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What is avg productivity (amt collected, not just amt biled) or family med doc, outpt only, seeing about 25 pts a day 5 days a wk w/ avg amt of procedures mainly joint injections

500K?
 

EdibleEgg

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I'm not sure about averages, but that seems about right.
 

digitlnoize

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Let me see if my math is right here:

25 pt/day
5 days/week
48 weeks/year (should I include more vacation time?)

= 6,000 patient visits per year.

$500,000 collected/year divided by 6,000 patients/year =

$83.33 collected per patient visit.

Why not save TONS of overhead, headache, time, and energy and simply charge each patient $80?

Hell, with the savings, charge $50...

Am I missing something?
 

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Let me see if my math is right here:

25 pt/day
5 days/week
48 weeks/year (should I include more vacation time?)

= 6,000 patient visits per year.

$500,000 collected/year divided by 6,000 patients/year =

$83.33 collected per patient visit.

Why not save TONS of overhead, headache, time, and energy and simply charge each patient $80?

Hell, with the savings, charge $50...

Am I missing something?
I know FPs/PCPs that have in fact gone to straight cash only and cut out insurance/medicare/medicaid.... for that very reason. I know some in rural areas that have cut the overhead more by purchasing a small conversion van and running out of their van and/or doing living room visits.....

Then you have the complete "boutique" folks......
 

Blue Dog

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The overhead in FM is high largely because of all of the insurance-related B.S. (billing, prior auths, etc.) that we have to do. If you go cash-only, your overhead percentage will likely be less than the usual 50-60%, so you don't need to see the same volume of patients to maintain your income.
 

JackADeli

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The overhead in FM is high largely because of all of the insurance-related B.S. (billing, prior auths, etc.)...

....go cash-only, your overhead percentage will likely be less than the usual 50-60%....
exactly.....

Again, the issue, as mentioned in other threads, is your ability to "compete". This means what are you willing to work for as opposed to the neighboring MD. If all the FPs in town accept medicare rates, you will have to accept as well.... unless you are in some way offering something unique. The same goes for any other insurance.... Thus, FP/PCP will locally get reimbursed based on what they are willing to locally accept. If FPs/PCPs all demanded more then the market would have to pay more. The insurance companies negotiate rates with practices.... Practices in turn will start removing themselves from low payers and medicare/medicaid programs as they start to gain in reputation and patient pool size.

As physicians, we have to start demanding what we feel is appropriate for our services. We also need to start to better educate patients on reasonable expectations. Insurance has gradually seperated patients from the costs..... i.e. most have no "skin in the game". Patients often expect the newest, fanciest, best drug/scooter/procedure/prosthetic.... and expect they have "already paid". The problem is, the physician eats the loss.

We need to tell patients....
"I am going to prescribe this drug/treatment/etc... I believe is most appropriate/efficacious for your medical health. There are alternatives x, y, z. Your insurance may pay a, b, c for these drugs/treatments/etc.... Your out of pocket will be more or less depending on your insurance. That is life. You make the choice. Having insurance does not give you carte blanche to anything you want..."
 
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Jack,

Good points... I am just learning the game and not in practice yet, but I think a few barriers for physicians to do what you say are:

1) it is illegal for physicians to talk about their insurance contracts, so no one really knows what everybody else is getting reimbursed, and if you don't know that how do you know what to ask for?

2) physicians would have to give up their taxpayer id's and form an entity w/ 1 taxpayer id for added leverage to negotiate better reimbursements. I don't think most physicians would be willing to do this

The biggest realization I have had through this process of learning the biz side of medicine is how important these negotiated contracts are... I always thought lowering overhead was the only way to improve your bottom line, but I think negotiating reimbursement w/ insurance companies is probably just as important and is not "standardized" as I once thought it was
 

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...it is illegal for physicians to talk about their insurance contracts, so no one really knows what everybody else is getting reimbursed, and if you don't know that how do you know what to ask for?...
I am not in any way recommending price fixing, etc... However, if you/your practice feels a rate of reimbursement is "unfair" or innappropriate, you walk.... It's like buying a car. I never know what the guy before me paid.

Bottom line, physicians do have choices.... out of fear we choose to be victims in a sense. Medicine is a business. You sell to the insurance company/companies. In effect, the insurance companies collecting agents are your patients. You choose to sell low because of fear of being out of business.... well, you made that choice.

It is fear (at best) that keeps folks complaining but not doing anything. though I suspect greed, laziness, etc... also play a role, thus physicians do not effectively support their own lobbies. In any event, business is business. You make choices and you push for the best deals. Physicians seem to sit back and talk about underpayment/low reimbursement. But, they take medicare/medicaid and accept contracts with insurance companies they feel are insufficient.... Those are business decisions. They are choices.

