump administration asks court to totally repeal Obama’s Affordable Care Act
House Speaker Nancy Pelosi, D-Calif., pledged that Democrats would “fight relentlessly” to preserve “affordable, dependable health care.”

In a significant shift, the Justice Department now says it backs a full repeal of the Affordable Care Act, the signature Obama-era health law.

It divulged its position in a legal filing Monday with the U.S. Court of Appeals for the 5th Circuit in New Orleans, where an appeal is pending in a case challenging the measure’s constitutionality. A federal judge in Texas ruled in December that the law’s individual mandate “can no longer be sustained as an exercise of Congress’s tax power” and further found that the remaining portions of the law are invalid.

Previously, the Trump administration had not gone as far, arguing in a June brief that the penalty for not buying insurance could be distinguished from other provisions of the law, which could still stand.

Officials said there were legal grounds only to strike down the law’s consumer protections, including those for people with pre-existing health conditions.

But in the new filing, signed by three Justice Department attorneys, the administration said that the decision of U.S. District Judge Reed O’Connor should be affirmed and that the entirety of the ACA should be invalidated.

“Because the United States is not urging that any portion of the district court’s judgment be reversed, the government intends to file a brief on the appellees’ schedule,” the filing stated.

If it were successful, the Justice Department’s position supporting the judge’s ruling would potentially eliminate health care for millions of people and create widespread disruption across the U.S. health care system — from removing no-charge preventive services for older Americans on Medicare to voiding the expansion of Medicaid in most states. The change comes as newly empowered Democrats in the House have vowed to protect the ACA from Republican attacks.

House Speaker Nancy Pelosi, D-Calif., pledged in a tweet Monday night that Democrats would “fight relentlessly” to preserve “affordable, dependable health care.”

Timothy Jost, an emeritus professor at the Washington and Lee University law school, called the Justice Department’s new position “crazy” and “legally untenable.”

“I can’t believe that even the 5th Circuit would take that position,” he said in an interview, suggesting that arguably the nation’s most conservative appeals court would still be reluctant to accept the reasoning backed by the administration. “It would be like invalidating the Interstate Highway System, causing chaos on an unimaginable scale. It’s conceivable that the entire Medicare payment system would collapse.”

The filing reflected “a strictly political decision, not a legal decision,” Jost said. “Trump has wanted to get rid of the ACA, and I guess he sees an opportunity here.”

I've asked this before.  Is there any motivation other than protecting rich and powerful people to do this?  Why remove health care from poor people?  Is it part of the "let them eat cake" thinking?  The answer i received before was basically "yes."  I still find it hard to believe.

sol

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Re: What comes after the ACA?
« Reply #5379 on: March 26, 2019, 06:27:30 PM »
We have previously discussed this case this justice department reversal refers to, in this very thread.  It appears to have so little legal grounds as to be laughable, like I couldn't find a single lawyer on the internet who thought it would hold up, except for the ones who wrote it and even they appeared to be taking a shot in the dark.

But if it did hold up, the ACA would be repealed, whole cloth, overnight.  There is no backup plan, no alternative in the works.  It would just shut down the subsidies, the reinsurance programs, the state exchanges, the consumer protections, everything.  Trump promised "beautiful, terrific, the best health care" for everyone by repealing and replacing the ACA.  It seems he has given up on the replacing part, but is still kind of keen on the repealing part?  I don't think anyone believes that would be an improvement over the current system.  There are lots of ways to improve the current system, but just blowing up the ACA without any sort of backup plan doesn't seem to be one of them.

ysette9

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Re: What comes after the ACA?
« Reply #5380 on: March 26, 2019, 06:35:56 PM »
Naively, it seems blowing up healthcare would be a big political liability for the next elections. Then again, normal rules don’t apply to this dude.

DavidAnnArbor

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Re: What comes after the ACA?
« Reply #5381 on: March 26, 2019, 07:04:16 PM »
I think the White House also calls for drastic cuts to Medicaid and Medicare in their budget proposal.

