Affordable Care Act challenged at Supreme Court

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I was wondering if I could hear from those who have kept up with this topic a bit more... What kind of consequences can future physicians (whether in primary care or not) can expect from the Affordable Care Act being kept or trashed? (in terms of workload, daily practice and paperwork, paycheck, etc) And of course no one knows for sure, but any predictions on which way it'll go?

Most commentary that I've heard predicts that the Court will uphold the law. As for what will happen, who knows - even healthcare economists aren't entirely sure what its impact will be.

Originally Posted by luckyducky87

I was wondering if I could hear from those who have kept up with this topic a bit more... What kind of consequences can future physicians (whether in primary care or not) can expect from the Affordable Care Act being kept or trashed? (in terms of workload, daily practice and paperwork, paycheck, etc) And of course no one knows for sure, but any predictions on which way it'll go?

Effects will be a lot more mild then people think. The ACA is not true healthcare reform, it is just minor insurance reform + an individual mandate. It does nothing to change how the system works. There will be an expansion both of the private insurance population due to the mandate (good for physicians) as well as the medicaid population (good for people to be on insurance, bad for physician payer mixes)

Net insurance prices may change, but its hard to predict how. More healthy people buying insurance = offsetting risk = lower costs. Inability to shut out people with preexisting conditions = higher costs, but good for social justice.

As for this case, unless the conservative judges act in a partisan manner, it will not be struck down. There is ample precedent for congress to force you to buy something (think automobile insurance) or change/make something (restrictions on agricultural output)

Sorry if this is a really ignorant question, but doesn't the fact that more people have insurance (which, of course, is a good thing for the society) mean that the workload of physicians will go up even more, especially with such slow progress in increasing the # of physicians?

Originally Posted by luckyducky87

Sorry if this is a really ignorant question, but doesn't the fact that more people have insurance (which, of course, is a good thing for the society) mean that the workload of physicians will go up even more, especially with such slow progress in increasing the # of physicians?

Sure, in theory, but just because there are more people to see doesn't mean they're all going to get seen quickly. I would guess that many physician groups will have x number of openings for commercial insurance, y for Medicare, z for Medicaid/charity/government and, of course, x >> y > z to ensure financial viability of the practice. This would result in the commercial patients being seen most quickly (perhaps a 2-4 week wait), followed by Medicare (perhaps a 1-2 month wait), and finally the Medicaid/charity/government patients (perhaps a 3-6 month wait). This is, of course, assuming the feds don't create specific limits on wait times. (Of course, in that case, those patients may simply be turned away due to a full schedule.) Those numbers, btw, are roughly based on what I see in the clinics locally. For those with commercial insurance, doctor's offices will generally see you within a few weeks. For those with Medicare (or Tricare), there are more restrictions (e.g., no double-booking Medicare patients to reduce the impact of no-shows) and reimbursements rarely cover the cost of the appointment (much less provide any revenue). As a result, these patients may have to wait up to double the amount of time for an appointment. Medicaid and charity patients are only seen by certain clinics and, where I am anyway, the wait times can easily exceed 6 months. Last I heard, the main safety net clinic here was still working through new patient applications from late November/early December in mid-March this year.

this is my understanding of the issue: insurance spreads risk around the population. if you have 100 people and there's a 1 percent chance of a life threatening illness, then on average, one person will suffer from it. in a system in which people pay the costs out of pocket and it costs one hundred thousand dollars, then the person who was unlucky enough to fall ill cannot pay and will die. but if everyone pays a thousand dollars as insurance since they all have the same probability of falling ill, then it's likely that the one person will be cured and everyone will be fine.

having more people on insurance is a good thing since they can have regular checkups and have relatively minor issues taken care of before they become much more difficult to treat. people who get sick and don't have insurance still get treated at hospitals but in the end, the costs are still spread out to those who have the means to pay. i think the main benefit is having peace of mind, knowing that you won't be financially ruined by receiving treatment and won't have trouble staying with your provider despite a chronic illness.

Most likely result in my opinion is 6-3 in favor, with the second result being 5-4 against (split down party lines).

In the unlikely but possible event that ACA gets over-ruled, everyone gets bumped over to Medicare.

the Supreme Court hearing of the healthcare law and, by the questioning by the court's conservative justices, the individual mandate, the central tenant of the law, seems to be in jeopardy. If this piece of the law is struck down, the entire law is on shaky ground.

Now, if it is indeed struck down, then this leads to another question: what do we do then to reform healthcare? It is clear that the current trajectory of healthcare costs is unsustainable. Insurance premiums are rising at a faster clip than inflation, insurance companies can cherry pick who they cover, even medical school costs are through the roof!

