Health Bill
Started by leorl
I don't consider myself politically astute however I believe this means very little at the moment. The Senate has yet to pass their version of a bill (which last I read is months away) then another committee will be formed to look at both bills and come up with a compromise bill which will then have to go back to both House and Senate for a vote.
It means nothing at the moment. Passage by the House was a foregone conclusion as the Democratic caucus is made up of a majority of "Progressive" politicians.
It is unlikely to pass the Senate in anything close to its current form. The votes to pass a socialist "Public Option" are simply not there.
In the short term any bill is unlikely to effect our bottom line much, however the implications of giving the government control over 1/6 of the entire economy are bound to harm our salaries in the long run.
It is unlikely to pass the Senate in anything close to its current form. The votes to pass a socialist "Public Option" are simply not there.
In the short term any bill is unlikely to effect our bottom line much, however the implications of giving the government control over 1/6 of the entire economy are bound to harm our salaries in the long run.
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As others have said, probably not much effect even if it passes lock stock and barrel in the senate given most of the bill doesn't take effect until 2013.
The 'socialist' "public option" essentially adds people to the socialist medicare ledger. And continues in the same streak of socialism this country has been going on since social security was enacted so old people, young people, pregnant people, disabled people, and others wouldn't starve to death or be left to die from other issues once their savings ran out (and naturally for some motherf#$ers to swindle from...i'm as angry about this as you, General).
In terms of salary, I don't think this will effect EM as we're simply fee for service based. Some provisions in this bill may eventually reduce income for Orthopods, Dermos, etc. I will point out again and again that in the socialist UK the avg GP earns the equivalent of ~$230k/year.
The 'socialist' "public option" essentially adds people to the socialist medicare ledger. And continues in the same streak of socialism this country has been going on since social security was enacted so old people, young people, pregnant people, disabled people, and others wouldn't starve to death or be left to die from other issues once their savings ran out (and naturally for some motherf#$ers to swindle from...i'm as angry about this as you, General).
In terms of salary, I don't think this will effect EM as we're simply fee for service based. Some provisions in this bill may eventually reduce income for Orthopods, Dermos, etc. I will point out again and again that in the socialist UK the avg GP earns the equivalent of ~$230k/year.
Words can't express how horrible this bill has become. The initial impetus behind "healthcare reform" was to cover the uninsured. One merely has to look at the CBO numbers to see why it is so off track.
Hypothetically there are 30 million Americans who don't have insurance (I'm leaving off the illegals included in the bogus 47 million claim). If you gave each of them a free private insurance plan with an average cost of $5000, that would amount to $150 Billion per year. That is not a small sum, but when you look at the CBO numbers for the current bill: $900 Billion over 10 years with benefits not kicking in until the last 5 years, and it still leaves 18 million Americans uninsured. Where is all that money going, and what exactly is it buying?
I still reject the notion that the Federal government has any constitutional authority to provide/regulate healthcare, or for that matter education, welfare, and myriad other issues that they've involved themselves with.
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Like Medicare and Medicaid, the public option will bring about lower reimbursements and will cause less physicians to accept it.
Except us, because EMTALA forces us to see everyone. I can foresee us becoming the primary care providers for those unfortunate souls enrolled in the "Public Option".
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Like we are for the Medicaid players. I see a lot of Medicaid patients who cannot find a specialist (GI, urology, neurology, etc.) that accepts Medicaid.
Agreed. This is not 'healthcare reform'. Just insurance reform and lotsa blubber added on, as is sadly the case with every piece of legislation written in Washington today.
Preamble of the US constitution:
We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America.
Article I section 8:
The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States;
We can argue about what "general welfare" means; fair enough, but this has long been settled in the courts. I'm more on the 'living constitution' side of things, so I think that term does not have to adhere to exactly what the beliefs of Franklin, etc were when they wrote that, just like we don't limit the interpretation of a word like "transportation" to mean horse and buggy.
You know as well as I do that the intent of "general welfare" is not to give the government permission for massive social programs and takeover of entire swaths of the economy.
By your logic a dictator could claim every single act is part of the "general welfare", provided it does not directly contradict another part of the Constitution.
If we really feel so strongly that government should be doing all of these things, then by all means have another Constitutional Convention where we amend the Constitution to grant these new Federal powers.
As I wrote, the issue of massive federal social programs paid for by taxation has long been settled as a matter of constitutional law. That, of course, does not mean you have to agree with it, but the majority of this country has long accepted that as 'normal' for whatever that's worth. Intent? Of course that's not what the "Fathers" intended, just like they didn't intend that "land and naval forces" would someday include an air force. I agree re the constitutional convention, but I think the extremization of the Right and Left that we are currently experiencing would make such a convention a stalemate/standoff with nothing getting accomplished.