Paul der Krake

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Re: What comes after the ACA?
« Reply #5382 on: March 26, 2019, 07:11:16 PM »
I think the White House also calls for drastic cuts to Medicaid and Medicare in their budget proposal.
Presidential budgets are little more than virtue signaling. Here's an article of Bush doing the same thing in 2008:
https://abcnews.go.com/Health/Healthday/story?id=4510329&page=1

I'd be shocked if cuts to entitlement haven't been proposed by every Republican president since WW2. Enacting them is a different story.

Exflyboy

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Re: What comes after the ACA?
« Reply #5383 on: March 26, 2019, 11:21:21 PM »
Naively, it seems blowing up healthcare would be a big political liability for the next elections. Then again, normal rules don’t apply to this dude.

Normal rules don't apply because his followers are so stupid you can tell them almost anything and they seem to believe it! If he repeals the ACA they'll still vote him in all while chanting "make America Great Again!"

Meanwhile deficit spending is going through the roof because the "tax cuts are paying for themselves"..

Sadly I think he'll get in again in 2020. I just hope the Dems come back from the brink and invent some sensible ideas so they become electible..:)

sol

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Re: What comes after the ACA?
« Reply #5384 on: March 27, 2019, 12:00:21 AM »
Normal rules don't apply because his followers are so stupid you can tell them almost anything and they seem to believe it!

Now now, that's not nice. 

But I do agree that there is core group of Trump's base supporters that will support him whatever he does, regardless of the consequences.  They hate Obama, so they hate the ACA.  They love Trump, so they love anything he does in including spitting on them.  For some people, it's not really about the issues or the implications, it's just about supporting their "team".  That makes them low-information voters, but it doesn't make them stupid.  They might also be stupid for other reasons, I guess, but not necessarily for this reason alone.

And let's not forget that the primary goal of the Russian election interference was not just to help Trump win the election, but more broadly to undermine American power by pitting Americans against each other.  The Russians worked hard to sow divisions.  They stoked hate groups on both sides of the political isle.  They want us at each other's throats, arguing over everything, unable to agree on doing anything in particular.  They want us to destroy ourselves from within.  Maybe don't help them out?

Let's not forget that we're all Americans, and we're supposed to be on the same side.  We all want responsible leadership.  We all want affordable health care.  We all want to protect America's interests abroad, and that includes protecting our institutions at home.  Some Americans will cheer for the destruction of the ACA solely because the democrats want to protect it, and that's the sort of national rift that makes Putin feel all warm and fuzzy inside. 

If we could instead remember that we all want affordable healthcare, maybe we could start to have a real conversation about how to achieve that, without theatrics like the Justice Department backing an obviously untenable interpretation of the law in order get the ACA overturned just because Trump hates Obama so much.

EnjoyIt

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Re: What comes after the ACA?
« Reply #5385 on: March 27, 2019, 10:11:57 AM »
Normal rules don't apply because his followers are so stupid you can tell them almost anything and they seem to believe it!

Now now, that's not nice. 

But I do agree that there is core group of Trump's base supporters that will support him whatever he does, regardless of the consequences.  They hate Obama, so they hate the ACA.  They love Trump, so they love anything he does in including spitting on them.  For some people, it's not really about the issues or the implications, it's just about supporting their "team".  That makes them low-information voters, but it doesn't make them stupid.  They might also be stupid for other reasons, I guess, but not necessarily for this reason alone.

And let's not forget that the primary goal of the Russian election interference was not just to help Trump win the election, but more broadly to undermine American power by pitting Americans against each other.  The Russians worked hard to sow divisions.  They stoked hate groups on both sides of the political isle.  They want us at each other's throats, arguing over everything, unable to agree on doing anything in particular.  They want us to destroy ourselves from within.  Maybe don't help them out?

Let's not forget that we're all Americans, and we're supposed to be on the same side.  We all want responsible leadership.  We all want affordable health care.  We all want to protect America's interests abroad, and that includes protecting our institutions at home.  Some Americans will cheer for the destruction of the ACA solely because the democrats want to protect it, and that's the sort of national rift that makes Putin feel all warm and fuzzy inside. 