I do hope my prefered option, that of a single payer system or an insurance exchange, will get a second look. I don't have a problem with the private sector, but if we leave healthcare in the hands of private businesses, costs WILL NEVER go down. The higher premiums we pay each year is just the increased profits insurance companies need for their shareholders.

In the context of medical school costs, if we had a single payer system, medical school costs will not be soo astronomical high.Yes, salaries under such a system will be slightly less, but you wouldn't have such a grave debt burden hovering over your head. Just look at Canada!

Easy there, tiger. The decision won't be rendered until June. Until then, we'd just be speculating/opening up arguments that are only tangentially related to being a neurotic pre-med whose life is over because they got an A- and don't have a URM to marry to make them a URM.

I know that the decision will not be handed down until June, and that it is unproductive to speculate before then. I was just sharing my thought in the event that the bill were to be struck down.

Originally Posted by GimpGenius

Easy there, tiger. The decision won't be rendered until June. Until then, we'd just be speculating/opening up arguments that are only tangentially related to being a neurotic pre-med whose life is over because they got an A- and don't have a URM to marry to make them a URM.

this is going to be around for a very long time lol

http://www.cnn.com/video/?hpt=hp_t2#...in-mandate.cnn

Merging related threads.

Originally Posted by pkwraith

Most likely result in my opinion is 6-3 in favor, with the second result being 5-4 against (split down party lines).

In the unlikely but possible event that ACA gets over-ruled, everyone gets bumped over to Medicare.

Unfortunately for your theory, the 5-4 split would be in the other direction (i.e., ruling against the ACA).

Also, a short little NYT article discussing this: http://www.nytimes.com/2012/03/28/us...-partisan.html

Originally Posted by pkwraith

Most likely result in my opinion is 6-3 in favor, with the second result being 5-4 against (split down party lines).

In the unlikely but possible event that ACA gets over-ruled, everyone gets bumped over to Medicare.

I think he understands this.

The real question is can the rest of it can stand if they deem the mandate unconstitutional.

Originally Posted by luckyducky87

I was wondering if I could hear from those who have kept up with this topic a bit more... What kind of consequences can future physicians (whether in primary care or not) can expect from the Affordable Care Act being kept or trashed? (in terms of workload, daily practice and paperwork, paycheck, etc) And of course no one knows for sure, but any predictions on which way it'll go?

Scenario #1: individual mandate upheld:
Reform patches existing system so that it staggers on for another 10-20 years before finally imploding. Result: single payer administered at the state level with concierge option for filthy rich.

Scenario #2: mandate struck down, rest of law goes belly up:
Current system implodes in <15 years due to vicious cycle of rising premiums and shrinking pools. Result: single payer administered at the state level with concierge option for filthy rich.

Scenario #3: mandate struck down, rest of law intact:
Version A: Congress finds new revenue patch that doesn't offend the SCOTUS. See Scenario #1.
Version B: Congress fails to find a new revenue patch, resulting semi-reformed system implodes in <10 years. Result: you guessed it.

Originally Posted by link2swim06

The real question is can the rest of it can stand if they deem the mandate unconstitutional.

Don't think it will. The lack of a mandate would lead to a slew of problems like adverse selection (people picking up insurance only when it's convenient).

Originally Posted by Gut Shot

Scenario #1: individual mandate upheld:
Reform patches existing system so that it staggers on for another 10-20 years before finally imploding. Result: single payer administered at the state level with concierge option for filthy rich.

Scenario #2: mandate struck down, rest of law goes belly up:
Current system implodes in <15 years due to vicious cycle of rising premiums and shrinking pools. Result: single payer administered at the state level with concierge option for filthy rich.

Scenario #3: mandate struck down, rest of law intact:
Version A: Congress finds new revenue patch that doesn't offend the SCOTUS. See Scenario #1.
Version B: Congress fails to find a new revenue patch, resulting semi-reformed system implodes in <10 years. Result: you guessed it.

Everyone says that the current system is unsustainable and will implode. I agree with this, but what exactly does implode mean? Outside of premiums getting higher and higher every year, is there really anything that will act as a sufficient trigger to enact such a significant change?

I can see where we are, and see that potential end point, but have trouble seeing exactly what this crisis is that will suddenly make this scarily right-leaning country accept single payer.

Originally Posted by DoctwoB

Everyone says that the current system is unsustainable and will implode. I agree with this, but what exactly does implode mean? Outside of premiums getting higher and higher every year, is there really anything that will act as a sufficient trigger to enact such a significant change?

I can see where we are, and see that potential end point, but have trouble seeing exactly what this crisis is that will suddenly make this scarily right-leaning country accept single payer.

It will be the rising costs that eventually break the current system. You cannot outpace inflation forever. It will catch up to you eventually. Education costs are in a similar boat.

