NYYk9005

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Okay don't hate me for asking this question, but I am a third-year medical student who is very interested in emergency medicine and is pretty dead set on going into it.
I just love the pace, diagnosing first, the variety of problems, the need to perform at your best at the most stressful/urgent time in a patients care, and the patient interaction.

I just wanted to know what people in this specific profession feel that direct impact of the ACA on emergency medicine is.

More patients? Less pay? Better job opportunities? Less primary care problems?

I searched the EM FAQ and couldn't find a relatively up to date thread.

Also, if anyone has any advice for a young kid like me on how to succeed in EM, I'd love it. Like what is the thing that separates a good EM doc from being a great one.

Thanks all.
 

daveyjwin

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I don't think anyone truly knows what's going to happen, it'll have to play out however it does, and I'm sure the rules will be adjusted, and any guesses now are just that: guesses.

My guess: More of our patient's will be insured, and total reimbursement will be less per patient, but it will more or less equal out in the long run. We'll probably be a little busier as well.
 

Arcan57

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Okay don't hate me for asking this question, but I am a third-year medical student who is very interested in emergency medicine and is pretty dead set on going into it.
I just love the pace, diagnosing first, the variety of problems, the need to perform at your best at the most stressful/urgent time in a patients care, and the patient interaction.

I just wanted to know what people in this specific profession feel that direct impact of the ACA on emergency medicine is.

More patients? Less pay? Better job opportunities? Less primary care problems?
Yes, probably not, maybe, no.

There's a lot that we don't know about how the ACA is going to impact things (especially with the mandatory Medicaid expansion being blocked) but if you look at systems that have implemented mandatory insurance there are trends that arise:

1) Insured people consume more health-care than their un-insured counterparts.
2) There is no flood of new primary care doctors to meet this demand. PCPs have long been trying to maximize revenue by maximizing volume and there's essentially no surge capacity left in the system (unless the new insurance paid high enough rates to reverse the trend towards concierge medicine, which they don't).
3) These newly insured pts without the ability to access primary care services for anything other than scheduled months-in-advance check-ups will utilize the ED for things they wouldn't have without insurance.
4) For actual emergencies, we'll come out ahead since the costs of an ED stay will zero out (or at least come quite close) the deductible and so the uninsured appy, TIA, etc. will be bringing in more revenue than when they were self pay. For the primary care stuff, it will be essentially the same scenario as it is now (at least in states without Medicaid expansion) since the majority of the newly insured are going to have huge deductibles for anything that's not preventive primary care.
5) Urgent cares will handle some of the PCP overflow, but the average NP is going to refer to the ED significantly more than the average MD (not sure the magnitude of the effect but it's worth mentioning).
6) Job opportunities are going to very locally, depending on how well the particular hospital systems in your area are at staying profitable.
7) We'll see more primary care issues because of 1,2,3, (and to a lesser extent) 5. Hospitals will continue trying to find reliable ways of diverting this business to a less expensive venue (screen-outs +/- referral to hospital owned UC/IM or FP office or nurse driven"medical home"), but at least at the moment the incentives for diversion aren't worth the effort for most systems.

Bonus:
The difference between being a good and great EP is two-fold:

1) Great EPs find the practice of emergency medicine intellectually interesting and cultivate and maintain that interest as their careers mature. Good EPs maintain competence but are just focused on executing their assigned tasks well. Good EPs probably notice a dozen things a day that could be done better but no longer (or never did) have the activation energy to work on improving them.

2) Great EPs care about their patients, all of them. When they talk about frequent flyers, there's a sadness in their faces that the rest of us don't have. They call back the patients they sent home to see how they're doing. They follow the course of patients upstairs. They want to do the right thing for the patient because it will make the patient better, not because it means they're less likely to get sued or get yelled at by another physician.

Unrelated tangent: The 2nd part was actually easier when the paternalistic model of medicine was the standard. It's a lot easier to care about someone if you're taking responsibility for their choices.
 