As physicians, we can complicate it, make arguments about compassion/caring, how it "really isn't about the money" or "it really isn't a business", etc..... But, if we are underpaid/innappropriately reimbursed.... then it is a business. It is either one or the other. You can run a business with compassion and caring but when the compassion and caring undercuts your business... you should join a charity/volunteer service.
 

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...I think a few barriers for physicians to do what you say are..
Some final points... because I think physicians like to be manipulated into believing they "have no choice". So, let me put it into some perspective....

so, apparently physicians can not go on strike.... either legally or ethically, etc.... Nurses and everyone else can. For those that like socialism abroad... well, in socialized systems the physicians do strike... surprisingly often!

But, we can quit, we can retire, etc....
More importantly, I don't know of any physician that couldn't do something other then medicine. You/we are not the HS drop out with a GED working a job given to us by pitty with few other options....

"Well, I have all this debt".... So, what makes you different? Default. Half the country defaulted on their homes/mortgages! Why are you special? Because your a "servant" of society?

Medicine is a business.... if done correct (IMHO), it is a business with compassion and caring... but you don't give away the store! What other industry in this country is there a shortage of product/service and somehow the price tag for the limited products/services available has been cut by 20+%!!!! The only way that happens is if the person selling the product allows it. They sure as hell don't do it with oil, corn, or anything else... We as physicians have sat back, allowed congress.... that sucks down more lobby/industry steak dinners, to tell us drug reps are bad, we should be noble and give away our services, etc..... We have rolled over year after year....

Why are we "negotiating" from a self-imposed position of "weakness"???? Correction, why did we not even really negotiate?
Again, to put it into perspective, I ask:

what other industry in this country is there a shortage of products/services and somehow the price tag for the limited products/services available has been cut by 20+%!!!!
 
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Blue Dog

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"Well, I have all this debt".... So, what makes you different? Default. Half the country defaulted on their homes/mortgages! Why are you special?
Really Bad Idea. Student loans aren't the same as mortgages. If you default on your student loans, all you'll do is rack up penalties, and the government will come after you. Even bankruptcy won't get you out of it.

http://www.finaid.org/loans/default.phtml
 

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Really Bad Idea. Student loans aren't the same as mortgages. If you default on your student loans, all you'll do is rack up penalties, and the government will come after you. Even bankruptcy won't get you out of it.

http://www.finaid.org/loans/default.phtml
That's fine.... get a low paying job, file the hardship papers, pay what you can, etc.... My point is, you can fall behind/~default. You do NOT have to use the outstanding debt as an excuse to why you must stay in a bad practice reality. The other thing is.... take a mortgage, pay student student with some of mortgage funds, etc.... there are ways to seperate that debt from "student loan" status to something else before you default/fall behind/etc....

I don't like it. I prefer good credit. I am simply saying we need to come down to earth and not self impose certain unreal standards and expectations.... thus imprisoning ourselves beyond what everyone else is doing.
YourLink said:
http://www.finaid.org/loans/default.phtml
do not make any payments on your federal student loans for 270-360 days and do not make special arrangements with your lender to...

...generally requires demonstrating that you made a good faith effort to repay the debt, that you will not be able to maintain a minimal standard of living and still repay the debt (usually using the lowest monthly payment under any of the repayment plans, typically income-contiengent or income-based repayment)...
So, I am obviously using the term "default" improperly... My point is you can fall behind, call make some payments (not necessarily full payments), etc.....
 
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digitlnoize

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I don't think there's really any need for going that far Jack. I'm not really concerned about coughing up 15% of my income for my loans...I just wish that I could get some more help if I go into FM. I'm certainly not going to let them dictate my life...

Again, though...I have to ask why everyone isn't just bailing on "The System" and going Cash Only? I guess it's harder to do if you're already in practice, but what about the new grads? Are there any lurking around here?
 

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The only thing that will get you out from under student loans is death... or faking your death... either way, not a great option.

The argument that should be made is this: if it costs X to obtain a medical education, then Y in income is required to justify X. Y is the return on X; if Y is insufficient, never invest in X.

Pay me.
 

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I don't think there's really any need for going that far Jack...

Again, though...I have to ask why everyone isn't just bailing on "The System" and going Cash Only? ...
...The argument that should be made is this: if it costs X to obtain a medical education, then Y in income is required to justify X. Y is the return on X; if Y is insufficient, never invest in X.

