Bernie Sanders announces he is running for President

[deleted480308]

Yea, we did try that once until things changed in 1935 and 1965. A return to the gilded age is certainly favored by some, but I'm not especially keen on the idea of the wealthiest nation in the world just letting its indigent elderly die in the street or declare medical bankruptcy after a bout of severe pneumonia and an ICU stay.

then donate your time and money. That’s how charitable impulses should be met, personally

At the very least, I can applaud you for your consistency. Making residents pay 100% of their own training costs and removing any federal subsidies from higher education would certainly ensure that only those with rich parents could go to medical school.....but at least you're consistent. Unsurprisingly I don't hear a lot of right-leaning physicians and residents supporting this view, though.

that’s a strawman.

Residents do provide value and should be able to charge for that value. It does not at all have to become “rich dudes only”

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[vector2]

I wouldn't say it had to be the same algorithm but there needs to be some benefit to paying more in. It could be diminished (and even more so if the rate goes down progressively at higher incomes) but it can't be the same for someone being taxed on 400k as it would be for someone at 138k (or whatever the current maximum is).

I'm sure there are some minor in the details of the benefit of paying more in, but overall I think we're in agreement.

CMS is paying you to do a job, its just capitated (I feel like I've said this before) since residents can't bill Medicare. They're still doing work on Medicare patients. Let residents bill and you could easily stop the CMS payments for residents. As for loans, if he/she doesn't have undergrad loans we're in agreement that there's no handout there then?

This opens up a whole can of worms of where in residency a resident becomes capable of actually independently billing for services without supervision. It also raises the question of how training licenses and liability/malpractice costs for residents would be handled. There are some PGY4 anesthesia residents who are more than capable of doing an entire complicated anesthetic on their own. There are some PGY4 anesthesia residents who are almost certainly not going to pass their boards and probably couldn't be trusted to anesthetize a cocker spaniel. Cardiothoracic surgery fellows pretty much never go into solo practice after graduation because they essentially still require a bit of backup and proctoring from a senior surgeon and don't really come into their own until 4, 5, 6 years out of fellowship. There's a reason there's a gradated granting of privileges from the resident -> fellow -> attending level and why initial board-certification is important for standardization of care, hospital credentialing, and the ability to bill for services.

For the time being, with CMS still providing 100k/yr/resident, we are not in agreement that there is "no handout" even if he doesn't have undergrad loans.

I actually opted out of Medicare at one point, and it wasn't a money issue. The rules for Medicare are stifling - if a Medicare patient wants to pay cash for something they are forbidden from doing so. Doctors have been sued for this by the government. In my practice, I was seeing probably 80% uninsured patients (blue collar, couldn't afford insurance and everyone else in town charged way more than I did). But I couldn't see Medicare in that clinic unless I wanted to bill Medicare even when the patients wanted to just pay me. At risk of a tangent, that's why I hate Medicare - its their way or the highway with the backing of the government, no appeals, no arguing, nothing. I could go on about issues I've had besides that but its not relevant to this thread.

I'm not going to argue your point here. There are many, many examples of how much of a clusterfck medicare/caid rules are about billing. Same goes often for private insurance/HMO/PPO. Once every couple weeks I get a patient who is essentially checked into preop, ready to go, case get canceled, and later I hear some nonsense about how their insurance is now disputing the prior authorization. All of this is the direct result of the crazy patchwork of federal, state, private, and hybrid systems we rely on to provide healthcare in this country. I land on the side of trying to fix the social program dysfunction, not abolish it and try to privatize medicare by handing it over to insurance companies which have much higher administrative costs and their own problems with bloat.

So you're not personally deciding to voluntarily not bill someone. Got it, you have a whole department (and likely hospital) subsidizing your salary. Noted.

Absolutely our salaries are subsidized, but I still remain internally consistent in regard to having accepted CMS funds while training and now continuing to treat medicare/caid. As I've said earlier in the thread, individuals can rarely be trusted to "do the right thing" on their own, and this is supported by every study of rational self-interest in the psychology of economics. That is the reason public policy at the population level is where real change is important. Me telling our psych resident to pay back his CMS funding or fox news telling warren buffet that he can write an extra check to the IRS if he wants higher taxes, or you suggesting that I should voluntarily not bill someone are all nice rhetorical zingers, but even if those things materialized they really don't effect any actual change, right? Social programs should be administered at the largest population level because that is where collective responsibility makes it easier for any one individual to shoulder a smaller part of the burden.

 

[vector2]

then donate your time and money. That’s how charitable impulses should be met, personally

See my post above about effecting change at the policy level. Rational self-interest essentially negates any dent in poverty if we are relying only on elective donation. As an example, just look at how tithing has changed in the US and keep in mind that religious people from my understanding, on average, are more charitable than the rest of the populace. Tithers make up only 10-25 percent of a normal congregation. - Christians are giving 2.5% of their income, during the Great Depression it was 3.3%. - For families making $75k, only 1% gave 10%+

that’s a strawman.

Residents do provide value and should be able to charge for that value. It does not at all have to become “rich dudes only”

Not really. Sure, residents provide some value, but the market governing most hospital corporation policy has decided that your value is zero unless your pay is subsidized by the government, else they would subsidize training slots on their own if it was so valuable. In reality, left to their own devices, no hospital is going to hire some fresh medical school graduate and go through the hassle of training you and paying you when their time and money is better spent hiring people who already have a license to practice and who can attract patients to the hospital for services (well, maybe some would, but it would be like 100 years ago when residents lived in the hospital and being fed 3 meals a day was their pay). As far as anesthesia residents, they are a direct drag on the anesthesia department and in high supervision regions the department loses money every minute (even including the CMS DME subsidy) by having attendings staff residents 2:1 instead of staffing CRNAs 3 or 4:1.

 

[agammaglobulin]

With globalization and technology making our world a smaller place, people and corporations are simply going to relocate to places with lower taxes. High-income individuals and businesses are not going to stay in a country with relatively higher taxes. Look at all the wealthy Chinese moving their money into real estate on the west coast. Domestically, this already happens on a smaller scale with individuals changing state of residence for tax purposes. On a corporate level, organizations move their headquarters and keep cash overseas in countries that have more favorable tax laws. The solution is NOT to tax the people/corporations you have more but to incentivize wealth creation and bring more people/corporations to your country. I.e. The governments' goal shouldn't be to maximize their share of the pie, but to assist in making more pies.

"The trouble with Socialism is that eventually, you run out of other people's money." -Margaret Thatcher

 

[nimbus]

Plastic Surgery, Unsupervised, Leads to a Fine For a Hospital



This is what happens without outside funding.

Tuition & Fees - Penn Dental Medicine

 

[deleted480308]

See my post above about effecting change at the policy level. Rational self-interest essentially negates any dent in poverty if we are relying only on elective donation. As an example, just look at how tithing has changed in the US and keep in mind that religious people from my understanding, on average, are more charitable than the rest of the populace. Tithers make up only 10-25 percent of a normal congregation. - Christians are giving 2.5% of their income, during the Great Depression it was 3.3%. - For families making $75k, only 1% gave 10%+

you have to consider the change in mindset after generations of a govt welfare state as now many people just assume govt does it for them

And that’s before the larger argument that it doesn’t matter how much private charity would take place, it still isn’t appropriate to seize people’s money for that. If you see a charitable need you want funded, just like if I do, it is on us to fund it voluntarily ourselves. We shouldn’t force our neighbors

Not really. Sure, residents provide some value, but the all-knowing free market governing most hospital corporation policy has decided that your value is zero unless your pay is subsidized by the government, else they would subsidize training slots on their own if it was so valuable. In reality, left to their own devices, no hospital is going to hire some fresh medical school graduate and go through the hassle of training you and paying you when their time and money is better spent hiring people who already have a license to practice and who can attract patients to the hospital for services (well, maybe some would, but it would be like 100 years ago when residents lived in the hospital and being fed 3 meals a day was their pay). As far as anesthesia residents, they are a direct drag on the anesthesia department and in high supervision regions the department loses money every minute (even including the CMS DME subsidy) by having attendings staff residents 2:1 instead of staffing CRNAs 3 or 4:1.