GeneralVeers

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Bad bad bad.

Nothing good can come of government intervention. Do any of you actually think increased government control will benefit taxpayers, physicians, or patients? Keep dreaming. It's all about power. The more of the healthcare system they take, the more power they have, and the more favors/waivers they can give out to favored interest groups.

Every physician should be against this monstrosity.
 
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NYYk9005

NYYk9005

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Yes, probably not, maybe, no.

There's a lot that we don't know about how the ACA is going to impact things (especially with the mandatory Medicaid expansion being blocked) but if you look at systems that have implemented mandatory insurance there are trends that arise:

1) Insured people consume more health-care than their un-insured counterparts.
2) There is no flood of new primary care doctors to meet this demand. PCPs have long been trying to maximize revenue by maximizing volume and there's essentially no surge capacity left in the system (unless the new insurance paid high enough rates to reverse the trend towards concierge medicine, which they don't).
3) These newly insured pts without the ability to access primary care services for anything other than scheduled months-in-advance check-ups will utilize the ED for things they wouldn't have without insurance.
4) For actual emergencies, we'll come out ahead since the costs of an ED stay will zero out (or at least come quite close) the deductible and so the uninsured appy, TIA, etc. will be bringing in more revenue than when they were self pay. For the primary care stuff, it will be essentially the same scenario as it is now (at least in states without Medicaid expansion) since the majority of the newly insured are going to have huge deductibles for anything that's not preventive primary care.
5) Urgent cares will handle some of the PCP overflow, but the average NP is going to refer to the ED significantly more than the average MD (not sure the magnitude of the effect but it's worth mentioning).
6) Job opportunities are going to very locally, depending on how well the particular hospital systems in your area are at staying profitable.
7) We'll see more primary care issues because of 1,2,3, (and to a lesser extent) 5. Hospitals will continue trying to find reliable ways of diverting this business to a less expensive venue (screen-outs +/- referral to hospital owned UC/IM or FP office or nurse driven"medical home"), but at least at the moment the incentives for diversion aren't worth the effort for most systems.

Bonus:
The difference between being a good and great EP is two-fold:

1) Great EPs find the practice of emergency medicine intellectually interesting and cultivate and maintain that interest as their careers mature. Good EPs maintain competence but are just focused on executing their assigned tasks well. Good EPs probably notice a dozen things a day that could be done better but no longer (or never did) have the activation energy to work on improving them.

2) Great EPs care about their patients, all of them. When they talk about frequent flyers, there's a sadness in their faces that the rest of us don't have. They call back the patients they sent home to see how they're doing. They follow the course of patients upstairs. They want to do the right thing for the patient because it will make the patient better, not because it means they're less likely to get sued or get yelled at by another physician.

Unrelated tangent: The 2nd part was actually easier when the paternalistic model of medicine was the standard. It's a lot easier to care about someone if you're taking responsibility for their choices.
Many thanks for this wonderful answer
 

dotcb

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Bad bad bad.

Nothing good can come of government intervention.
Are you serious? Like streets, public schools, police, the coast guard...?"

It's extremist thinking like this shows the flaws in your reasoning. The point is to insure more of the 44 million+ uninsured, and those with pre-existing conditions. I have a sneaking suspicion you're going to be OK.
 

sb247

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Are you serious? Like streets, public schools, police, the coast guard...?"

It's extremist thinking like this shows the flaws in your reasoning. The point is to insure more of the 44 million+ uninsured, and those with pre-existing conditions. I have a sneaking suspicion you're going to be OK.

The gov builds roads at 6 times the cost of what I build them (and yes, I build them). The gov schools are largely crap and in most cases those with the money to escape them go to private. It is the govs love of control that stops voucher programs because students would flee in droves. (Save me the hero stories of teachers, my wife is one). Police are a bloated expense that quite often abuse their power and do very little crime prevention as their main function is crime investigation/prosecution. The coast guard wastes too much time chasing down drugs that should be legal to begin with.