Sent from my HTC Glacier using Tapatalk

Originally Posted by NickNaylor

Most commentary that I've heard predicts that the Court will uphold the law. As for what will happen, who knows - even healthcare economists aren't entirely sure what its impact will be.

I was listening to the audio and reading the transcripts at http://www.supremecourt.gov/ and it doesn't look like the justices are fans of the law. After listening to today's arguments, it seems like there is a higher chance of the mandate getting struck down.

Originally Posted by DoctwoB

Everyone says that the current system is unsustainable and will implode. I agree with this, but what exactly does implode mean? Outside of premiums getting higher and higher every year, is there really anything that will act as a sufficient trigger to enact such a significant change?

I can see where we are, and see that potential end point, but have trouble seeing exactly what this crisis is that will suddenly make this scarily right-leaning country accept single payer.

One possible scenario involves health insurers not being able to find enough customers who can afford the premiums. A few massive bankruptcies will leave large swaths of people without coverage, begging local, state, and/or federal authorities to step in and provide public insurance. It would be pretty dramatic.

Think of this as the post-hurricane model. When natural disasters left private flood insurance an untenable option in many southern coastal regions, the feds had to provide coverage.

Another option would emerge if the number of uninsured reaches levels large enough to start turning state elections. Blue and purple states might start following Vermont's lead in establishing single-payer systems. Such systems would essentially run private insurance out of business, with the exception of gap insurance policies.

Originally Posted by jippyslim

Now, if it is indeed struck down, then this leads to another question: what do we do then to reform healthcare? It is clear that the current trajectory of healthcare costs is unsustainable. Insurance premiums are rising at a faster clip than inflation, insurance companies can cherry pick who they cover, even medical school costs are through the roof!

1. Cut down on new tech. That's the biggest cost factor right now.
2. Malpractice reform. The threat of malpractice leads to CYA diagnoses and treatments, and the use of the greatest and bestest tech.

Originally Posted by Gut Shot

Another option would emerge if the number of uninsured reaches levels large enough to start turning state elections. Blue and purple states might start following Vermont's lead in establishing single-payer systems. Such systems would essentially run private insurance out of business, with the exception of gap insurance policies.

And single payer --> less salaries for doctors?

Originally Posted by ElCapone

And single payer --> less salaries for doctors?

Not a fan of a single payer system, but people need to realize that doctors' salaries are going to go down regardless. Single payer system, we all know why. If we stay on the for profit sysem, we will reach a point were people aren't going to pay higher premiums and companies will continue to look for ways to increase profits. Insurance companies will begin to pay what single payers pay. There is no scenario that results in doctors continuing to make what they do now (at least not the cash doctors like plastic surgeons).

I think gut shot is right. The system is about to go bellyup if we don't make a change to the system. Patching it doesn't fix it.

Originally Posted by NickNaylor

Unfortunately for your theory, the 5-4 split would be in the other direction (i.e., ruling against the ACA).

Seems like it's going to be that way in reality.

There are 9 judges on the court.

4 Democrat: Ginsburg, Breyer, Kagan and Sotomayor

4 Republican: Scalia, Thomas, Alito and Robers (Chief justice)

1 Swinger: Kennedy

The NY Times reports the decision as going largely along party lines. So that's 4 For and 4 Against. Now, Kennedy is known to swing from one party line to another and the NY Times also said that he seems to be against the bill.

So 5-4 against, but I wouldn't bet on that since the court has a history of producing surprises.

x

Originally Posted by kpcrew2oo2

this is my understanding of the issue: insurance spreads risk around the population. if you have 100 people and there's a 1 percent chance of a life threatening illness, then on average, one person will suffer from it. in a system in which people pay the costs out of pocket and it costs one hundred thousand dollars, then the person who was unlucky enough to fall ill cannot pay and will die. but if everyone pays a thousand dollars as insurance since they all have the same probability of falling ill, then it's likely that the one person will be cured and everyone will be fine.

having more people on insurance is a good thing since they can have regular checkups and have relatively minor issues taken care of before they become much more difficult to treat. people who get sick and don't have insurance still get treated at hospitals but in the end, the costs are still spread out to those who have the means to pay. i think the main benefit is having peace of mind, knowing that you won't be financially ruined by receiving treatment and won't have trouble staying with your provider despite a chronic illness.

I'm totally in favor of helping low-income people pay for health care. My big concern is that we have to be careful when we separate actions from consequences. If you eat fast food and get diabetes, you should face the health and financial consequences of your decisions. If you smoke and get COPD or emphysema, the bill should be yours to foot.

It also be a good idea to limit where welfare debit cards can be purchased, and what they can be used to buy. Since everything is scanned now, it wouldn't be hard to make the debit cards NOT work at fast food joints, or for any purchase that includes hard liquor, cigarettes, etc. Just an idea...