There are privately funded residencies and would be more if the govt backed out. The training system would adjust

 

[vector2]

you have to consider the change in mindset after generations of a govt welfare state as now many people just assume govt does it for them

And that’s before the larger argument that it doesn’t matter how much private charity would take place, it still isn’t appropriate to seize people’s money for that. If you see a charitable need you want funded, just like if I do, it is on us to fund it voluntarily ourselves. We shouldn’t force our neighbors

We have a fundamental disagreement about the pervasiveness of the so-called welfare queens and what the definition of "seize" is. I'll leave it at that.

There are privately funded residencies and would be more if the govt backed out. The training system would adjust

Privately funding all residencies is a horrible idea. Big pharma and medical device makers would be some of the first ones to line up to sponsor these slots, and this would be terrible for obvious reasons (introducing ABC Hospital's new Interventional Cardiology fellowship, now brought to you by the Abbott XIENCE™ next generation drug-eluting stent). Hospitals would start adding new slots based solely on whether that particularly residency slot is profitable or not. Ortho, derm, neurosurgery, and surg subspecialty slots would explode and the shortage of IM, FM, peds, psych would worsen exponentially. The training system would certainly adjust- except it would be to the detriment of everybody except corporations.

 

[deleted480308]

We have a fundamental disagreement about the pervasiveness of the so-called welfare queens and what the definition of "seize" is. I'll leave it at that.

never said welfare queens, that’s strawmanning again

Privately funding all residencies is a horrible idea. Big pharma and medical device makers would be some of the first ones to line up to sponsor these slots, and this would be terrible for obvious reasons (introducing ABC Hospital's new Interventional Cardiology fellowship, now brought to you by the Abbott XIENCE™ next generation drug-eluting stent). Hospitals would start adding new slots based solely on whether that particularly residency slot is profitable or not. Ortho, derm, neurosurgery, and surg subspecialty slots would explode and the shortage of IM, FM, peds, psych would worsen exponentially. The training system would certainly adjust- except it would be to the detriment of everybody.

If the market really demands more pcps it will find a way to make them. It would likely look a lot different than now

 

[VA Hopeful Dr]

I'm sure there are some minor in the details of the benefit of paying more in, but overall I think we're in agreement.

Yeah. I mean, I don't love the idea but something has to give.

This opens up a whole can of worms of where in residency a resident becomes capable of actually independently billing for services without supervision. It also raises the question of how training licenses and liability/malpractice costs for residents would be handled. There are some PGY4 anesthesia residents who are more than capable of doing an entire complicated anesthetic on their own. There are some PGY4 anesthesia residents who are almost certainly not going to pass their boards and probably couldn't be trusted to anesthetize a cocker spaniel. Cardiothoracic surgery fellows pretty much never go into solo practice after graduation because they essentially still require a bit of backup and proctoring from a senior surgeon and don't really come into their own until 4, 5, 6 years out of fellowship. There's a reason there's a gradated granting of privileges from the resident -> fellow -> attending level and why initial board-certification is important for standardization of care, hospital credentialing, and the ability to bill for services.

For the time being, with CMS still providing 100k/yr/resident, we are not in agreement that there is "no handout" even if he doesn't have undergrad loans.

We should be as CMS is paying residents to do a job that ordinarily they'd pay a physician to do. Its not like they're being paid to sit around and NOT be doctors.

I'm not going to argue your point here. There are many, many examples of how much of a clusterfck medicare/caid rules are about billing. Same goes often for private insurance/HMO/PPO. Once every couple weeks I get a patient who is essentially checked into preop, ready to go, case get canceled, and later I hear some nonsense about how their insurance is now disputing the prior authorization. All of this is the direct result of the crazy patchwork of federal, state, private, and hybrid systems we rely on to provide healthcare in this country. I land on the side of trying to fix the social program dysfunction, not abolish it and try to privatize medicare by handing it over to insurance companies which have much higher administrative costs and their own problems with bloat.

My issue with this is 2 fold. A) You can't sue Medicare. You can BC/BS or whoever or they lose enough market share to get their act together. B) Insurance companies have rules, albeit often confusing and nonsensical ones. I've never had a problem with them assuming their rules are followed. CMS I have literally gotten 2 different answers from 2 different people 20 minutes apart on pretty major issues. Make CMS accountable for its **** and you might win me over.

Oh, and I have no faith that anyone can actually fix Medicare because the people who would be responsible for doing it can't accomplish anything worthwhile (Congress)

Absolutely our salaries are subsidized, but I still remain internally consistent in regard to having accepted CMS funds while training and now continuing to treat medicare/caid. As I've said earlier in the thread, individuals can rarely be trusted to "do the right thing" on their own, and this is supported by every study of rational self-interest in the psychology of economics. That is the reason public policy at the population level is where real change is important. Me telling our psych resident to pay back his CMS funding or fox news telling warren buffet that he can write an extra check to the IRS if he wants higher taxes, or you suggesting that I should voluntarily not bill someone are all nice rhetorical zingers, but even if those things materialized they really don't effect any actual change, right? Social programs should be administered at the largest population level because that is where collective responsibility makes it easier for any one individual to shoulder a smaller part of the burden.

I wasn't making any grand social argument here merely pointing out that payer mix doesn't apparently affect your income much so I don't care what you have to say on the subject. My current job will pay me the same whether I see 100% commercially insured patients or 100% Medicaid, so I'm in no position to judge others on what patients they see and what patients they don't.

 

[VA Hopeful Dr]

Privately funding all residencies is a horrible idea. Big pharma and medical device makers would be some of the first ones to line up to sponsor these slots, and this would be terrible for obvious reasons (introducing ABC Hospital's new Interventional Cardiology fellowship, now brought to you by the Abbott XIENCE™ next generation drug-eluting stent). Hospitals would start adding new slots based solely on whether that particularly residency slot is profitable or not. Ortho, derm, neurosurgery, and surg subspecialty slots would explode and the shortage of IM, FM, peds, psych would worsen exponentially. The training system would certainly adjust- except it would be to the detriment of everybody except corporations.

This is absolutely false. In the last 5 years 3 new FM programs have opened up in my state. All 3 are privately funded (2 by a large hospital system in state, one by HCA).

 

[nimbus]

We have a fundamental disagreement about the pervasiveness of the so-called welfare queens and what the definition of "seize" is. I'll leave it at that.



Privately funding all residencies is a horrible idea. Big pharma and medical device makers would be some of the first ones to line up to sponsor these slots, and this would be terrible for obvious reasons (introducing ABC Hospital's new Interventional Cardiology fellowship, now brought to you by the Abbott XIENCE™ next generation drug-eluting stent). Hospitals would start adding new slots based solely on whether that particularly residency slot is profitable or not. Ortho, derm, neurosurgery, and surg subspecialty slots would explode and the shortage of IM, FM, peds, psych would worsen exponentially. The training system would certainly adjust- except it would be to the detriment of everybody except corporations.

Yeah they could fund a year of residency on the revenues of 3 stents.

 

[nimbus]

This is absolutely false. In the last 5 years 3 new FM programs have opened up in my state. All 3 are privately funded (2 by a large hospital system in state, one by HCA).

I think you just made his point. Cattle farmers don’t raise cattle because they love calves. Those hospital systems are playing the long game.

 

[deleted480308]

I think you just made his point. Cattle farmers don’t raise cattle because they love calves. Those hospital systems are playing the long game.

But it doesn’t have to be bad training just because it’s paid for privately, that’s a snuck premise

 

[VA Hopeful Dr]

I think you just made his point. Cattle farmers don’t raise cattle because they love calves. Those hospital systems are playing the long game.

I'm merely pointing out that primary care isn't screwed should it be come more prevalent (hence why I put that part of his/her response in bold).

 

[vector2]

We should be as CMS is paying residents to do a job that ordinarily they'd pay a physician to do. Its not like they're being paid to sit around and NOT be doctors.