In almost every circumstance imaginable, private business can handle a function better than gov
 
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swamprat

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Its outrageous we have attendings on here that are for obamacare. So me being in my mid 20s I should be OK with being forced to pay for insurance I don't want and will not use at a higher rate just so I can subsidize all the older and unhealthy patients some of which could have bought insurance previously but chose not to. And for those completely happy with their insurance and liked their doctors, its ok that they got their insurance canceled? Obama didn't promise that if you like your doctor, your plan, you can keep it.. did he? This whole thing is a mess and considering 6 million plans got canceled and only like 1.2 million have signed up it seems like so far we have just further contributed to the uninsured population. Lets not forget that it seems like many hard working middle class americans are going to have to pay MORE for LESS now that their policies have been canceled. And good luck find a PCP thats going to take this medicaid like insurance, once the government comes in they can set the bar as low as they want and private companies will follow suit.. we want less government in our lives not more.
 

RustedFox

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Its outrageous we have attendings on here that are for obamacare. So me being in my mid 20s I should be OK with being forced to pay for insurance I don't want and will not use at a higher rate just so I can subsidize all the older and unhealthy patients some of which could have bought insurance previously but chose not to. And for those completely happy with their insurance and liked their doctors, its ok that they got their insurance canceled? Obama didn't promise that if you like your doctor, your plan, you can keep it.. did he? This whole thing is a mess and considering 6 million plans got canceled and only like 1.2 million have signed up it seems like so far we have just further contributed to the uninsured population. Lets not forget that it seems like many hard working middle class americans are going to have to pay MORE for LESS now that their policies have been canceled. And good luck find a PCP thats going to take this medicaid like insurance, once the government comes in they can set the bar as low as they want and private companies will follow suit.. we want less government in our lives not more.

The ACA gets my libertarian hackles up, but it has had three distinct advantages for me.

1. I'm one of those "unhealthy" patients that you refer to. One day, in my mid-to-late twenties... BOOM, autoimmune-disease city. Your assertion of "could have bought insurance previously but chose not to" is just flat wrong. I tried every carrier I could. Rejected. Denied. KTHXBYE. - Those were the only answers that I got. Now, I can actually take my purchasing power down to BCBS (or any other carrier) and there's no discriminating. Lets face it; if you don't have insurance coverage, you're not getting care beyond the public health/ED setting. Forget cancer screening, forget maintenance care, forget being able to afford disease-controlling drugs.

2. Wifey is one of these similar "uninsurably healthy" people. We moved down here to Florida, so she had to quit her job. Her COBRA coverage was close to 500 bucks/month, and we had to pay 100% of the upfront costs of Rx meds, only to get reimbursed the (whatever amount) several months later, after the company made every attempt to not pay-up by making us jump thru every hoop imaginable. "Here, have these forms signed by both your PMD, and your pharmacist by X date, and if its not returned by Y, then... too bad." Her disease ? Well, its not a life-altering autoimmune one, but it was still enough to get her the same flat denials that I got from every insurance carrier that we shopped at. It was COBRA or nothing, and COBRA only gets you so many months of coverage, leaving us scrambling to come up with a contingency plan after that. Once the ACA passed, we simply walked in to BCBC (my carrier at work), and saved a ton of money over the COBRA plan, with much better benefits.

3. So, with me being uninsurable, being an IC is not an option for me. I need disease-controlling meds, so I had to take a "full-employee" position with prescription coverage. Before you ask: Yes, the cost of the meds is prohibitively high. I'd be 'chained' to this full-employee position if it weren't for the ACA, and this job is becoming pretty toxic. Now, I am free to pay for my own coverage, declare myself IC, and do locums or travel work, or find a new gig.

Sure, there's a lot of the ACA that I stand in serious opposition of, but a lot of it could have been avoided if the insurance companies would have just been honest and cooperative to begin with. What a concept: I have an honest job, that pays me honest money, and I'd like to buy an honest product. No ? Wow, hmmm. Something's very wrong here.