Originally Posted by Joe the Plumber

I'm totally in favor of helping low-income people pay for health care. My big concern is that we have to be careful when we separate actions from consequences. If you eat fast food and get diabetes, you should face the health and financial consequences of your decisions. If you smoke and get COPD or emphysema, the bill should be yours to foot.

It also be a good idea to limit where welfare debit cards can be purchased, and what they can be used to buy. Since everything is scanned now, it wouldn't be hard to make the debit cards NOT work at fast food joints, or for any purchase that includes hard liquor, cigarettes, etc. Just an idea...

This would only worsen things. What would Medicaid recipients do when they couldn't get assistance with meds for hypertension, diabetes, or a host of other conditions due in part to lifestyle? Throngs of patients would suffer from complications of uncontrolled chronic diseases. It's much cheaper to manage these patients medically than to wait for them to become critically ill and require much more intensive treatment in the hospital.

Originally Posted by bucks2010

This would only worsen things. What would Medicaid recipients do when they couldn't get assistance with meds for hypertension, diabetes, or a host of other conditions due in part to lifestyle? Throngs of patients would suffer from complications of uncontrolled chronic diseases. It's much cheaper to manage these patients medically than to wait for them to become critically ill and require much more intensive treatment in the hospital.

At some point, such an approach would require the rationing of care. Honestly, I would expect that such an approach is going to [eventually] be necessary, anyway. The fact of the matter is that the way we provide care is unsustainable and with some 5% of the population eating up 95% of this country's healthcare resources, perhaps some degree of rationing is, in fact, necessary. Perhaps we need to define certain degrees of care available to the general public without "premium" costs. Perhaps, we need to reduce the expectation of treatment/cure to something below the 100% that the public currently expects. Perhaps, we should work to change the public perception of healthcare from what it is today to that of your auto mechanic. When you take in your car with certain s/s, you are often given a general estimate. You are charged for the dx and told how much it might cost to fix the problems. If you cannot afford the repairs, you live with the issues. On the other hand, if they missed something during the brief dx because they didn't do a full repair, their liability is generally quite small (since they did not actually remove X, Y, and Z as this would have cost you more). Further, you are informed (and realize the fact) that your actual bill may be much higher than the estimate. No one expects this service for free but generally people do appreciate their mechanic's help....

Originally Posted by music2doc

At some point, such an approach would require the rationing of care. Honestly, I would expect that such an approach is going to [eventually] be necessary, anyway. The fact of the matter is that the way we provide care is unsustainable and with some 5% of the population eating up 95% of this country's healthcare resources, perhaps some degree of rationing is, in fact, necessary. Perhaps we need to define certain degrees of care available to the general public without "premium" costs. Perhaps, we need to reduce the expectation of treatment/cure to something below the 100% that the public currently expects. Perhaps, we should work to change the public perception of healthcare from what it is today to that of your auto mechanic. When you take in your car with certain s/s, you are often given a general estimate. You are charged for the dx and told how much it might cost to fix the problems. If you cannot afford the repairs, you live with the issues. On the other hand, if they missed something during the brief dx because they didn't do a full repair, their liability is generally quite small (since they did not actually remove X, Y, and Z as this would have cost you more). Further, you are informed (and realize the fact) that your actual bill may be much higher than the estimate. No one expects this service for free but generally people do appreciate their mechanic's help....

"Rationing" by removing financial support for the treatment of lifestyle-associated diseases will increase the financial burden on the healthcare system when these patients present to emergency departments with acute conditions that require expensive interventions and treatment that could've been easily avoided had the patient had access to affordable medications. Increasing the burden on poor populations and increasing the financial strain on the institutions that care for these patients is a no-win situation.

Originally Posted by bucks2010

"Rationing" by removing financial support for the treatment of lifestyle-associated diseases will increase the financial burden on the healthcare system when these patients present to emergency departments with acute conditions that require expensive interventions and treatment that could've been easily avoided had the patient had access to affordable medications. Increasing the burden on poor populations and increasing the financial strain on the institutions that care for these patients is a no-win situation.

I think we're thinking of different things. I would always consider preventive medicine to be outside any sort of rationing system. However, illnesses that could have been prevented had the person chosen to use available treatments early on could be argued to be that individual's responsibility. If the person is unable to pay for necessary services, it might mean they cannot receive those services. That sort of approach naturally bothers me, but I am honestly not so sure any approach that seeks to unconditionally treat complex illnesses brought on my lifestyle choices can be sustained for any length of time. As it is, patients are paying many times what it costs for their treatments in the ED simply because they are paying for their entire hall of patients in many cases. For instance, my hospital considers 1 in 6 patients paying their bill for their ED visit to be "on target" for collections -- that's ridiculous!