CMS is giving the hospital $100k per resident per year. The resident gets half of that as a salary, the other half is a government handout of sorts on behalf of the resident to the hospital. I've listened to half a dozen people (not specifically you) throughout this thread talk about the wisdom of the C-suite and board in regard to running the numbers and coming up with employee salaries, but yet in the case of residents, if the hospital board decides $50k is the number that works, this is somehow now unfair. Believe me, I remember the resentment a senior resident when I was making $50k a year and I knew I was clearly more capable than some CRNA sitting next door making $150k, but as I said earlier, some residents can function at a high percentage of a staff physician, most can't. Is the intern generating $100k worth of productivity when each and every decision they take or action they make for months on end has to be checked and double checked by a senior or attending? Would the increased liability and malpractice costs outweigh the billing they can do? It varies so wildly between specialties and PGY year that the idea of allowing residents to bill would be almost impossible to figure out. At the end of the day, apprentices do not make as much as master craftsmen in every other field and profession out there. Medicine is no different.

My issue with this is 2 fold. A) You can't sue Medicare. You can BC/BS or whoever or they lose enough market share to get their act together. B) Insurance companies have rules, albeit often confusing and nonsensical ones. I've never had a problem with them assuming their rules are followed. CMS I have literally gotten 2 different answers from 2 different people 20 minutes apart on pretty major issues. Make CMS accountable for its **** and you might win me over.

Just LOL at BC/BS or the other big guys being held accountable for anything. They did nothing but make healthcare more inaccessible and more expensive before ACA. Lawsuits? $20 million for a class-action suit here, $50 million for a suit there. Big deal. Hell, UnitedHealth has a market cap of $232 billion. The big carriers all have regional monopolies and stories of legitimate claims being rejected by premium-paying customers are dime a dozen. Don't get me wrong though, I would love to make CMS accountable for their BS and I would love to have a Congress that can do anything. But with divided government and the senate filibuster likely here for the long haul for better or worse, it's likely a pipedream.

I wasn't making any grand social argument here merely pointing out that payer mix doesn't apparently affect your income much so I don't care what you have to say on the subject. My current job will pay me the same whether I see 100% commercially insured patients or 100% Medicaid, so I'm in no position to judge others on what patients they see and what patients they don't.

I'm not sure what the definition of "much" is to you, and while I don't bill fee-for-service, my job (hybrid academic- no A-days, working 50-60 hrs a week) pays $30-40k less than the region average and that's almost certainly due to the payer mix affecting the capitalization of the medical center and how much they can afford to subsidize the university medical group's contract. I like my job, the case mix, and teaching residents. If I was more craven, I'd just go across town to the AMC group at the private hospital for likely less stress, no traumas/sick disaster cases, no teaching totally green residents, and more money.

 

[vector2]

This is absolutely false. In the last 5 years 3 new FM programs have opened up in my state. All 3 are privately funded (2 by a large hospital system in state, one by HCA).

We were talking about the implication of what would happen in the future going to a totally privately funded residency system, not what's historically happened in our mishmash of mostly public/some private funding. An anecdote about 3 FM programs in one state over 5 years doesn't negate my argument- did HCA have some unmet need for PCPs in that region as to increase their referral base to specialists? Is their primary care payer mix good and would primary care residents actually be a net income boost by increasing throughput? How many more private specialty/subspecialty spots opened in the state compared to FM increase?

What we do know from NRMP is that even with the current CMS, non-commercial, non-incentivized system in place, residency spots in anesthesiology, EM, plastics, gen surg, thoracic, vascular have increased by about 10-15% over the last decade. The numbers of FM, IM, peds have also increased somewhere in that range. You would know better than me, but shouldn't the percentage increase of FM, IM, peds be much, much higher than the specialists to meet the future demand? Assuming I'm not missing something about the potential profitability of a PGY 3 IM resident vs a PGY5 ortho resident, color me skeptical for thinking a private system is going to correct the residency slot trajectory

 

[vector2]

But it doesn’t have to be bad training just because it’s paid for privately, that’s a snuck premise

"Why yes, Dr. Pulmonology Chairman, we here at Altria Group will only sponsor the best, most up-to-date education and training for your Pulmonology fellowship program. And, of course, I'm sure you wouldn't mind if we just make a small donation to fund a totally non-biased pilot program on the safety of our new electronic cigarettes. Heck, we'll even throw in 5 more brand new bronchoscopes. Oh, and here's your plane ticket and hotel voucher to the lung conference in Oahu. Enjoy."

 

[deleted480308]

"Why yes, Dr. Pulmonology Chairman, we here at Altria Group will only sponsor the best, most up-to-date education and training for your Pulmonology fellowship program. And, of course, I'm sure you wouldn't mind if we just make a small donation to fund a totally non-biased pilot program on the safety of our new electronic cigarettes. Heck, we'll even throw in 5 more brand new bronchoscopes. Oh, and here's your plane ticket and hotel voucher to the lung conference in Oahu. Enjoy."

There are IRBs, specialty societies, nonprofit research groups, and doctors with personal ethics to combat that boogeyman

 

[vector2]

never said welfare queens, that’s strawmanning again

Dude, look at what you said: "generations of a govt welfare state as now many people just assume govt does it for them" This is about as close as you can get to dogwhistling "welfare queen" without actually using the derogatory term yourself. If I'm wrong, and you're not referring to people on CHIP/medicaid/medicare/TANF/food stamps etc who you think are freeloading, please let me know who precisely you are talking about.

If the market really demands more pcps it will find a way to make them.

This is pure conjecture, and if anything, applying total free market principles to training would lead to an expansion of specialties that are profitable, not necessary what's needed. Just take a look at the case of airports. They are vital to the functioning of our country, but in your free market utopia (if I'm reading your libertarian slant correctly) they probably wouldn't exist. Fully 75% of airports in the US are public. Corporations realize that owning and running one is usually a money loser, so the government steps in in the hope that a keeping an airport running will bring additional commerce to the area. Heathrow is the busiest private airport in the world, but is totally useless to those who live in England who are trying to fly regionally around the UK because those flights (compared to intl) don't make a lot of money. Same thing with PCPs- training spots may increase in places with high specialty referral rates, but those who need to see a PCP for the sake of seeing a PCP will likely suffer.

 

[deleted480308]

Dude, look at what you said: "generations of a govt welfare state as now many people just assume govt does it for them" This is about as close as you can get to dogwhistling "welfare queen" without actually using the derogatory term yourself. If I'm wrong, and you're not referring to people on CHIP/medicaid/medicare/TANF/food stamps etc who you think are freeloading, please let me know who precisely you are talking about.

maybe you are legitimately unaware of what the "Welfare queen" image is...it's someone living lavishly off of clearly unneeded support. Which again, I never implied or stated.

I said that charity for those who need help has been somewhat subdued by the generational belief that caring for those in need is the role of govt and therefore not requiring private charity. I stand by that claim.

This is pure conjecture, and if anything, applying total free market principles to training would lead to an expansion of specialties that are profitable, not necessary what's needed. Just take a look at the case of airports. They are vital to the functioning of our country, but in your free market utopia (if I'm reading your libertarian slant correctly) they probably wouldn't exist. Fully 75% of airports in the US are public. Corporations realize that owning and running one is usually a money loser, so the government steps in in the hope that a keeping an airport running will bring additional commerce to the area. Same thing with PCPs- training spots may increase in places with a high specialty referral rates, but those who need to see a PCP for the sake of seeing a PCP will likely suffer.

But when we suddenly have double the amount of ortho docs, their salaries will drop as they become too numerous for the cases needed and those applicants shift elsewhere, the same will happen in reverse should there be not enough FM docs. Hospitals could offer training in exchange for a work contract. They need to docs to keep the hospital filled and docs to see the patients once they are there. The market does actually work for what it's supposed to work for and supply and demand is what it is best at

Regarding airports going public through the bully power of govt: Privatizing U.S. Airports

 

[VA Hopeful Dr]

We were talking about the implication of what would happen in the future going to a totally privately funded residency system, not what's historically happened in our mishmash of mostly public/some private funding. An anecdote about 3 FM programs in one state over 5 years doesn't negate my argument- did HCA have some unmet need for PCPs in that region as to increase their referral base to specialists? Is their primary care payer mix good and would primary care residents actually be a net income boost by increasing throughput? How many more private specialty/subspecialty spots opened in the state compared to FM increase?