If we could instead remember that we all want affordable healthcare, maybe we could start to have a real conversation about how to achieve that, without theatrics like the Justice Department backing an obviously untenable interpretation of the law in order get the ACA overturned just because Trump hates Obama so much.

Very well said. I could not agree with you more.

soccerluvof4

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Re: What comes after the ACA?
« Reply #5386 on: March 27, 2019, 10:38:53 AM »
Normal rules don't apply because his followers are so stupid you can tell them almost anything and they seem to believe it!

Now now, that's not nice. 

But I do agree that there is core group of Trump's base supporters that will support him whatever he does, regardless of the consequences.  They hate Obama, so they hate the ACA.  They love Trump, so they love anything he does in including spitting on them.  For some people, it's not really about the issues or the implications, it's just about supporting their "team".  That makes them low-information voters, but it doesn't make them stupid.  They might also be stupid for other reasons, I guess, but not necessarily for this reason alone.

And let's not forget that the primary goal of the Russian election interference was not just to help Trump win the election, but more broadly to undermine American power by pitting Americans against each other.  The Russians worked hard to sow divisions.  They stoked hate groups on both sides of the political isle.  They want us at each other's throats, arguing over everything, unable to agree on doing anything in particular.  They want us to destroy ourselves from within.  Maybe don't help them out?

Let's not forget that we're all Americans, and we're supposed to be on the same side.  We all want responsible leadership.  We all want affordable health care.  We all want to protect America's interests abroad, and that includes protecting our institutions at home.  Some Americans will cheer for the destruction of the ACA solely because the democrats want to protect it, and that's the sort of national rift that makes Putin feel all warm and fuzzy inside. 

If we could instead remember that we all want affordable healthcare, maybe we could start to have a real conversation about how to achieve that, without theatrics like the Justice Department backing an obviously untenable interpretation of the law in order get the ACA overturned just because Trump hates Obama so much.




This could not be better said. The greatest country in the world is so busy arguing whos fault is what that something like this if they would all shut there pie holes , sit down, and make something that works for the American people examining what has or has not worked in other countries, I would think we could come up with a system that works and works well. And all party's involved so just like one side doesn't take all the blame from one election to the other one doesn't take all the credit. Its just so juvenile by all.

sherr

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Re: What comes after the ACA?
« Reply #5387 on: March 28, 2019, 09:44:29 AM »
This could not be better said. The greatest country in the world is so busy arguing whos fault is what that something like this if they would all shut there pie holes , sit down, and make something that works for the American people examining what has or has not worked in other countries, I would think we could come up with a system that works and works well. And all party's involved so just like one side doesn't take all the blame from one election to the other one doesn't take all the credit. Its just so juvenile by all.

That's exactly what the Democrats tried to do with the ACA. It's based in a lot of ways off of a Heritage Foundation (conservative think-tank) plan from the 90's, they accepted hundreds of Republican amendments to the ACA, and Obama was constantly pleading with Republicans to come to the negotiating table and help them craft something that could pass with broad bipartisan support. Precisely so that it wouldn't be an ultra-partisan issue.

Republicans refused. They had already openly decided on a policy of unwavering obstruction to attempt to make Obama a 1-term president, and thus history was set. Even now they are completely uninterested in working with Democrats to modify, fix, or update the ACA, only to "repeal" it so that they can replace it with a "Republican version". Republicans didn't even let the Democrats see their replacement ideas until a couple hours before the vote, much less ask for input and cooperation.

If we want bipartisanship we need to elect better Republican representatives. Or at least get rid of McConnell. Bipartisanship requires two sides who are willing to work together, and right now we only have one.
« Last Edit: March 28, 2019, 10:07:11 AM by sherr »

Monkey Uncle

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Re: What comes after the ACA?
« Reply #5388 on: March 28, 2019, 06:11:41 PM »
If we want bipartisanship we need to elect better Republican representatives. Or at least get rid of McConnell. Bipartisanship requires two sides who are willing to work together, and right now we only have one.