The term "general welfare" in the constitution simply applies to taxation and the the government providing a service for the "general welfare", not to limiting constitutional freedoms. Dictators will, of course, claim that what they do is needed for 'general welfare'. That doesn't mean the term is synomous with dicatatorship. Hitler had a mustache, but that doesnt make all mustached people evil.
The term "general welfare" in the constitution simply applies to taxation and the the government providing a service for the "general welfare", not to limiting constitutional freedoms. Dictators will, of course, claim that what they do is needed for 'general welfare'. That doesn't mean the term is synomous with dicatatorship. Hitler had a mustache, but that doesnt make all mustached people evil.
"General Welfare" is more of a guiding principle rather than a specific power granted to the Federal Government. I'm just not seeing your argument, because if you're correct, then there is little point in having a Constitution at all, if everything is done to further the "General Welfare".
BTW a healthcare bill that increases costs for 80% of Americans in order to bring coverage to 10%, doesn't seem to be promoting the "General Welfare" to me. Rather it's a wealth redistribution from the many to a few.
General, I think I'd enjoy hashing this stuff out over a beer sometime.
I agree re it being a guiding principle, but the point of guiding principles is indeed to be general and to convey a power that can be interpreted by lawmakers of that generation into legislation. I agree that the writers never imagined what those words would be used for today, but the same goes for most of what they wrote. I think a constitution is important in 1) setting down basic freedoms that can rarely be overturned, and 2) setting a structure for how law will be legislated. Obviously there are many idiosyncrasies in the US constitution that go beyond basics (post office, pirates) that could well have been included in the mandates to provide for "common defence" and "general welfare". If you expect any modern state/country to be run off a document 200 years old, you have no choice but to ‘read between the lines', and yes, sometimes you're just imagining between the lines.
I know, outrageous. I'm similarly outraged by how all of us adults are forced to pay for those little buggers to have baby formula; wtf, let them die, little parasites. It's not us adults' fault that that two poor humans decided to shag around have produce a poor little duckling. So you're 3yo and have ALL? Tough luck, kiddo. Your parents should've gotten health insurance that covers more than just 25k in costs. Die little leukemic parasite. Let the 80% of insured, non-leukemics live in peace dammit. Long live the constitution.
C'mon. You can do better than that, General.
Okay, I'm being a little dramatic to prove a point, but my basic point is that yes, you may be pissed off that "general welfare" is being interpreted this way. Well, that's what elections are for: to vote for/against the interpreters.
Kinda supports my argument for a new Constitutional convention? I happen to think it's one of the best documents ever written and (for the most part) has withstood the test of time.
So can you. The current health bill does nothing to address pediatric care, in fact it's a completely separate argument. As far as I know SCHIP was just expanded to cover all children up to a family income of $100,000 (hardly poor). They're hardly an issue in the current health care debate. The current bill was design to address the "adult uninsured" and it doesn't even manage that, despite spending $1 trillion!
I try, but both parties enact unconstitutional policies. It's a choice of which freedoms you want to preserve, since apparently they all can't be preserved.
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deleted65604
I have a hard time believing that the current crop of doctors, myself included, don't care about the poor. We see the poor on a daily basis and take care of them. Everyone does. The problem is that people who aren't destitute still have this attitude that they should get things for free.
I was on medicaid myself for 3 years. Even though I wasn't terribly poor, I could still manage to pay more for my healthcare than what I was required to (basically nothing). The more you FORCE people to take care of the poor, the less quality, truly compassionate care you will get.
Charity at the point of a gun, or under threat of imprisonment, is not charity. It makes me bitter, and the poor ungrateful. Our current system takes care of the truly poor, and those people who honestly tell doctors that they can't pay the full bill get a discount.
Healthcare is a local problem, best dealt with by local doctors, coming up with local solutions. When the government starts interposing themselves in things nationwide, I predict that at a local level, physicians are going to stop the creative sacrifice that currently provide for the destitute.
Yes, in the end, I would predict that giving everyone insurance for free is going to paradoxically provide less care for the poor. I fear this could produce massive physician shortages as physicians retire in droves, the elderly population explodes, and the profession of medicine becomes less desirable to be in with more government intervention and plummeting reimbursement for sub-specialties.
Be careful what you ask for America, because what you get, might not be what you wanted.
I was on medicaid myself for 3 years. Even though I wasn't terribly poor, I could still manage to pay more for my healthcare than what I was required to (basically nothing). The more you FORCE people to take care of the poor, the less quality, truly compassionate care you will get.