Pay me.
1. to Digit:
My point is just that.... a) it doesn't need to come to that. But, then we should not use the loans as an excuse to tolerate a financial arrangement we feel is innappropriate.
b) again, while it need not come to that, it can, if a physician chooses. One does not have to remain in a business arrangement that is ludicrous. We tolerate it for any number of reasons... but we are choosing to do so.

2. to MOHS..... exactly what folks are saying. we have invested, we are continuing to actively invest. This is a business. Physicians seem to be the only one in the business model that have to bend over and eat it.... The patients, they want their free-bees, cause they believe somehow that insurance premiums equates carte blanche care. The insurance companies run a fairly tight ship with around 3% profit margins. The hospitals, as noted collect 2-10x revenues from the physicians. If a physician is loved but costing the hospital.... well, the hospital as a good business should, cuts the physician. But, in some lopsided rationale, a physician should run their business as an impoverished monk... according to the pres, we didn't go into medicine for the money but rather cause we care and have compassion. Thus, in this huge hundreds of billions dollar industry, everyone has a business but physicians and society are convinced the physicians have a charity.....

There is no excuse why physicians keep taking cuts in this issue. There is no excuse why physicians all but sat back and allowed the medicare/medicaid thing to continue in the fashion it has or allowed a new system to be initiated. Again, "we" are the commodity. yet, we sit back and allow our limited product to have deep price cuts...... senseless.
ForPerspective said:
...In 2004, there were about 216 million people in the US who were able to vote. Out of these people, only about 126 million actually voted. (58%) The 2004 elections had the largest percentage of people who voted since 1968...
 
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Jack,

Are you med student/resident/practicing physician?

How do you know what is good reimbursement and what is bad if you don't know what the going rate is? Your comparison to negotiating w/ insurance companies was buying a car... but there are resources like Kelly Blue Book/Edmunds/talking to others that bought same car that tell you what the "going rate" is on buying a car. Is there such a resource for reimbursement w/ a particular insurance company?

I would love to hear thoughts from those who have actually negotiated w/ insurance companies... is there room for negotiating, or is it a take it or leave it kind of thing? Blue Dog?
 

Blue Dog

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I would love to hear thoughts from those who have actually negotiated w/ insurance companies... is there room for negotiating, or is it a take it or leave it kind of thing? Blue Dog?
Depends on your leverage. If you're a solo doc in an area with plenty of other doctors, your leverage will be just about nil. If you're part of a larger group, you likely have more clout.

We know what we're getting paid by other insurance companies, and we usually have a pretty good idea what the insurance company is trying to accomplish (e.g., are they buying market share, being squeezed out by somebody else, etc.) We tend to play hardball, and we're not afraid to drop an insurer if they aren't being competitive with the other payers in the market.
 

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What % of productivity is good salary for graduating FM resident to join large, multi-specialty group?
Our guarantees for new physicians are typically based on the market rate, not tied directly to productivity. We expect that a new physician will take some time to build their practice, and we're essentially going to have to carry them until they get to the point where they're paying their own way.

Under our model, you're better off taking a lower guarantee and becoming a shareholder in the group as quickly as possible. That's where the real money is.
 

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...How do you know what is good reimbursement and what is bad if you don't know what the going rate is? Your comparison to negotiating w/ insurance companies was buying a car... but there are resources like Kelly Blue Book/Edmunds/talking to others that bought same car that tell you what the "going rate" is on buying a car. Is there such a resource for reimbursement w/ a particular insurance company?...
So, BD has provided some info. Others too... To your question above, it is an individual decision based on business calculations. Those calculations are not particularly difficult or complex and have been laid out in the earlier replies:
What is avg productivity ...amt collected...outpt only...25 pts a day 5 days a wk w/ avg amt of procedures...500K?
...that seems about right.
That's in the ballpark.
Let me see if my math is right here:

25 pt/day
5 days/week
48 weeks/year (...vacation time?)
= 6,000 patient visits per year.

$500,000 collected/year divided by 6,000 patients/year =

$83.33 collected per patient visit...
The overhead in FM ...the usual 50-60%...
So, you need to see around 6k patients a year at around $80 COLLECTED (i.e. reimbursed) per patient for your business to receive $500k/yr. You subtract 50-60% for overhead = operating costs. This would include rent/utilities, staff costs (i.e. salaries/benefits/etc...), business insurance costs, etc... what is left is yours.

You thus need to decide, based on your business model, are you willing to accept ~$80/patient, and 6k visits to earn what is left? Its not complicated math. If you want more, you negotiate more, etc... It will be a balance between what you will be willing to bear (i.e. you CHOOSE to accept) and what the market will bear (i.e. market CHOOSES to pay). That is about the "kelly Blue Book".....
 