Less government is generally a very good thing, yes: but this time, just this one little bit of the plan has helped me a big deal.
 
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deuist

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More patients? Less pay? Better job opportunities? Less primary care problems?
With more insured patients, they'll show up in droves to the ED screaming, "You have to treat me! I have insurance!" I do think that ED docs stand to make more money now that patients will be able to pay their bills. However, the volume will increase to astronomical levels (also leading to more pay), but will also likely decrease job satisfaction. I'm not sure what you mean by job opportunities. We will see MORE primary care as the ACA does nothing to create more primary care physicians.
 

GeneralVeers

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There is not one thing the government does that is more efficient or has better results than the private sector.
I can make some arguments for very specific, narrow things government should do:
1. Protect the constitutional rights of citizens
2. Protect private safety
3. Protect the national borders from invasion

That should be it. Every other portion of government can be taken over by the private sector and be more efficient and effective. As I stated above it's all about power. Once these guys in D.C. control one thing, and thrive on the power it gives them, they seek more and more and more.

Controlling healthcare, and by extension people's lives and personal decisions will grant the idiots in D.C. enormous power and control. It will give them freedom to regulate what you eat, how often you exercise, how much television you watch, and virtually every other private aspect of your life that "could" impact your health. If you don't think they will do this over time, then you are delusional
 

swamprat

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Fox,
I'm really sorry to hear about your hardships. My point was not to state that the current (or I guess now former) system worked in every way (I think we all know there were and still are a lot of problems) but to argue against such LARGE government involvement and their take over of the system. At the beginning of this whole transition one of the new laws was insurance companies couldn't deny based on preexisting conditions and it extended the amount of time children could be on their parents insurance without having to go out and buy their own(one of which benefited me obviously as you stated the other benefited you.) those are good things and I'm not against people getting insured I am however against this whole redistribution of wealth everyone's equal liberal crap Obama is shoving down our throats and being forced to purchase a product that many Americans don't want. Where's the incentive to work hard or do anything these days it seems like the harder you work, the more you make, the more they take. I could go on and on about all the lies and borderline unconstitutional things that Obama has been doing but I don't want to open up that can of worms. I'm glad it worked out quiet we'll for you and I don't blame you for being for the aca when you really were getting a raw deal beforehand but most young people aren't in that boat and don't necessarily want to be forced to pay out the ass for something they will rarely use.
 

GeneralVeers

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Doxy,

The problem with the "good portion" of the law whereby pre-existing conditions are covered, is that it can't exist without the "bad parts" of the law. You can't have guaranteed issue for high-risk people without also forcing the young and healthy to sign up AND pay a lot more in order to subsidize the unhealthy. If you take out the individual mandate portion, you could in theory have guaranteed issue, however the premiums would be stratospheric for those people and unaffordable. That is the house of cards the ACA is built on. Take out almost any core element of the law, and the whole thing becomes untenable.
 

RustedFox

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Veers, I'm with you 99+% of the time. Especially with those points that you make above.

Private insurance marginalized me and my wifey. Period. "We" just weren't worth it to them. I would be left to die. For realsies.

I think what we all want to do is slice-and-dice the ACA. Don't make the mistake of saying that I'm "for" it. I'm "for" honest and fair business practices. Everyone knows the quote "with great power comes great responsibility". The private insurance fatcats wanted all the power, and none of the responsibility. Sadly, the pendulum has swung far in the other direction, instead of back to neutral position.

A lot of this would not have ever come to pass if the insurance companies would just provide an honest product that pays what they promised, instead of trying to deny every little penny at every little turn. We've all seen the 60-minutes documentaries that have all the testimonials from docs whose job was to "find a reason to deny".
 

GeneralVeers

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Veers, I'm with you 99+% of the time. Especially with those points that you make above.