Originally Posted by music2doc

I think we're thinking of different things. I would always consider preventive medicine to be outside any sort of rationing system. However, illnesses that could have been prevented had the person chosen to use available treatments early on could be argued to be that individual's responsibility. If the person is unable to pay for necessary services, it might mean they cannot receive those services. That sort of approach naturally bothers me, but I am honestly not so sure any approach that seeks to unconditionally treat complex illnesses brought on my lifestyle choices can be sustained for any length of time. As it is, patients are paying many times what it costs for their treatments in the ED simply because they are paying for their entire hall of patients in many cases. For instance, my hospital considers 1 in 6 patients paying their bill for their ED visit to be "on target" for collections -- that's ridiculous!

Where does this line of reasoning stop? Do you deny angioplasty to a STEMI patient who was non-compliant with their htn meds? It would take not only a drastic and highly unlikely reversal of EMTALA for this to happen, but also IMO some pretty soulless physicians.

Originally Posted by ElCapone

And single payer --> less salaries for doctors?

Wow, you don't waste time beating around the bush.

Not necessarily, physicians still have leverage. It may surprise you to know that, on a whole, primary care physicians in Canada (the closest example) earn more than their counterparts in the US, which specialists earn less. Specialists still earn more than generalists, the gap just isn't nearly as dramatic as it is in this country.

If I were willing to emigrate I could actually make more money up north. With less liability and fewer billing headaches. And virtually zero charity care.

Hmmmmm...

Originally Posted by bucks2010

Where does this line of reasoning stop? Do you deny angioplasty to a STEMI patient who was non-compliant with their htn meds? It would take not only a drastic and highly unlikely reversal of EMTALA for this to happen, but also IMO some pretty soulless physicians.

The biggest problem is, no matter what happens, the ACA being overturned or upheld, single-payer becoming a reality or never being passed, rationing will be necessary. You cannot have the most expensive patients covered by the government (or private insurance for that matter) with no caps and the people who are not footing the bill (the patient's family) making all calls about what interventions to use. It simply cannot work that way, and rationing of care is necessary. Yes, we will get to the point where we have to say "sorry, your chances of recovery are too slim, we can only offer comfort care" or "sorry, you chose not to manage your DM/you smoked your whole life/you are morbidly obese and haven't done anything about it, you have to cover your care out of pocket." This is the reality in countries that have single payer/nationalized care, and will have to be the reality here, sooner or later.

It isn't a question of being soulless, it is a question of how much money can be spent on the latest and greatest health care for everyone, whether they can pay or not, before we run out of money.

Originally Posted by theseeker4

The biggest problem is, no matter what happens, the ACA being overturned or upheld, single-payer becoming a reality or never being passed, rationing will be necessary. You cannot have the most expensive patients covered by the government (or private insurance for that matter) with no caps and the people who are not footing the bill (the patient's family) making all calls about what interventions to use. It simply cannot work that way, and rationing of care is necessary. Yes, we will get to the point where we have to say "sorry, your chances of recovery are too slim, we can only offer comfort care" or "sorry, you chose not to manage your DM/you smoked your whole life/you are morbidly obese and haven't done anything about it, you have to cover your care out of pocket." This is the reality in countries that have single payer/nationalized care, and will have to be the reality here, sooner or later.

It isn't a question of being soulless, it is a question of how much money can be spent on the latest and greatest health care for everyone, whether they can pay or not, before we run out of money.

Exactly. The inequity in dollars spent among the various population is pretty stark (something like the top 10% of spenders in Medicare and private insurance use more than 50% of the resources while the bottom 50% of spenders use less than 5% of the resources). To some extent this is largely expected because of how insurance works, but I think it also speaks to our culture's inability to let go and not do "everything possible," especially with respect to older patients. The question isn't whether rationing will occur or not, it's where that rationing will be applied.

Originally Posted by Joe the Plumber

I'm totally in favor of helping low-income people pay for health care. My big concern is that we have to be careful when we separate actions from consequences. If you eat fast food and get diabetes, you should face the health and financial consequences of your decisions. If you smoke and get COPD or emphysema, the bill should be yours to foot.

That's actually a terrible idea (though it makes for great soundbites, especially when proclaimed while waving a Gadsden flag overhead). How would you account for the myriad other contributory factors? Genetic predisposition? Other environmental issues (occupational, regional, etc.)? Concomitant disease states?

I'm truly interested in the system you would use to assign degrees of patient responsibility for disease states.

It also be a good idea to limit where welfare debit cards can be purchased, and what they can be used to buy. Since everything is scanned now, it wouldn't be hard to make the debit cards NOT work at fast food joints, or for any purchase that includes hard liquor, cigarettes, etc. Just an idea...

Kind of agree (although fast food is sort of a gray area for me).

Originally Posted by redsquareblack

Kind of agree (although fast food is sort of a gray area for me).