What we do know from NRMP is that even with the current CMS, non-commercial, non-incentivized system in place, residency spots in anesthesiology, EM, plastics, gen surg, thoracic, vascular have increased by about 10-15% over the last decade. The numbers of FM, IM, peds have also increased somewhere in that range. You would know better than me, but shouldn't the percentage increase of FM, IM, peds be much, much higher than the specialists to meet the future demand? Assuming I'm not missing something about the potential profitability of a PGY 3 IM resident vs a PGY5 ortho resident, color me skeptical for thinking a private system is going to correct the residency slot trajectory

You are. PCP residents start to out-earn their cost sometime during PGY-2. The vast majority of PGY-3s out-earn their costs by a fair amount. I don't think procedural fields ever really do that since they have to have an attending present in the OR for most/all of the procedure in question.

As for the first paragraph, I don't think there's been much added specialty wise (we only have 3 hospitals that have them and I keep an eye on 2 of them). Interestingly, all 3 programs are within 15 miles of other, pre-existing programs.

 

[VA Hopeful Dr]

CMS is giving the hospital $100k per resident per year. The resident gets half of that as a salary, the other half is a government handout of sorts on behalf of the resident to the hospital. I've listened to half a dozen people (not specifically you) throughout this thread talk about the wisdom of the C-suite and board in regard to running the numbers and coming up with employee salaries, but yet in the case of residents, if the hospital board decides $50k is the number that works, this is somehow now unfair. Believe me, I remember the resentment a senior resident when I was making $50k a year and I knew I was clearly more capable than some CRNA sitting next door making $150k, but as I said earlier, some residents can function at a high percentage of a staff physician, most can't. Is the intern generating $100k worth of productivity when each and every decision they take or action they make for months on end has to be checked and double checked by a senior or attending? Would the increased liability and malpractice costs outweigh the billing they can do? It varies so wildly between specialties and PGY year that the idea of allowing residents to bill would be almost impossible to figure out. At the end of the day, apprentices do not make as much as master craftsmen in every other field and profession out there. Medicine is no different.

This may be a difference between your field and mine, but by PGY-3 I could handle about 90% of what my attendings could at about the same pace for outpatient clinic. Being FM nothing I do is that high in terms of liability.

Just LOL at BC/BS or the other big guys being held accountable for anything. They did nothing but make healthcare more inaccessible and more expensive before ACA. Lawsuits? $20 million for a class-action suit here, $50 million for a suit there. Big deal. Hell, UnitedHealth has a market cap of $232 billion. The big carriers all have regional monopolies and stories of legitimate claims being rejected by premium-paying customers are dime a dozen. Don't get me wrong though, I would love to make CMS accountable for their BS and I would love to have a Congress that can do anything. But with divided government and the senate filibuster likely here for the long haul for better or worse, it's likely a pipedream.

The point is you can negotiate/argue/sue/whatever private insurance. Sure it might not effect them much in the long run but you do have some recourse that can make a difference to you. You have none of that with Medicare. Trust me, I hate them all equally (there's a reason I opened a DPC office) but at the moment Medicare is worse to work with when it comes to disagreements.

I'm not sure what the definition of "much" is to you, and while I don't bill fee-for-service, my job (hybrid academic- no A-days, working 50-60 hrs a week) pays $30-40k less than the region average and that's almost certainly due to the payer mix affecting the capitalization of the medical center and how much they can afford to subsidize the university medical group's contract. I like my job, the case mix, and teaching residents. If I was more craven, I'd just go across town to the AMC group at the private hospital for likely less stress, no traumas/sick disaster cases, no teaching totally green residents, and more money.

Does the group across town do 40k less charity care per doctor than you do?

My assumption was that anything remotely academic pays less because it can not because it has to. Our local FM program pays their teaching attendings slightly more than they do their regular clinic doctors (amazing what having trouble finding people can do for you).

And for what its worth, I hope I'm not coming off as attacking you personally for your choice of job. I think we all should do what we enjoy and works for us, doing anything approaching charity care is a bonus.

 

[Twiggidy]

Somehow and Sociopolitical Forum topic has made it over to the Anesthesiology Forum......if @Arch Guillotti did his thing I wouldn't miss it

 

[vector2]

maybe you are legitimately unaware of what the "Welfare queen" image is...it's someone living lavishly off of clearly unneeded support. Which again, I never implied or stated.

I said that charity for those who need help has been somewhat subdued by the generational belief that caring for those in need is the role of govt and therefore not requiring private charity. I stand by that claim.

So that we're actually clear on what you desire, would you agree with the following: all the programs I just mentioned are unnecessary government waste and a redistribution of wealth from the taxpayer, a significant number of people are abusing those programs instead of working, we should defund those programs, and those that truly need them should rely on the charitable giving of their neighbors

But when we suddenly have double the amount of ortho docs, their salaries will drop as they become too numerous for the cases needed and those applicants shift elsewhere, the same will happen in reverse should there be not enough FM docs. Hospitals could offer training in exchange for a work contract. They need to docs to keep the hospital filled and docs to see the patients once they are there. The market does actually work for what it's supposed to work for and supply and demand is what it is best at

Simple supply and demand economics in regard to residency slots sounds good on paper, but it's nowhere near that simple because a board certified physician isn't a uniform widget pumped out by a factory every 3 seconds and sent to market. Under a private model, even if a relative oversupply of specialists develops, there is still no financial incentive for medical students to pick primary care until there are so many orthopedic surgeons that their median income has dropped from $600k to $200k. You are talking about a massive oversupply of specialists before free market forces ever nudged the numbers of PCPs higher. In the meantime, you're still left with a bazillion people who don't have primary care in the interim.

Regarding airports going public through the bully power of govt: Privatizing U.S. Airports

Your CATO institute (lol) article supports exactly the point I was making about Heathrow. They say: "Airports should be self-funded by revenues from passengers, airlines, concessions, and other sources. Federal subsidies should be phased out, and state and local governments should privatize their airports to improve efficiency, competitiveness, and passenger benefits."

Thousands of regional airports that serve actual communities would be closed if this idiotic model were implemented. To many of these communities (including the small town I grew up in), the airport operates at a loss but the eventual amount of revenue it brings into the community by making that community more attractive for businesses to set up shop there is invaluable. This kind of short-sighted "free market at all costs" thinking is infuriating sometimes.

 

[deleted480308]

So that we're actually clear on what you desire, would you agree with the following: all the programs I just mentioned are unnecessary government waste and a redistribution of wealth from the taxpayer, a significant number of people are abusing those programs instead of working, we should defund those programs, and those that truly need them should rely on the charitable giving of their neighbors

of course. charity is a personal, voluntary function

Simple supply and demand economics in regard to residency slots sounds good on paper, but it's nowhere near that simple because a board certified physician isn't a uniform widget pumped out by a factory every 3 seconds and sent to market. Under a private model, even if a relative oversupply of specialists develops, there is still no financial incentive for medical students to pick primary care until there are so many orthopedic surgeons that their median income has dropped from $600k to $200k. You are talking about a massive oversupply of specialists before free market forces ever nudged the numbers of PCPs higher. In the meantime, you're still left with a bazillion people who don't have primary care in the interim.

except some folks just plain don't want to be surgeons. We all have different motivators in life, but the money one would work itself out.

Your CATO institute (lol) article supports exactly the point I was making about Heathrow. They say: "Airports should be self-funded by revenues from passengers, airlines, concessions, and other sources. Federal subsidies should be phased out, and state and local governments should privatize their airports to improve efficiency, competitiveness, and passenger benefits."