Charity at the point of a gun, or under threat of imprisonment, is not charity. It makes me bitter, and the poor ungrateful. Our current system takes care of the truly poor, and those people who honestly tell doctors that they can't pay the full bill get a discount.
Healthcare is a local problem, best dealt with by local doctors, coming up with local solutions. When the government starts interposing themselves in things nationwide, I predict that at a local level, physicians are going to stop the creative sacrifice that currently provide for the destitute.
Yes, in the end, I would predict that giving everyone insurance for free is going to paradoxically provide less care for the poor. I fear this could produce massive physician shortages as physicians retire in droves, the elderly population explodes, and the profession of medicine becomes less desirable to be in with more government intervention and plummeting reimbursement for sub-specialties.
Be careful what you ask for America, because what you get, might not be what you wanted.
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I don't think anyone will argue that doctor's don't "care about the poor" and that is certainly not what I was trying to say. I think we'll all agree that one of the underlying problems in our system is the payment structures and incentives (why does Derm make $1000/hour while EM makes $250 and FM $120...and so forth). But in an era of multimillion dollar treatment regimens and the basic fact that wont change that as a country we do not let people simply die (EMTALA, etc), I don't see how healthcare is a local problem.
The local doctors in McAllen, Tx certainly had the right solutions...for lining their pockets, not their patients.
http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
I am as pissed of as you at people who readily have enough money for cable TV, SUV's, bling, sports tickets, etc but are 'poor' when it comes to paying for their healthcare. But this makes it a national problem, not a local one. Giving insurance for free? I believe our/their taxes would pay for it. I mean we defend this country for free for poor people too. Why don't we create a little peninsula where poor people can live and we'll just call it open season for anyone to attack it; will certainly save us from the runaway defense sepending. I mean how dare they live off our backs? It must make people in the military very resentful.
Plummeting reimbursements in sub-specialties would be a welcome change. People should get paid according to how much they trained and how much work they put in, not simply because they can pop more pimples or rip out more prostates (with a NNT of 48!) than the local GP in an hour.
General, I agree with the convention thing but as I wrote above, it won't work in the current polarized environment. And with my peds health story I wasn't making a comment about the current healthcare bill but a general one about the idea that 'general welfare' does not always mean what's good for the wallets of 51% of the payors. It's a moral issue as well. And this country has decided it would sleep better at night if we did not let anyone die (EMTALA, etc) simply because they were poor. Of course poor people still live shorter lives, but at least we don't have to read in the morning paper about how someone showed up at the ED with a STEMI and was turned away. That would have just ruined too many breakfasts.
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deleted65604
Thomas Jefferson said:
What do you think Jefferson would think of the current monstrousity that is our modern government?
John Fiske, a historian around the time of Jefferson wrote:
We have become the very nation that our founding fathers shed blood and risked their lives to escape and become independent of.
I never said that we should ignore the poor. I just think that we do take care of the poor in this country already. I also happen to believe that the poor in this nation don't have it all that bad. Growing up, I lived a few miles from Government housing and rode the same bus with the kids that lived there. In medical school, I lived a few hundred yards from government housing. In residency, I lived a block from government housing, and my kid attended the same school as the kids that lived there. Compared with 99.9% of the people who have ever lived on this planet, these people live like kings. Clean water, plenty of food, warm comfortable beds, free schooling, free libraries, college scholarships, pell-grants, medicaid, and the list goes on.
I lived in the Dominican Republic for 2 years and I saw true poverty on a daily basis. You know what? The people, even though destitute, still took care of each other. Some of the happiest people I've seen on this earth walked barefoot on dirt floors and lived with their family of 7 in a one room hut. They were truly a community, helping the poor, watching out for each other, without intervention from the government.
Local problems, dealt with on a local level.
What do you think Jefferson would think of the current monstrousity that is our modern government?
John Fiske, a historian around the time of Jefferson wrote:
We have become the very nation that our founding fathers shed blood and risked their lives to escape and become independent of.
I never said that we should ignore the poor. I just think that we do take care of the poor in this country already. I also happen to believe that the poor in this nation don't have it all that bad. Growing up, I lived a few miles from Government housing and rode the same bus with the kids that lived there. In medical school, I lived a few hundred yards from government housing. In residency, I lived a block from government housing, and my kid attended the same school as the kids that lived there. Compared with 99.9% of the people who have ever lived on this planet, these people live like kings. Clean water, plenty of food, warm comfortable beds, free schooling, free libraries, college scholarships, pell-grants, medicaid, and the list goes on.