Well, the problem (and this has been discussed ad nauseum in other threads, so I'll summarize quickly) with this system is that some people simply don't have food available that ISN'T fast food for myriad reasons, including lack of transportation, lack of grocery store within a reasonable distance even having proper transportation, and inadequate tools for cooking. It all costs money. Thus, by limiting these cards such that certain places are completely inaccessible, namely, fast food joints, you condemn a certain cohort to starvation.

Keep in mind, though, that that explanation is extremely simplified.

Originally Posted by tantacles

Well, the problem (and this has been discussed ad nauseum in other threads, so I'll summarize quickly) with this system is that some people simply don't have food available that ISN'T fast food for myriad reasons, including lack of transportation, lack of grocery store within a reasonable distance even having proper transportation, and inadequate tools for cooking. It all costs money. Thus, by limiting these cards such that certain places are completely inaccessible, namely, fast food joints, you condemn a certain cohort to starvation.

Keep in mind, though, that that explanation is extremely simplified.

Can you please support your statements with facts?

If you have a refrig and stove you can cook most meals. Plus the majority have microwaves anyway...nearly everyone was the tools.


Lack of transport would support using the grocery MORE, because you could go get food once a week, instead of three times a day. Add up the distance traveled per week...the once a week trip to the grocery will always be far less.

You claim "forcing" these people to travel a mile or two to the grocery is going to cause them to starve? Considering everyone should get exercise a few times a week, a 20-30 minute walk once a week doesn't sound like a bad idea.

Originally Posted by link2swim06

Can you please support your statements with facts?

If you have a refrig and stove you can cook most meals. Plus the majority have microwaves anyway...nearly everyone was the tools.


Lack of transport would support using the grocery MORE, because you could go get food once a week, instead of three times a day. Add up the distance traveled per week...the once a week trip to the grocery will always be far less.

You claim "forcing" these people to travel a mile or two to the grocery is going to cause them to starve? Considering everyone should get exercise a few times a week, a 20-30 minute walk once a week doesn't sound like a bad idea.

They are called food islands. Look them up.

You are incorrectly assuming that these people live far away from both fast food and grocery stores.

You are also neglecting the cost of all these groceries, the quality of the appliances you've cited, and time available to the people preparing/getting the food.

Originally Posted by link2swim06

Can you please support your statements with facts?

If you have a refrig and stove you can cook most meals. Plus the majority have microwaves anyway...nearly everyone was the tools.


Lack of transport would support using the grocery MORE, because you could go get food once a week, instead of three times a day. Add up the distance traveled per week...the once a week trip to the grocery will always be far less.

You claim "forcing" these people to travel a mile or two to the grocery is going to cause them to starve? Considering everyone should get exercise a few times a week, a 20-30 minute walk once a week doesn't sound like a bad idea.

Let me preface this by saying that I'm in favor of not allowing fast food to be purchased with food stamps. I agree with everything you've said.

I think it's important to realize that when we talk about a certain group starving, we're not talking about the average person. You're absolutely right: The average person, with a stove, a microwave, and a refrigerator/freezer should absolutely be able to use a grocery store. A 20-30 minute walk would be great for some people; you're right.

What if, however, the nearest grocery store is 20 miles away? What if the nearest fast food place, by comparison, is 2 miles away? It doesn't seem reasonable to ask that that person go to the grocery store rather than live off of fast food.

And what about that 1.5% that doesn't have a stove or oven? What about that 12.1% who doesn't have a microwave? Again, I'm not saying the average person would starve and couldn't make a 20 minute walk to a grocery store. I'm saying that there are significant problems with uniformly making EBT cards impossible to use at fast food establishments.

And what about the cost of running a gas stove and oven? Or an electrical stove or oven, for that matter?

Originally Posted by tantacles

Let me preface this by saying that I'm in favor of not allowing fast food to be purchased with food stamps. I agree with everything you've said.

I think it's important to realize that when we talk about a certain group starving, we're not talking about the average person. You're absolutely right: The average person, with a stove, a microwave, and a refrigerator/freezer should absolutely be able to use a grocery store. A 20-30 minute walk would be great for some people; you're right.

What if, however, the nearest grocery store is 20 miles away? What if the nearest fast food place, by comparison, is 2 miles away? It doesn't seem reasonable to ask that that person go to the grocery store rather than live off of fast food.

And what about that 1.5% that doesn't have a stove or oven? What about that 12.1% who doesn't have a microwave? Again, I'm not saying the average person would starve and couldn't make a 20 minute walk to a grocery store. I'm saying that there are significant problems with uniformly making EBT cards impossible to use at fast food establishments.

And what about the cost of running a gas stove and oven? Or an electrical stove or oven, for that matter?