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digitlnoize

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So, BD has provided some info. Others too... To your question above, it is an individual decision based on business calculations. Those calculations are not particularly difficult or complex and have been laid out in the earlier replies:
So, you need to see around 6k patients a year at around $80 COLLECTED (i.e. reimbursed) per patient for your business to receive $500k/yr. You subtract 50-60% for overhead = operating costs. This would include rent/utilities, staff costs (i.e. salaries/benefits/etc...), business insurance costs, etc... what is left is yours.

You thus need to decide, based on your business model, are you willing to accept ~$80/patient, and 6k visits to earn what is left? Its not complicated math. If you want more, you negotiate more, etc... It will be a balance between what you will be willing to bear (i.e. you CHOOSE to accept) and what the market will bear (i.e. market CHOOSES to pay). That is about the "kelly Blue Book".....
Why not reduce your overhead though? By only accepting cash, overhead would no longer be 50-60%, and you could probably charge less than $80 and still make a good salary. Check out Blue's buddy The Village Doc (can't find the link, but I'm Blue has recently posted it, and I'm sure he would again).

Why not negotiate directly with your patients, rather than the pain in the ass insurance companies?
 

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AFSmiley

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So ya,

I've always like the cash based stuff for clinic visits - it makes sense to me and I suspect there is a pretty good niche for it in large cities with a good population of the working uninsured- Houston comes to mind.

I'm afraid Healthcare Reform will eliminate this niche, as everyone is going to have insurance, and insurance companies are going to be required to provide certain benefits- so I worry if this niche will still be around by the time I finish my time in the military.

That is all,
Smiley.
 

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Why wouldn't it be around? There will continue to be a shortage of doctors the way things are going. Prices will not go down on insurance premiums. We haven't fixed those problems. The only way to reduce premium price is to increase the deductible. This is where primary care comes in.

People with Health Savings accounts will be your ideal clients. You have seen the many physicians who practice great medicine, but fail in the patient communication realm. If you know how to talk and dissuage patient concerns and fears you will be successful. However, it will take time to build a practice.
 

digitlnoize

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I'm afraid Healthcare Reform will eliminate this niche, as everyone is going to have insurance, and insurance companies are going to be required to provide certain benefits- so I worry if this niche will still be around by the time I finish my time in the military.
I actually think the opposite is going to happen.

Everyone is going to have insurance, but no one will be able to get in to see a doctor. How long are wait times in Mass.?

This is assuming that all the docs don't just drop the insurance companies and Medicare for paying so poorly and being such a headache, of course.
 

bronx43

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So ya,

I've always like the cash based stuff for clinic visits - it makes sense to me and I suspect there is a pretty good niche for it in large cities with a good population of the working uninsured- Houston comes to mind.

I'm afraid Healthcare Reform will eliminate this niche, as everyone is going to have insurance, and insurance companies are going to be required to provide certain benefits- so I worry if this niche will still be around by the time I finish my time in the military.

That is all,
Smiley.
The niche of boutique medicine exists because of accessibility to physicians, or the lack thereof. There would be more people willing to shell out cash if they know they can see you on the day of, and command more of your time than the usual 15 minute "quickie."
 

montessori2md

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Why not reduce your overhead though? By only accepting cash, overhead would no longer be 50-60%, and you could probably charge less than $80 and still make a good salary. Check out Blue's buddy The Village Doc (can't find the link, but I'm Blue has recently posted it, and I'm sure he would again).

Why not negotiate directly with your patients, rather than the pain in the ass insurance companies?
Because I have insurance, and under the new law, my preventive services will be FREE for me (no copay, my insurance company pays the MD). Why would I pay you $80 cash when I can go see someone who will take my insurance?
Answer: I don't have US citizenship, or I'm so rich I don't care, or I have a ton of money in my health savings account that is going to expire.

Above posts are right, the cash based concierge practices are going to dry up in any market without a large immigrant population.

As I understand, overhead for billing runs somewhere between 5-10%. That still leaves another 40+% for you to tweak while still taking patients who have insurance.

Regarding loans: 1) Blue dog is right, as usual. 2) Current grads didn't pay interest while in residency, like we will, and probably have lower interest rates than we will. 3) YOU CAN GET LOAN REPAYMENT, assuming you are not insisting on practicing in a posh suburb the day you complete residency. You don't have to go to the middle of nowhere or the ghetto to get loans repaid, plenty of hospitals and practices will negotiate deals, and if they are a non-profit, paying your loans can give them a nice tax write-off. 4) Currently there are fed loans avail at 5%, you are eligible when you match into primary care (ask your finaid advisor) with no strings other than you actually go into primary care. I imagine more incentives will roll out, not less.