I'm beginning to wonder if there is such thing as a better Republican, except maybe for Susan Collins.  My own state's Republican senator (Capito) has a reputation for being bipartisan, but she voted in lockstep with McConnell et al. on repealing the ACA; she even voted for the insane last-minute Hail Mary bill that would have repealed the ACA with no replacement whatsoever.  This despite the fact that tens of thousands of her own poor constituents finally gained access to health insurance under the ACA's Medicaid expansion.  That's what passes for "bipartisanship" in today's Republican party.

I think a better idea would be just getting rid of the Republican party entirely, and then splitting the Democratic party in two.  There's more than enough ideological diversity between the two poles of the Democratic party to form two functional parties.  See: Joe Manchin vs. Alexandria Ocasio-Cortez.

jim555

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Re: What comes after the ACA?
« Reply #5389 on: March 28, 2019, 07:16:41 PM »
Good news for Medicaid...

Judge Blocks Medicaid Work Requirements in Arkansas and Kentucky
https://www.nytimes.com/2019/03/27/health/medicaid-work-requirement.html

"WASHINGTON — A federal judge on Wednesday threw out Medicaid work requirements in two states, a blow to Republican efforts to profoundly reshape a program that has provided free health insurance to the poorest Americans for more than 50 years.

In twin rulings, Judge James E. Boasberg of the Federal District Court for the District of Columbia rejected for a second time Kentucky’s attempt to require recipients to work or volunteer as a condition of coverage and blocked a similar rule in Arkansas, which has resulted in more than 18,000 people there losing coverage since last summer.

So far, the Trump administration has allowed eight states to begin requiring many of their Medicaid recipients to work, volunteer or train for a job to be eligible for benefits. Seven other states are seeking permission from the Department of Health and Human Services to impose similar rules....."

Exflyboy

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Re: What comes after the ACA?
« Reply #5390 on: March 28, 2019, 08:02:15 PM »
Seems on the one side we have Trump repealing and er repealing.. On the other we have Dems starting to bark about jacking up long term cap gains rates and wealth taxes!

Choose your crazy in 2020.. Ugh!

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Re: What comes after the ACA?
« Reply #5391 on: March 28, 2019, 08:02:23 PM »
That is some good news this morning.

ysette9

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Re: What comes after the ACA?
« Reply #5392 on: March 28, 2019, 08:05:31 PM »
Seems on the one side we have Trump repealing and er repealing.. On the other we have Dems starting to bark about jacking up long term cap gains rates and wealth taxes!

Choose your crazy in 2020.. Ugh!
Let’s be serious though: we could stand to have the long term capital gains rates go up.
Sure, it would negatively impact me, but I can afford it.

When we had some financial consulting recently tell us that we could FIRE with something like $100k/yr spending from investments and pay no federal taxes at all, qualify for ACA subsidies, and possibly even qualify for college financial aid down the line should we spend our taxable account down to zero by the time our kids grow up, I was blown away. It’s an awesome boon for me, but it hardly seems fair.

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5393 on: March 29, 2019, 05:51:47 AM »
Good news for Medicaid...

Judge Blocks Medicaid Work Requirements in Arkansas and Kentucky
https://www.nytimes.com/2019/03/27/health/medicaid-work-requirement.html

"WASHINGTON — A federal judge on Wednesday threw out Medicaid work requirements in two states, a blow to Republican efforts to profoundly reshape a program that has provided free health insurance to the poorest Americans for more than 50 years."
My understanding is that these types of requirements typically apply (or are intended to apply) only to able-bodied people who are simply choosing not to work.  Why is blocking such rules a good thing?

jim555

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Re: What comes after the ACA?
« Reply #5394 on: March 29, 2019, 07:30:32 AM »
Helpful ACA ruling against Association Health Plans.

Trump’s Group Health Plan Rules Struck Down as ACA ‘End-Run’
https://www.bloomberg.com/news/articles/2019-03-28/trump-s-group-health-plan-rules-struck-down-as-aca-end-run

"One of President Donald Trump’s health-care initiatives intended as a cheaper alternative to Obamacare suffered a crucial defeat when a judge ruled the policy violates the Affordable Care Act.