The thing is the majority of people ARE within a walk-able distance/ have access to public transportation AND have a oven. The minority without the above should be given transportation once every week and a subsidy for an oven, it would be cheaper than paying for their future chronic problems. Oh we can give them $5 extra for their electric gas bill too...it is cheaper than paying for 10 years of dialysis.

There are other solutions than paying for people to eat crap.

Per the other person's post:

1) You can ALWAYS get more nutrition/food for the price at a grocery than any fast food restaurant. I challenge you to show one item which is a better value at a fast food restaurant. It doesn't exist, anywhere.
2) Does it really take more time to walk to a fast food restaurant, order, wait, walk home, than heat something up on the oven?
3) Finally I am not saying people live closer to a grocery store, I am saying for the majority its within a few miles...plus going to the grocery is a once a week activity. Its really not that big of a burden to walk a few miles or take a bus once a week.

Originally Posted by theseeker4

The biggest problem is, no matter what happens, the ACA being overturned or upheld, single-payer becoming a reality or never being passed, rationing will be necessary. You cannot have the most expensive patients covered by the government (or private insurance for that matter) with no caps and the people who are not footing the bill (the patient's family) making all calls about what interventions to use. It simply cannot work that way, and rationing of care is necessary. Yes, we will get to the point where we have to say "sorry, your chances of recovery are too slim, we can only offer comfort care" or "sorry, you chose not to manage your DM/you smoked your whole life/you are morbidly obese and haven't done anything about it, you have to cover your care out of pocket." This is the reality in countries that have single payer/nationalized care, and will have to be the reality here, sooner or later.

It isn't a question of being soulless, it is a question of how much money can be spent on the latest and greatest health care for everyone, whether they can pay or not, before we run out of money.

First I think it's important to clarify that I'm not referring to end-of-life care here, particularly for elderly folks with terminal illnesses. More people need to make use of advance directives and think through how they would like their last days and hours to be before they end up in the ED and the family says 'do everything'. I am referring to people being denied life-saving treatment on account of their disease history (see MI example from earlier).

Rationing may seem like the easiest way to cut costs, but in reality all it's going to do is shift costs from Medicaid to hospitals. Patients are still going to be provided with the standard of care (seeing as they must be according to EMTALA), the hospital is just going to end up footing the bill. It would actually likely increase costs because it's hard enough to find rehab placement for Medicaid patients - changing these patients to self-pay will mean they are going to stay in the hospital for weeks-months longer than necessary because they can't go home but rehab facilities will not have any available charity beds.

Originally Posted by link2swim06

The thing is the majority of people ARE within a walk-able distance/ have access to public transportation AND have a oven. The minority without the above should be given transportation once every week and a subsidy for an oven, it would be cheaper than paying for their future chronic problems. Oh we can give them $5 extra for their electric gas bill too...it is cheaper than paying for 10 years of dialysis.

There are other solutions than paying for people to eat crap.

Per the other person's post:

1) You can ALWAYS get more nutrition/food for the price at a grocery than any fast food restaurant. I challenge you to show one item which is a better value at a fast food restaurant. It doesn't exist, anywhere.
2) Does it really take more time to walk to a fast food restaurant, order, wait, walk home, than heat something up on the oven?
3) Finally I am not saying people live closer to a grocery store, I am saying for the majority its within a few miles...plus going to the grocery is a once a week activity. Its really not that big of a burden to walk a few miles or take a bus once a week.

Once again: I agree. If implemented, the kinds of solutions you suggested ate better than allowing people to buy crappy food with subsidies. Which is why I said that I DON'T think that should be allowed. I was merely stating problems with uniformly disallowing food stamps to be used on fast food with no other changes being made to the system.

And again, if the purpose of a food stamp program is to feed everyone, the minority matters, which is why I'm focusing on them. We can't make rules that prevent one group from eating completely even if it means 100 other groups will eat better food as a result.

We're not arguing about whether fast food is good for you or whether it's a good idea for people, whether on aid or not, to buy fast food; we both agree that it's bad and that going to a grocery store and buying raw produce and eating that would probably be healthier, even if it isn't cooked. My concern is making sure that everyone is taken care of, including those who really CAN'T get to a grocery store easily.

Originally Posted by tantacles

Once again: I agree. If implemented, the kinds of solutions you suggested ate better than allowing people to buy crappy food with subsidies. Which is why I said that I DON'T think that should be allowed. I was merely stating problems with uniformly disallowing food stamps to be used on fast food with no other changes being made to the system.

And again, if the purpose of a food stamp program is to feed everyone, the minority matters, which is why I'm focusing on them. We can't make rules that prevent one group from eating completely even if it means 100 other groups will eat better food as a result.

We're not arguing about whether fast food is good for you or whether it's a good idea for people, whether on aid or not, to buy fast food; we both agree that it's bad and that going to a grocery store and buying raw produce and eating that would probably be healthier, even if it isn't cooked. My concern is making sure that everyone is taken care of, including those who really CAN'T get to a grocery store easily.