Private insurance marginalized me and my wifey. Period. "We" just weren't worth it to them. I would be left to die. For realsies.

I think what we all want to do is slice-and-dice the ACA. Don't make the mistake of saying that I'm "for" it. I'm "for" honest and fair business practices. Everyone knows the quote "with great power comes great responsibility". The private insurance fatcats wanted all the power, and none of the responsibility. Sadly, the pendulum has swung far in the other direction, instead of back to neutral position.

A lot of this would not have ever come to pass if the insurance companies would just provide an honest product that pays what they promised, instead of trying to deny every little penny at every little turn. We've all seen the 60-minutes documentaries that have all the testimonials from docs whose job was to "find a reason to deny".
I don't have the answer for you. The solution is not a government takeover of ALL healthcare which is in process. I don't think anyone has a really good answer for someone in your situation. Do you think your care would be much better if the government provided all your healthcare and made your decisions? To the government they may conclude that your value to society does not exceed the cost of your (and your wife's) expensive care and could deny your treatment. At that point, who do you turn to in order to appeal? Rationing must be part of any government system, and seems like it's a great idea, until its your (or a family member's) care that is being rationed.
 

Arcan57

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Fox,
I'm really sorry to hear about your hardships. My point was not to state that the current (or I guess now former) system worked in every way (I think we all know there were and still are a lot of problems) but to argue against such LARGE government involvement and their take over of the system. At the beginning of this whole transition one of the new laws was insurance companies couldn't deny based on preexisting conditions and it extended the amount of time children could be on their parents insurance without having to go out and buy their own(one of which benefited me obviously as you stated the other benefited you.) those are good things and I'm not against people getting insured I am however against this whole redistribution of wealth everyone's equal liberal crap Obama is shoving down our throats and being forced to purchase a product that many Americans don't want. Where's the incentive to work hard or do anything these days it seems like the harder you work, the more you make, the more they take. I could go on and on about all the lies and borderline unconstitutional things that Obama has been doing but I don't want to open up that can of worms. I'm glad it worked out quiet we'll for you and I don't blame you for being for the aca when you really were getting a raw deal beforehand but most young people aren't in that boat and don't necessarily want to be forced to pay out the ass for something they will rarely use.
You pay "out the ass" for tons of things you don't use. Something's individual utility to you is a very reasonable reason for a personal position, but makes extremely poor public policy. We, as a society, have decided (by an extraordinarily small margin) that we want everyone to have health insurance and that the ACA is the most practical way of achieving that goal under current conditions. Presumably there is some good to society from Rusted being an EP and not disabled. What has been missing from the national conversation is any sort of meaningful dialogue about what's worth covering and what's not. Leaving it up to the individual patient and doctor provides the most freedom but is also extraordinarily wasteful because 1) the patient has an very incomplete understanding of the possible options and 2) the doctor (in most current systems) is economically incentivized to offer the costliest care for which the patient/insurance carrier can pay.
 

RustedFox

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I don't have the answer for you. The solution is not a government takeover of ALL healthcare which is in process. I don't think anyone has a really good answer for someone in your situation. Do you think your care would be much better if the government provided all your healthcare and made your decisions? To the government they may conclude that your value to society does not exceed the cost of your (and your wife's) expensive care and could deny your treatment. At that point, who do you turn to in order to appeal? Rationing must be part of any government system, and seems like it's a great idea, until its your (or a family member's) care that is being rationed.
I get it, man. - but here's the rub, thanks to the government's intervention, the private sector became 'available' to me. Fatcat private insurance bigwigs finally said - "Ah, sh!t, the jig is up; we'd rather HAVE your business now than lose it to the fed." So sure, the private sector now 'works' for me.

It might not be a solution, but its a good idea: Nonprofit insurance companies; might keep everyone honest.
 

GeneralVeers

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I get it, man. - but here's the rub, thanks to the government's intervention, the private sector became 'available' to me. Fatcat private insurance bigwigs finally said - "Ah, sh!t, the jig is up; we'd rather HAVE your business now than lose it to the fed." So sure, the private sector now 'works' for me.