Thousands of regional airports that serve actual communities would be closed if this idiotic model were implemented. To many of these communities (including the small town I grew up in), the airport operates at a loss but the eventual amount of revenue it brings into the community by making that community more attractive for businesses to set up shop there is invaluable. This kind of short-sighted "free market at all costs" thinking is infuriating sometimes.

If the local businesses want an airport that a third party won't build, they can band together voluntarily and start an airport.

 

[vector2]

This may be a difference between your field and mine, but by PGY-3 I could handle about 90% of what my attendings could at about the same pace for outpatient clinic. Being FM nothing I do is that high in terms of liability.

Yes, that's my point exactly- where do we draw the line on resident independence and liability in regard to resident billing? A PGY3 FM resident solo outpatient visit is not the same as a PGY3 anesthesia resident doing a solo anesthetic is not the same thing as a PGY3 neurosurgery resident doing a craniotomy. What about that 10% of what your attendings do that you couldn't handle? It is a nightmare from the hospital's standpoint and it would take a decade just to figure out the red tape on a specialty by specialty, PGY to PGY basis. Not to mention, is the patient who is presumably paying for services from a board-certified physician not entitled to that care? Do they get some kind of discounted rate on their lap chole if the PGY 4 does the entire thing solo?

The point is you can negotiate/argue/sue/whatever private insurance. Sure it might not effect them much in the long run but you do have some recourse that can make a difference to you. You have none of that with Medicare. Trust me, I hate them all equally (there's a reason I opened a DPC office) but at the moment Medicare is worse to work with when it comes to disagreements.

You won't find me disagreeing. Lack of accountability is one of the biggest problems people have with the administration of social programs.

Does the group across town do 40k less charity care per doctor than you do?

My assumption was that anything remotely academic pays less because it can not because it has to. Our local FM program pays their teaching attendings slightly more than they do their regular clinic doctors (amazing what having trouble finding people can do for you).

And for what its worth, I hope I'm not coming off as attacking you personally for your choice of job. I think we all should do what we enjoy and works for us, doing anything approaching charity care is a bonus.

The group across down does essentially zero charity care since they can just ship 'em here, but I'm not sure what their medicare/caid/private breakdown is. As I was saying, I'm at a hybrid shop and the goal (according to the big bosses) is to run the department similar to a private practice but with residents (which is unfortunately to their detriment). No one has academic days,the research throughput isn't great except for editing papers, very little original research, and we essentially have to relieve each other at work if there's some academic duty like a lecture which needs attending to. The only real different is that on days with residents, we are 2:1 instead of 4:1. According to the bosses, the lower salary is not by design- because certainly the workload is not cush like most academic gigs.

 

[Stagg737]

It’s funny that those who talk about shunning any and all identity politics inevitably turn to either be far right, center right, or right wing libertarian.

It's even funnier because I don't really fall into any of those categories.

I personally have a different opinion on the ethos of work than most- the idea of a society making people working 40-60 hrs a week until they’re at an age where they’re too decrepit to enjoy life is ridiculous. I work to live, not live to work.

We agree on that sentiment. I think training in medicine is different, but once I'm out of debt and have the foundation of a nest egg build up (will probably be around 40 by that time) I don't plan to work over 50 hours a week if possible. It would be nice if this were a reality for everyone, but I also don't think it's the government's job to do so.

Actually, it’s not, hoss. You’ve been talking this entire time about individual responsibility and the dangers of the nanny state and government handouts and yet you chose a profession and training where you would be the beneficiary of $200,000 over 4 yrs of sweet government loot. Yes, you are required to accept the CMS funding to train, but no one is stopping you from just giving the money back to Uncle Sam when you file taxes this year since you’re so principled.

You're being really stupid about this, so let's clarify. No one in this country can become a legally practicing physician without accepting CMS funding for residency for at least a few years. It is not legally possible thanks to Uncle Sam. Also, I have no idea why anyone should feel obligated to give that back to Uncle Sam as that money was granted in exchange for a service being provided. Idk what kind of ethical backflips you're trying to perform with this thought process, but I see no reason why anyone should reimburse the federal government for residency. If you want to try and be very clear why that's unethical I'd love to hear the reasoning, because they reasoning you've given so far seems pretty convoluted and strange.

This doesn’t even include the possibility that you may have (like so many “individual responsibility” types in medicine) have been the recipient of federally subsidized loans instead of walking down to a Wells Fargo and taking your chances.

Fair assumption, but another incorrect one. I paid for half my UG education (scholarships for other half), my grad school, and my first year of med school on my own. Took out private loans for the rest of med school. There are also no longer federally subsidized loans available for med school, so that point is moot.

Whatever you have to tell yourself. If you are purposefully not going to accept medicare/caid/charity at all, especially in a field where poverty is so closely linked to severe disease processes and the shortages are that bad, then yes, you are giving patients the finger as well.

You're assuming I won't be seeing those in poverty at all. I worked in free clinics before and throughout med school and plan to continue with that trend once I've paid off my debt. Keep making assumptions though, that's working out really well for you...

No sh1t Sherlock, I didn’t say the slang was invented here or patented. But since you didn’t understand me, I’ll clarify: casual references to the specialty as “gas” by someone who is not in the specialty is considered rude and ignorant.

Idc? I use this term all the time irl with anesthesiologists. I'm not about to change that on SDN because it hurts your feelz. Deal with it.

 

[vector2]

You're being really stupid about this, so let's clarify. No one in this country can become a legally practicing physician without accepting CMS funding for residency for at least a few years. It is not legally possible thanks to Uncle Sam. Also, I have no idea why anyone should feel obligated to give that back to Uncle Sam as that money was granted in exchange for a service being provided. Idk what kind of ethical backflips you're trying to perform with this thought process, but I see no reason why anyone should reimburse the federal government for residency. If you want to try and be very clear why that's unethical I'd love to hear the reasoning, because they reasoning you've given so far seems pretty convoluted and strange.

As others in this thread have pointed out, there actually are some privately funded (either by a private medical school or hospital system like HCA) residency spots which receive money from sources other than CMS, so your statement that no one can become a legally practicing physician without it is incorrect. Also, no residency spot is technically required to accept CMS DME funding, but if they do then that training program must be part of an institution that accepts CMS as a payer. Since most institutions already have a bunch of medicare patients, it makes sense to get that funding from CMS.

You don't feel obligated to pay the money back (or pay it forward by having a practice that treats some portion of medicare/medicaid) because you're apparently totally thoughtless about what you have received. CMS paid you $50k as a salary- great you don't have to pay that back. But they also gave the institution another $50k on your behalf. Ultimately you cost the taxpayer about $50k/yr.

Another poster stated that residents by the time they're seniors are providing more value than what they're getting paid by CMS- I disagree because for the time being residents do not bill independently and attendings having to supervise residents is a drag on the productivity of many specialties. Even if I didn't disagree on the point about seniors, we can all agree that there is no intern on earth who is worth $100k in their first 6-8 months of training.

I honestly can't explain the ethics of my position any more simply. You made a choice to become an MD. You chose a residency which subsidized your education with CMS dollars. After you've reaped all the benefits of a govt subsidy, you're now ready to go tell the govt and pts who use govt healthcare to F themselves. It's hypocritical on its face. At least people like @VA Hopeful Dr have been around the block a couple times as an attending physician and can come up with a legitimate reason why medicare has been difficult or untenable for their practice.

You're assuming I won't be seeing those in poverty at all. I worked in free clinics before and throughout med school and plan to continue with that trend once I've paid off my debt. Keep making assumptions though, that's working out really well for you...

Assumptions? You, yourself, have literally said: "I'm psychiatry, not gas. So it would be extremely easy in the current climate for me to open up a shop that doesn't accept medicare/caid tomorrow and fill my practice pretty easily. Heck, I could open up a cash only practice in my city tomorrow and have a full patient panel in under 6 months without much excess effort. A plethora of reimbursement models is a (small) part of why I chose my field. Because if worse comes to worst with our healthcare system I can still give the gov the finger and open a PP very easily and still sleep easy knowing I'm providing a desperately needed service to patients in need."