I think medical students stew over the loans a little too much when it comes to primary care. There are a lot of opportunities to unload them, or to temporarily boost your income to knock them out. I'd be more concerned about long term income and being able to practice they way I want to practice if I wanted to worry.
 

digitlnoize

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Because I have insurance, and under the new law, my preventive services will be FREE for me (no copay, my insurance company pays the MD). Why would I pay you $80 cash when I can go see someone who will take my insurance?
Because you won't be able to find a doctor otherwise. Between the physician shortage, the millions of newly insured, and covered preventive care (how much preventive care can actually get done in a 15-20 minute office visit?)...good luck finding a doctor that will see you when you want to be seen.

I think a lot of people are willing to pay a reasonable fee (not the $5000/yr some people are charging) if it means access to a doctor when you want/need it. Maybe not everyone, but enough to pay your salary. I know that if there was a doc near me offering 1 hour comprehensive visits for a reasonable fee (i.e. less than my cell phone bill) I would gladly drop my cell phone coverage to pay for it, if it meant I got good customer service.

Maybe I'm wrong and everyone will have a doctor, but even with all the NP's and PA's getting full practice rights, I still don't see this being enough to alleviate the shortage. Expect >6 month waiting times, as we've seen in Mass. (which had the highest # of docs per capita in the nation when they enacted their similar universal coverage plan). It will be worse for the rest of us.
 

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Because I have insurance, and under the new law, my preventive services will be FREE for me (no copay, my insurance company pays the MD). Why would I pay you $80 cash when I can go see someone who will take my insurance?...
Because you won't be able to find a doctor otherwise. Between the physician shortage, the millions of newly insured, and covered preventive care...good luck finding a doctor that will see you when you want to be seen.

I think a lot of people are willing to pay a reasonable fee ...if it means access to a doctor when you want/need it...

...Expect >6 month waiting times, as we've seen in Mass. (which had the highest # of docs per capita in the nation when they enacted their similar universal coverage plan).
If you look at examples accross the globe.... from Latin America to Canada or to Europe, etc... numerous "socialized" care systems.... so called, "free-care" systems. yet, in those countries plenty of folks paying premiums and extra costs to obtain care outside of the "free-care" systems. And, don't take my word for it... research it, look it up. There are all sorts of information sources you can look at.... if even nothing more then intensive web searches. Also, as noted with Mass, we have some hints at domestic information. There have been some very telling anectdotal stories about "free care". Places that initially provided high end comprehensive coverage for employees with no co-pays/low co-pays (i.e. some university med ctrs) saw an almost immediate overwhelming of their systems...especially their PCPs' offices. This was dramatically reversed when co-pays and/or other restrictions were added.

I know of plenty of folks in Latin America in which the country provides "free-care".... called carnet de pobre/"insurance for the poor"(best translation I can think of). yet, numerous folks I know that fall into "lower middle class" if not outright "working poor", spend significant funds to purchase "private" coverage to get care and attention outside of the "free-care system". While others actually abuse these systems....
http://oneminute.rationalmind.net/socialized-healthcare/
http://lainformacion.lacoctelera.net/post/2007/02/02/denunciado-senador-uruguayo-usar-carnet-pobre-
You can look at the Canadians that come accross the boarders... or people from the UK, etc....

IMHO, I doubt many Americans will be willing to tolerate the delays and/or limits on care that arise from increasing levels of, for lack of better term, "socialized" system. I don't see "boutique" care drying up unless there are laws enacted outright declaring these options of care as "illegal" and prohibited.
 
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Blue Dog

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I doubt many Americans will be willing to tolerate the delays and/or limits on care that arise from increasing levels of, for lack of better term, "socialized" system.
That's the rub. I think Americans need to be reminded of the old saying, "Be careful what you ask for, you just might get it."

"Free" healthcare will be worth exactly what you pay for it.
 

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..."Free" healthcare will be worth exactly what you pay for it.
Probably worse... it will be worth LESS then what you pay. The largest denier of healthcare/etc IS medicare/medicaid.

You see no "co-pay", you don't pay insurance companies $5-8K/year. Instead, you pay $10-20k/year additional taxes.... not very free. But, probably less "care" then what you enjoy now.
 

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you don't pay insurance companies $5-8K/year. Instead, you pay $10-20k/year additional taxes.... not very free. But, probably less "care" then what you enjoy now.
No, we (you and me) will pay more taxes because we are "among the highest-earning Americans" and deserve to have our "wealth redistributed." Charity at the point of a gun.

The average American won't notice. To them, it'll be "free."