It might not be a solution, but its a good idea: Nonprofit insurance companies; might keep everyone honest.
Arguably there will be a 2 million net loss of insured people by January 1st. At least 4 million have gotten cancellations while about 2 million have signed up (but don't necessarily have insurance). So in essence we've disrupted the entire system, thrown a lot of people off of insurance to help a few people like RustedFox. A good tradeoff? I'm not sure.

Arcan: You are wrong in that a majority have decided that the ACA is the way forward. In every poll more people disapprove of the ACA than support it. Obama only won re-election because he told outright lies about the ACA. Had he told the truth, I'm certain the people would not have returned him to office.
 

Arcan57

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Arcan: You are wrong in that a majority have decided that the ACA is the way forward. In every poll more people disapprove of the ACA than support it. Obama only won re-election because he told outright lies about the ACA. Had he told the truth, I'm certain the people would not have returned him to office.
Are you denying that the majority of the elected representatives voted for the ACA? Obama wasn't the person that passed the ACA. He doesn't confide in me, but I'm relatively certain that the version of the ACA that passed has little to no resemblance to how he envisioned it. It just the latest in a long string of bills that started out with a reasonable impact on the budget and had the cost-saving provisions nerfed to get through the Senate and House. Obama definitely oversold his ability to get legislation through Congress and he hasn't been an effective president. But I also don't think anyone could have anticipated 6 years of a branch of Congress that would rather watch the country burn than compromise on anything.

Also, only a minority of Americans favor repealing the ACA. It's about neck and neck between keeping as is vs. improving in recent polls. Let's not forget that healthcare was irreparably f%^ed prior to the ACA, so some of people's dissatisfaction with it is actually them being forced to confront changes that have little/nothing to do with the ACA itself. Health insurance was getting more expensive with or without the ACA and fewer business were going to be springing for health insurance as part of the employment package in coming years.
 
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GeneralVeers

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Arcan, we will have to agree to disagree as far as the function of government and what is appropriate for it to be legislating.

As far as the ACA you are correct that a Democratic MAJORITY voted for the law. Their vote was based on all the lies I have detailed above, and I am doubtful they would have voted for it knowing what they know now. Regardless of how the law was intended, the results have been destructive and entirely predictable. We now have a MAJORITY Republican party in Congress who want to repeal the law. They are merely reflecting the wishes of their own constituents. BTW the role of opposition is to oppose, not rubber stamp the policies of whoever is in power. I for one hope the Republicans continue to block, stall, and circumvent every last one of Obama's disastrous policies for the remainder of time he is in power. A government that governs least, governs best.
 

Arcan57

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Arcan, we will have to agree to disagree as far as the function of government and what is appropriate for it to be legislating.

As far as the ACA you are correct that a Democratic MAJORITY voted for the law. Their vote was based on all the lies I have detailed above, and I am doubtful they would have voted for it knowing what they know now. Regardless of how the law was intended, the results have been destructive and entirely predictable. We now have a MAJORITY Republican party in Congress who want to repeal the law. They are merely reflecting the wishes of their own constituents. BTW the role of opposition is to oppose, not rubber stamp the policies of whoever is in power. I for one hope the Republicans continue to block, stall, and circumvent every last one of Obama's disastrous policies for the remainder of time he is in power. A government that governs least, governs best.
And I know you're chuffed about the current gridlock, but it's not like we're starting from some reasonably neutral position. The board is tilted (and will continue to tilt without intervention) in all kinds of ways that are detrimental to the country. The role of elected representatives is to use their knowledge and wisdom to the benefit of their constituents. Collapsing that responsibility into a blind opposition to the policies of the prevailing party is tantamount to a dereliction of duty.

Also, since anarchy is widely assumed to be the worst form of government, your ending statement can't possibly be true.
 
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