Indeed, I read that paragraph and immediately thought, "hmm, yes, this sounds like a chap who is going to do just oodles of free clinic work once he's out in practice."

Idc? I use this term all the time irl with anesthesiologists. I'm not about to change that on SDN because it hurts your feelz. Deal with it.

Good stuff, good stuff. You're a real class act.

 

[potential_fut_doc]

I wonder how many people seriously think he has a chance. And this is coming from a long time bernie fan. The current world order just cant stand having someone like bernie in a position of power.

 

[deleted480308]

I wonder how many people seriously think he has a chance. And this is coming from a long time bernie fan. The current world order just cant stand having someone like bernie in a position of power.

because he's a horrible person who doesn't respect the rights of others

 

[Stagg737]

I didn't say he shouldn't pursue the path. He's absolutely entitled to pursue residency training. I just want him to realize that he's likely been recipient of numerous 'handouts' like CMS allocation along the way and recognize that railing against those 'handouts' once the shiny board-certification is in hand is hypocritical.

Again, it's not a handout if you're exchanging a service for payment. The logical gymnastics here....

This opens up a whole can of worms of where in residency a resident becomes capable of actually independently billing for services without supervision. It also raises the question of how training licenses and liability/malpractice costs for residents would be handled. There are some PGY4 anesthesia residents who are more than capable of doing an entire complicated anesthetic on their own. There are some PGY4 anesthesia residents who are almost certainly not going to pass their boards and probably couldn't be trusted to anesthetize a cocker spaniel. Cardiothoracic surgery fellows pretty much never go into solo practice after graduation because they essentially still require a bit of backup and proctoring from a senior surgeon and don't really come into their own until 4, 5, 6 years out of fellowship. There's a reason there's a gradated granting of privileges from the resident -> fellow -> attending level and why initial board-certification is important for standardization of care, hospital credentialing, and the ability to bill for services.

The variability you mention is the best argument against this model and why I agree with. In surgical fields it may be completely inappropriate. I just calculated how much I bring in the hospital for my average week on an inpt unit as an intern and I already bring in more than that 100k/yr (~$150k per year billing about 30 99232s + 5 99222s per week, this doesn't include any consults or admissions I do when on call).

As I've said earlier in the thread, individuals can rarely be trusted to "do the right thing" on their own, and this is supported by every study of rational self-interest in the psychology of economics. That is the reason public policy at the population level is where real change is important.

Unfortunately, I agree with you here. I don't like a lot of the social welfare programs, but believe that they are necessary d/t human nature.

Social programs should be administered at the largest population level because that is where collective responsibility makes it easier for any one individual to shoulder a smaller part of the burden.

This I don't agree with. I think breaking it down to smaller levels allows those systems to identify the actual need of that smaller populace better and direct funds more appropriately. You pointed out yourself earlier that blanket changes to systems like SS would impact the most needy the worst, so I'm not sure why you'd think this principle would be different for other social welfare programs.

With globalization and technology making our world a smaller place, people and corporations are simply going to relocate to places with lower taxes. High-income individuals and businesses are not going to stay in a country with relatively higher taxes. Look at all the wealthy Chinese moving their money into real estate on the west coast. Domestically, this already happens on a smaller scale with individuals changing state of residence for tax purposes. On a corporate level, organizations move their headquarters and keep cash overseas in countries that have more favorable tax laws. The solution is NOT to tax the people/corporations you have more but to incentivize wealth creation and bring more people/corporations to your country. I.e. The governments' goal shouldn't be to maximize their share of the pie, but to assist in making more pies.

"The trouble with Socialism is that eventually, you run out of other people's money." -Margaret Thatcher

This. I come from a state where the government is an absolute disaster and I have no faith in larger governing bodies to act efficiently or in the best interest of the most people. The above is part of why I will never move back to the state where I grew up and why both my parents and wifes parents (all very liberal in a democratically controlled state) are looking to move away asap.

It varies so wildly between specialties and PGY year that the idea of allowing residents to bill would be almost impossible to figure out. At the end of the day, apprentices do not make as much as master craftsmen in every other field and profession out there. Medicine is no different.

Agree. For some fields this is feasible, for many it is not.

As others in this thread have pointed out, there actually are some privately funded (either by a private medical school or hospital system like HCA) residency spots which receive money from sources other than CMS, so your statement that no one can become a legally practicing physician without it is incorrect.

Fair point, my previous statement was not 100% accurate. However let's not pretend that those programs are very few and far between at this point in time. So the vast majority to the point that the minority in this situation is basically negligible are required to accept CMS funding to be a legally practicing physician. How many MDs or DOs do you actually know who finished residency in the last 20 years do you know who did not receive CMS funding during residency? That's my point.

Also, no residency spot is technically required to accept CMS DME funding, but if they do then that training program must be part of an institution that accepts CMS as a payer.

This is irrelevant within the current system and you've made many arguments as to why this is how the system should be, so I find your point within the context above to be hypocritical.

You don't feel obligated to pay the money back (or pay it forward by having a practice that treats some portion of medicare/medicaid) because you're apparently totally thoughtless about what you have received.

Not at all true. I'm fully aware and participate in something necessary but not desirable in order to do more good in the future. The absolutes in your statements are pretty childish.

Assumptions? You, yourself, have literally said: "I'm psychiatry, not gas. So it would be extremely easy in the current climate for me to open up a shop that doesn't accept medicare/caid tomorrow and fill my practice pretty easily. Heck, I could open up a cash only practice in my city tomorrow and have a full patient panel in under 6 months without much excess effort. A plethora of reimbursement models is a (small) part of why I chose my field. Because if worse comes to worst with our healthcare system I can still give the gov the finger and open a PP very easily and still sleep easy knowing I'm providing a desperately needed service to patients in need."

Indeed, I read that paragraph and immediately thought, "hmm, yes, this sounds like a chap who is going to do just oodles of free clinic work once he's out in practice."

Why do you assume that anything in the above statement is mutually exclusive with also providing charitable or free care? You continue to make a lot of dumb assumptions and it may benefit you to check your own biases before making more.

Good stuff, good stuff. You're a real class act.

I'll quote myself again since you seem to enjoy trolling: "I don't get bothered by ignorant mislabeling".

because he's a horrible person who doesn't respect the rights of others

Disagree. I think Bernie's probably a really good guy who legitimately wants to look out for the best interests of his constituents and the American people. At one point I was heavily considering voting for him simply for the fact that he actually seems to care more about doing what he believes is the right thing than what is best for his own political agenda. I also didn't mind because if he'd somehow won there's no way he'd have actually gotten any of his bat-s*** crazy policies in 2016 passed and we'd have 4 years of gridlock. I disagree with almost every policy of his which I've read, but I don't think he's a bad person.

 

[vector2]

because he's a horrible person who doesn't respect the rights of others

yep, he's a real horrible person who's never cared about other people's rights

 

[BLADEMDA]

Measured as a share of GDP, the biggest long-term growth in federal spending has come in human services, a broad category that includes various kinds of social insurance, other health programs, education aid and veterans benefits. From less than 1% of GDP during World War II (when many Depression-era aid programs were either ended or shifted to the war effort), federal spending on human services now amounts to 15.5% of GDP. It actually was higher – 16.1% – in fiscal 2010, largely due to greater spending on unemployment compensation, food assistance and other forms of aid during the Great Recession. Now, the main growth drivers of human-services spending are Medicaid, Medicare and Social Security.

Based on the above we can’t afford AOC or the left. We need to shore up our existing entitlement programs before we create even more entitlements. This isn’t politics, it is common sense.

 

[BLADEMDA]

Again, it's not a handout if you're exchanging a service for payment. The logical gymnastics here....



The variability you mention is the best argument against this model and why I agree with. In surgical fields it may be completely inappropriate. I just calculated how much I bring in the hospital for my average week on an inpt unit as an intern and I already bring in more than that 100k/yr (~$150k per year billing about 30 99232s + 5 99222s per week, this doesn't include any consults or admissions I do when on call).