I get what you are saying...it is just really dumb in my mind to advocate of a solution which creates more problems.

I mean you could also pay for all poor people to have three meals cooked/delivered to their door...that also would "fix" the hunger problem. However, like feeding the poor with fast food, that is not financially feasible.

Originally Posted by link2swim06

I get what you are saying...it is just really dumb in my mind to advocate of a solution which creates more problems.

I mean you could also pay for all poor people to have three meals cooked/delivered to their door...that also would "fix" the hunger problem. However, like feeding the poor with fast food, that is not financially feasible.

I absolutely agree. At this current point, especially given political inertia, we unfortunately have to acknowledge that allowing food aid to be used on fast food is the least worst option given the option of either allowing or disallowing fast food purchases given no other changes to the system.

Originally Posted by ElCapone

1. Cut down on new tech. That's the biggest cost factor right now.
2. Malpractice reform. The threat of malpractice leads to CYA diagnoses and treatments, and the use of the greatest and bestest tech.



And single payer --> less salaries for doctors?

I'm afraid this will not work, Capo. New tech is in the hands of private companies and you can't tell a comp what they should charge for their product, worse a new one. i.e. a new i-phone is more expensive (r&d +profit) than an old one. I agree that there needs to be malpractice reform, but not for the reason you mentioned. Patients, if left to their own vices, will want every conceivable test on the menu regardless of malpractice reform, which is why some amount of rationing makes sense.

Originally Posted by bucks2010

First I think it's important to clarify that I'm not referring to end-of-life care here, particularly for elderly folks with terminal illnesses. More people need to make use of advance directives and think through how they would like their last days and hours to be before they end up in the ED and the family says 'do everything'. I am referring to people being denied life-saving treatment on account of their disease history (see MI example from earlier).

Rationing may seem like the easiest way to cut costs, but in reality all it's going to do is shift costs from Medicaid to hospitals. Patients are still going to be provided with the standard of care (seeing as they must be according to EMTALA), the hospital is just going to end up footing the bill. It would actually likely increase costs because it's hard enough to find rehab placement for Medicaid patients - changing these patients to self-pay will mean they are going to stay in the hospital for weeks-months longer than necessary because they can't go home but rehab facilities will not have any available charity beds.

Rationing is never a particularly pleasant topic; however, neither is the thought that we are essentially enslaving healthcare workers and hospitals. The fact that we have a system which requires healthcare workers to provide charity care is part of the problem. EMTALA, itself, is of questionable constitutionality:

Originally Posted by http://allbleedingstops.blogspot.com/2007/02/in-which-i-shall-make-unpopular.html

One appropriately dramatic action would be for EMTALA to be overturned. Obviously, it is politically untouchable from a legislative point of view; it may, however, be vulnerable from a judicial approach.The Fifth Amendment to the US Constitution states, in part, “… nor shall private property be taken for public use, without just compensation.” The Fourteenth Amendment similarly reads, “nor shall any State deprive any person of life, liberty, or property, without due process of law.” The argument to be made here is that EMTALA requires private citizens, largely physicians, to provide the fruits of their labor without compensation or due process, and as such represents an unconstitutional “taking” of private property.

Also see http://www.kevinmd.com/blog/2011/03/...ty-emtala.html


That said, I don't know that I would support overturning it, although I could certainly see value in updating/modifying it. The fact of the matter is that seeing every single patient who walks in an ED inevitably worsens patient care for the group at-large, since it means that we cannot properly appropriate resources as they are most likely to be effective. Instead, we are forced to distribute the most resources to the people least likely to improve (whether that is due to failure to cooperate with providers or simply having an illness that is highly resistant to treatment (but for which the patient wishes to be treated anyway -- without being able to afford treatment). While in an ideal world we could treat these illnesses anyway with no limit to our financial, human, or medicinal/surgical resources, we do not live in an ideal world. Few politicians seem to realize this simple fact -- an entire political party is formed around the idea that we have infinite financial resources and should be able to provide for everyone's needs, wants, and desires!

Fundamental question:

Is health care a right or a commodity?

If the government is arguing for this law on the basis of health care being a right, then there should be no reason for the Supreme Court to overturn the ACA. If they have articulated it as a commodity, then I can see them striking parts of the bill down. Unfortunately it seems like it's leaning towards the latter...

And then the million-dollar question:

How does the political left react if this bill cannot be implemented properly?

A push for single-payer would make sense if health care costs cannot be controlled (which they wouldn't be with reform/privatization). But that would require some chutzpah on the part of the Democrats

Originally Posted by music2doc

an entire political party is formed around the idea that we have infinite financial resources and should be able to provide for everyone's needs, wants, and desires!