U.S. District Judge John Bates in Washington on Thursday blocked new rules governing so-called association health plans, or AHPs, which let businesses and individuals band together to create group health plans that offer less expensive coverage than the ACA -- but without some of its protections....."

Mr. Green

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Re: What comes after the ACA?
« Reply #5395 on: March 29, 2019, 10:17:46 PM »
Good news for Medicaid...

Judge Blocks Medicaid Work Requirements in Arkansas and Kentucky
https://www.nytimes.com/2019/03/27/health/medicaid-work-requirement.html

"WASHINGTON — A federal judge on Wednesday threw out Medicaid work requirements in two states, a blow to Republican efforts to profoundly reshape a program that has provided free health insurance to the poorest Americans for more than 50 years."
My understanding is that these types of requirements typically apply (or are intended to apply) only to able-bodied people who are simply choosing not to work.  Why is blocking such rules a good thing?
I suppose if you were 55 or 60 and felt like you could retire and live off 20k a year comfortably, the income limits for the ACA could force you to use Medicaid depending on your household size. So either you're forced to earn more money to qualify for private insurance or forced to work for Medicaid? Kind of a bummer.

zolotiyeruki

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Re: What comes after the ACA?
« Reply #5396 on: March 30, 2019, 06:19:45 AM »
I don't see a problem with that, though. Either way, you're trying to make other people pay for your health insurance when you are perfectly capable of providing it for yourself. Healthcare costs should be factored into the decision to retire.

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Re: What comes after the ACA?
« Reply #5397 on: March 30, 2019, 01:16:55 PM »
I don't see a problem with that, though. Either way, you're trying to make other people pay for your health insurance when you are perfectly capable of providing it for yourself. Healthcare costs should be factored into the decision to retire.

Medicaid work requirements are designed to bury people under complicated paperwork to either prove they can't work or prove that they're working enough. They are kafkaesque rules that wash people out of the system that are eligible for coverage but can't complete the absurd amounts of paperwork for whatever reason. These programs typically cost more to implement than they save in direct costs. Add in the indirect costs of people delaying care because they don't have coverage and ending up in the ER where they can't pay the bill and work requirement polices make zero sense. These polices are designed to hurt people. Full stop.
« Last Edit: March 30, 2019, 01:20:57 PM by protostache »

sol

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Re: What comes after the ACA?
« Reply #5398 on: March 30, 2019, 01:36:35 PM »
I don't see a problem with that, though. Either way, you're trying to make other people pay for your health insurance when you are perfectly capable of providing it for yourself. Healthcare costs should be factored into the decision to retire.

Wouldn't this problem be made much simpler if we just forced everyone to pay for minimal health coverage, through taxes?  We already do this with OASDI taxes, and I think millions of Americans would be better off if we raised those taxes in exchange for "free" basic health insurance through an extended federal program that covered people under 65 too.

That way, no one has to go without health insurance for any reason, and people who genuinely don't have any money don't have to die in the streets.  I mean we already provide basic emergency coverage to those folks, but right now the rest of us pay for it with increased rates instead of everyone contributing to their own good health.

It's always struck me that the republican's "personal responsibility" narrative was somehow shoehorned into a system that encourages freeloaders.  Universal coverage, paid for with taxes, would make every individual responsible in a way that our current system does not.
« Last Edit: March 30, 2019, 02:24:03 PM by sol »

jim555

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Re: What comes after the ACA?
« Reply #5399 on: March 30, 2019, 01:50:45 PM »
The problem is the Republicans tried and failed to change the law.  So "rule of law" goes out the window and they try to add conditions (work requirements) that don't exist in the law through a waiver process.  This is an abuse of what a waiver is for, to try out new things that will help the ends of Medicaid program.  Something designed to take away coverage from people is not helping the ends of the program, it is arbitrary, capricious and unlawful.  States do not have to expand Medicaid, but if they do, they must abide by law.  The Feds pay 90% of the costs of the expansion group.  States are not saving much after they factor in all the added administrative costs of a work requirement scheme.