Unfortunately, I agree with you here. I don't like a lot of the social welfare programs, but believe that they are necessary d/t human nature.



This I don't agree with. I think breaking it down to smaller levels allows those systems to identify the actual need of that smaller populace better and direct funds more appropriately. You pointed out yourself earlier that blanket changes to systems like SS would impact the most needy the worst, so I'm not sure why you'd think this principle would be different for other social welfare programs.



This. I come from a state where the government is an absolute disaster and I have no faith in larger governing bodies to act efficiently or in the best interest of the most people. The above is part of why I will never move back to the state where I grew up and why both my parents and wifes parents (all very liberal in a democratically controlled state) are looking to move away asap.



Agree. For some fields this is feasible, for many it is not.



Fair point, my previous statement was not 100% accurate. However let's not pretend that those programs are very few and far between at this point in time. So the vast majority to the point that the minority in this situation is basically negligible are required to accept CMS funding to be a legally practicing physician. How many MDs or DOs do you actually know who finished residency in the last 20 years do you know who did not receive CMS funding during residency? That's my point.



This is irrelevant within the current system and you've made many arguments as to why this is how the system should be, so I find your point within the context above to be hypocritical.



Not at all true. I'm fully aware and participate in something necessary but not desirable in order to do more good in the future. The absolutes in your statements are pretty childish.



Why do you assume that anything in the above statement is mutually exclusive with also providing charitable or free care? You continue to make a lot of dumb assumptions and it may benefit you to check your own biases before making more.



I'll quote myself again since you seem to enjoy trolling: "I don't get bothered by ignorant mislabeling".



Disagree. I think Bernie's probably a really good guy who legitimately wants to look out for the best interests of his constituents and the American people. At one point I was heavily considering voting for him simply for the fact that he actually seems to care more about doing what he believes is the right thing than what is best for his own political agenda. I also didn't mind because if he'd somehow won there's no way he'd have actually gotten any of his bat-s*** crazy policies in 2016 passed and we'd have 4 years of gridlock. I disagree with almost every policy of his which I've read, but I don't think he's a bad person.

Bernie’s policies are bad for this country. We are already in huge debt. We can’t fund our existing entitlements but Bernie wants to create trillions more in national debt.

Bernie is probably a better hunan being than Donald Trump. But, which one will do less damage to this country overall? I know many of you will say Harris or Sanders but I disagree. The left is completely wrong on economics and the adoption of these programs could bankrupt this country.

Forget politics. The policies these nutcases are proposing are preposterous and dangerous to this country.

 

[BLADEMDA]

The United States holds the most debt of any country in the history of the world. In fairness, when our debt-to-GDP ratio is factored in, there are many countries in far more perilous economic situations than the U.S. But there will come a tipping point. How much debt can the system hold? When will the cracks grow too big to hide? When will the foundation crumble? There’s a great deal of ruin in a nation, said Adam Smith, and our ruin must ultimately come.

Is bankruptcy possible? As some Beltway economists remind us, no. Technically the government has the power to artificially create as many dollars as it needs to pay its debts. But this kind of hyper-inflation would deprive the U.S. dollar of any value and tank the global economy that trades with it. Simple failure to pay back our debt might even be a better scenario that such an inflationary hellscape.

When the world loses confidence in the American government’s ability to pay its debt, or the interest rate on our debt becomes unsustainably high, choices will have to be made. No more kicking the can down the road, no more 10-year projections to balance the budget. Congress, in a state of emergency, will have to take a buzzsaw to appropriations

The Coming Bankruptcy of the American Empire

 

[BLADEMDA]

But several potential 2020 Democratic presidential candidates, including Sanders and senators Elizabeth Warren of Massachusetts, who co-sponsored Sanders’ “Medicare for all” bill; Corey Booker of New Jersey; Kamala Harris of California; and Kirsten Gillibrand of New York; have endorsed big chunks of it (the jobs guarantee plus a $15-an-hour national minimum wage, Medicare for all, and free public college tuition for everyone). So by the time voters go to the polls in November 2020, this may be Democratic orthodoxy.

That’s too bad, because not only do these radical plans not stand a chance of passing a highly polarized Congress; they’re genuinely bad ideas. Why?

Running out of money
Primarily because, repeat after me, we just can’t afford them.

Let’s start with Medicare for all. Didn’t any of these politicians read the recent report by the trustees for Medicare and Social Security stating that the Social Security trust fund will run out of money in 2034 and Medicare’s fund will go insolvent by 2026? Truth is, with 10,000 baby boomers turning 65 every day from now until 2029, we can barely afford the current program, let alone expanding it to the whole population.

But if we did, it — and the free-public-tuition giveaway, when barely a third of Americans have a four-year college degree — would add $32 trillion to the national debt over the following decade (or a mere $18 trillion if Sen. Sanders’ 2016 tax increases on the rich were also passed to pay for some of it), according to the Tax Policy Center.

That’s more than 10 times as much as the Republicans’ recent tax-cut giveaways to its big corporate donors are projected to add over the next decade and would, at the very least, more than double the national debt in the hands of the public, which is currently over $15 trillion.

Also, thanks to a profligate GOP, we’re going to see trillion-dollar annual federal deficits for years to come. These plans could easily triple those annual gaps.

Howard Gleckman of the Tax Policy Center estimated the original Sanders plan would add $3 trillion in interest costs alone, calling it “an unprecedented increase in government borrowing.” By the way, the Tax Policy Center isn’t some right-wing think tank; it’s affiliated with the left of center Urban Institute and Brookings Institution. But their economists know how to add and subtract.

Krugman estimates the guaranteed-job proposal — which comes as the unemployment rate is hitting multiyear lows — would cost around $270 billion a year. Former Democratic Treasury Secretary Lawrence Summers pegs the cost at $840 billion annually. And what would all these people actually do on their taxpayer-subsidized jobs?

Add the maraschino cherry on this rich cake — Ocasio-Cortez’s plan to forgive all student debt — and you get another $ 1 trillion-plus goodie. A trillion here, a trillion there, and pretty soon it’s real money.

Total price tag: anywhere from $20 trillion to $40 trillion over 10 years, depending on how much taxes would have to be raised to pay for all this.

Ever since the election, Democrats have been desperate for “big ideas” to defeat President Trump and Republicans at the polls. But these hare-brained schemes ain’t it.

Turns out, socialism doesn’t come cheap.

Democrats’ ‘socialism’ will bury us in debt we won’t be able to get out from under

 

[BLADEMDA]

“An increasingly popular theory espoused by progressives that the government can continue to borrow to fund social programs such as Medicare for everyone, free college tuition and a conversion to renewable energy in the next decade is unworkable, Federal Reserve Chairman Jerome Powell said Tuesday.”

 

[deleted480308]

yep, he's a real horrible person who's never cared about other people's rights

compare that to all the pictures of those killed and damaged by socialism? yep, still a horrible person

 

[deleted480308]

Disagree. I think Bernie's probably a really good guy who legitimately wants to look out for the best interests of his constituents and the American people. At one point I was heavily considering voting for him simply for the fact that he actually seems to care more about doing what he believes is the right thing than what is best for his own political agenda. I also didn't mind because if he'd somehow won there's no way he'd have actually gotten any of his bat-s*** crazy policies in 2016 passed and we'd have 4 years of gridlock. I disagree with almost every policy of his which I've read, but I don't think he's a bad person.

his intentions mean nothing, what he wants to do is incredibly evil and damaging

 

[Stagg737]

his intentions mean nothing, what he wants to do is incredibly evil and damaging

Then I guess most of our government and people in general are "incredibly evil and damaging".

 

[BLADEMDA]

 

[deleted162650]

Then I guess most of our government and people in general are "incredibly evil and damaging".

This is the most accurate statement in this entire thread.

 

[BLADEMDA]

32 Trillion over 10 years.

 

[vector2]

Again, it's not a handout if you're exchanging a service for payment. The logical gymnastics here....

The variability you mention is the best argument against this model and why I agree with. In surgical fields it may be completely inappropriate. I just calculated how much I bring in the hospital for my average week on an inpt unit as an intern and I already bring in more than that 100k/yr (~$150k per year billing about 30 99232s + 5 99222s per week, this doesn't include any consults or admissions I do when on call).

Do you have any idea how ridiculous it sounds saying that "as an intern" that you are bringing in > 100k/yr? You doing an H&P and then presenting it to your senior or attending for final approval does not constitute you bringing in that money. If you had an unrestricted medical license, board certification, malpractice insurance, the ability to treat the most complex patients independently, and the ability to bill an insurance company, then yes, you could say that you bring in >100k / yr.

Unfortunately, I agree with you here. I don't like a lot of the social welfare programs, but believe that they are necessary d/t human nature.

Good, I can only hope you vote accordingly at the ballot box.

This I don't agree with. I think breaking it down to smaller levels allows those systems to identify the actual need of that smaller populace better and direct funds more appropriately. You pointed out yourself earlier that blanket changes to systems like SS would impact the most needy the worst, so I'm not sure why you'd think this principle would be different for other social welfare programs.

I'm still for national social security even if I think FICA taxes should be progressively structured. Just like I'm for federal income tax that's progressively structured and a national health program that can at least provide basic medical care, catastrophic care, and access to required surgeries. Just because I'm not for rash, blanket changes to the programs does not mean I'm not for the programs at all. Breaking these programs up into smaller geographies is ineffective as you can see from what's happened to state administered medicaid. Rich states do OK, poor states get killed. Put the money in the biggest pool possible and then target it where it's needed. Economies of scale can't be beat in many regards.

Fair point, my previous statement was not 100% accurate. However let's not pretend that those programs are very few and far between at this point in time. So the vast majority to the point that the minority in this situation is basically negligible are required to accept CMS funding to be a legally practicing physician. How many MDs or DOs do you actually know who finished residency in the last 20 years do you know who did not receive CMS funding during residency? That's my point.

This is irrelevant within the current system and you've made many arguments as to why this is how the system should be, so I find your point within the context above to be hypocritical.

Not at all true. I'm fully aware and participate in something necessary but not desirable in order to do more good in the future. The absolutes in your statements are pretty childish.

You need to learn the difference between a rhetorical point and me literally suggesting you do something. Nobody rationally expects you to literally give back the 50k non-salary CMS dollars to Uncle Sam. Nobody rationally expects you or anybody else to literally seek out the 1% of residencies which are private in order to avoid the whiff of impropriety or hypocrisy that results from accepting CMS dollars for training and then shunning CMS the second you don't need them anymore. Think about this: if you are indeed so valuable as a resident, why is it that there are so few privately funded residencies in existence? Shouldn't corporations and private med schools be chomping at the bit to create more spots?

Honestly, what I'm more concerned about is convincing you of the folly of considering government involvement in medical education "something necessary but not desirable." I keep wondering why many shy away from it when the rest of the first world has already embraced it. Surely you have read about the history of medical school and the history of residency training in the United States, especially in the early 20th century. National standardization of admissions criteria, curriculum, and USMLE did wonders for the the quality of medical care and its practitioners. Granted, the Flexner report was independent and the changes were implemented under the auspices of the AAMC/LCMC and not the govt, but it demonstrates the power of how a centralized body can effect massive change for the better. Unfortunately, this national standardization didn't trickle down to individual state medical boards, and physicians who desire geographic mobility have to go through an expensive nightmare every time they move or do out of state locums.

CMS/govt similarly, for all its problems, has been a boon to medical education for the last 30 years. We have a problem nowadays with number of applicants vs. residency spots, but just imagine how much worse that problem would be if the govt washed its hands of subsidizing medical education. Would the noble corporations step in to fix the issue with a slew of privately funded residency spots? My bet is no.

Why do you assume that anything in the above statement is mutually exclusive with also providing charitable or free care? You continue to make a lot of dumb assumptions and it may benefit you to check your own biases before making more.

The game you're playing where you think it's reasonable to go on a rant that essentially implied that you've won the private practice/cash pay/no medicare lottery by picking psychiatry and then chide me for making a reasonable assumption about your presumable lack of interest in charity care has gotten rather tiring.

I'll quote myself again since you seem to enjoy trolling: "I don't get bothered by ignorant mislabeling".

No, you see, trolling is what it's called when you post a bunch of stuff that definitely implies one thing and then you retort endlessly with a bunch of pedantry about how people are making false assumptions based on the stuff you definitely just implied.

 

[DirtDocMD]

The “road to hell is paved with good intentions.” Does anyone REALLY think, that even under the most PERFECT of circumstances, that there’s not going to ALWAYS be a certain percentage of the populace (10-20% ????) that is going to be “disadvantaged” or “poor”?? Perhaps it’s due to mental illness? Maybe drug abuse? Lack of education or the mental ability to be adequately educated? Maybe just pure “laziness”??

Are we going to drag down the entire country, and put everyone into a “one size fits all” system of healthcare/education/high taxation, with overly complex and expensive schemes, merely in hopes of reaching the unattainable goal of 100% “prosperity” and “good health”??? Perhaps consider acknowledging that a prosperous ECONOMY (lots of jobs, reasonable taxes, deregulation) would allow us to take care of “most” of these ills? Rather than choking taxpayers/industry/etc to death, a strong ECONOMY could work just as well, without killing folks’ freedom/independence/work ethic in the process.

Remember when churches and charities used to help folks and build hospitals, and could do so, because they were flush with cash from successful American workers? The same applies to the Govt’s tax “coffers” if employment is high with good jobs. Do you take a “few” of the goose’s “golden eggs”, or do you take so many, that she just gives up, gets depressed, and stops laying???

 

[vector2]

compare that to all the pictures of those killed and damaged by socialism? yep, still a horrible person

speaking of strawmen.....


conflating modern democratic socialism and communism reminds me of the disingenuous people who conflate the republican party and nazis/fascists

 

[GravelRider]

maybe you are legitimately unaware of what the "Welfare queen" image is...it's someone living lavishly off of clearly unneeded support. Which again, I never implied or stated.

I used to call the dishonest partners at my first job “welfare queens.” You have never seen such a lazy and pathetic collection of useless and unskilled losers in your entire life. I would take almost any unsupervised CRNA over them every single time. Yet they were the biggest talkers of “capitalism this” and “free market” that.

 

[deleted480308]

I used to call the dishonest partners at my first job “welfare queens.” You have never seen such a lazy and pathetic collection of useless and unskilled losers in your entire life. I would take almost any unsupervised CRNA over them every single time. Yet they were the biggest talkers of “capitalism this” and “free market” that.

I don't like dishonest people either

 

[deleted480308]

Then I guess most of our government and people in general are "incredibly evil and damaging".

a lot of them, yes

 

[GravelRider]

I’m a supporter of single payer healthcare because, to be honest with you, I don’t want the reason for me to continue working full time in my 50s and beyond to be that healthcare is too expensive and I need to wait until I’m eligible for Medicare to cut back or retire.

The bottom line is this, the government has become a tool by which the corporations and rich have continued to concentrate power and wealth. We don’t have a free market. As a result, the middle class in America has suffered. You need a very expensive college degree to even have a shot at covering not only living expenses, but saving for things like retirement and health surprises. Upward social mobility essentially doesn’t exist and many children are worse off than their parents are despite working harder with more education. At some point something has to give.

The opinions on this board, while valuable, don’t mean much in the grand scheme. We all make more than enough money to live comfortably. The majority of Americans support these ideas (including the Republican voters if you talk to them away from the Fox propaganda machine). The majority of Americans are asking for a hand with these big expenses...education and healthcare. It does not seem all that unreasonable for the well off to chip in a bit more for the benefit of our fellow citizens. That ideal is written directly into our Constitution by the founding fathers. It’s not Communism, it’s just good citizenry. Who knows, free up some of people’s capital from the worries of things like healthcare and student debt and you might unlock more young people creativity to create new businesses and a more vibrant economy.