I lived in the Dominican Republic for 2 years and I saw true poverty on a daily basis. You know what? The people, even though destitute, still took care of each other. Some of the happiest people I've seen on this earth walked barefoot on dirt floors and lived with their family of 7 in a one room hut. They were truly a community, helping the poor, watching out for each other, without intervention from the government.
Local problems, dealt with on a local level.
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deleted65604
National defense is the only reason that we banded together as states and became a nation. The forefathers recognized the need for a strong centralized government, for the soul purpose of national defense. We nearly lost the Revolutionary War because individual states refused to do their part and the weak national government at that time had no way to force them to provide troops and provide supplies for the war effort.
I don't quite follow your logic. When a surgeon goes to residency for 7 years and then does a fellowship, you want them to get paid the same as an FP doc? By your reasoning, the sub-specialties should continue to get paid more money than PCP's.
I, for one, want my orthopedic surgeon, interventional cardiologist, cardio-thoracic surgeon to get paid a crap-load. That way, I know that the field will be competitive, and that my doctor is the cream of the crop, not the dregs of medical school like you'll occasionally find with family practice. (I said OCCASIONALLY. A few of the brightest people in my class went into FP)
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As I wrote, specialists should get paid according to years of training and work put in. Following that, yes, surgeons, interventional cards, etc should and will get paid more. But proportionally so. General surgeons and most IM specialists are probably the only ones who get paid proportionally today. Dermos, etc, however get paid substantially more than what they should if we go by the training/work parameters, relative to FP, etc.
Umm, I don't believe orthopods/cardiothoracic sureons/dermos are smarter than an FP. They obviously trained differently and to a different tune, but that does not make them the "cream of the crop". And I'm sorry, in my class most of those going into FP are what you would call 'cream of the crop'. And yes you said occasionally, but you know as well as I do that you will (occasionally) find dregs in all these fiercely competitive specialties as well. Test scores may determine the cream of the crop of medical students, but has little correlation with how they will be as doctors. And even following your logic, I would argue we need more "cream of the crop" in FP, IM, EM, etc than we need them in Ortho, Derm, etc. Being a good diagnostician takes a lot more (thinking) brains than learning the rote mechanics of re-routing a coronary or screwing together a bone (though granted, learning the rote mechanics does take more years and they should get compensated for it).
Umm, I don't believe orthopods/cardiothoracic sureons/dermos are smarter than an FP. They obviously trained differently and to a different tune, but that does not make them the "cream of the crop". And I'm sorry, in my class most of those going into FP are what you would call 'cream of the crop'. And yes you said occasionally, but you know as well as I do that you will (occasionally) find dregs in all these fiercely competitive specialties as well. Test scores may determine the cream of the crop of medical students, but has little correlation with how they will be as doctors. And even following your logic, I would argue we need more "cream of the crop" in FP, IM, EM, etc than we need them in Ortho, Derm, etc. Being a good diagnostician takes a lot more (thinking) brains than learning the rote mechanics of re-routing a coronary or screwing together a bone (though granted, learning the rote mechanics does take more years and they should get compensated for it).
Just because I am against an enormous Federal program that wastes billions of dollars doesn't mean I am "against the poor".
I simply think that it is inappropriate for the Feds to be managing enormous social program, and should stick to the limited powers granted by the Constitution.
There is no reason whatsoever that individual states cannot provide whatever health insurance, welfare, or education that they deem appropriate. In fact I think the public would be better served by individual state programs which address the unique needs of their populations rather than a one-size-fits-all Federal government entitlement system. It would also bring a degree of market competition as different states would try out different methods, and some would be more successful than others.
The biggest problem we have with healthcare is not cost, but rather consumption. To say you want to decrease costs means that you would have to halt medical innovation, and decrease interventions. By necessity the newest treatments cost more. Sure we could regress to the 1950's cost structure of medical care, but say goodbye to imaging, interventional techniques, advanced surgeries and effective chemotherapies.
The current bill does nothing to address consumption of services, and in fact will make it worse. If you give 10-20 million more people free medical care, of course they are going to use it, and we all will have to pay for it. To address consumption we need to have a user co-pay structure for all Medicare and Medicaid (as well as all private insurance). If Joe Six-Pack has to spend $5 out of pocket on his ER visit for a runny nose, he may think twice about going. Will it deter people from going when they are really sick? I highly doubt it.
I simply think that it is inappropriate for the Feds to be managing enormous social program, and should stick to the limited powers granted by the Constitution.
There is no reason whatsoever that individual states cannot provide whatever health insurance, welfare, or education that they deem appropriate. In fact I think the public would be better served by individual state programs which address the unique needs of their populations rather than a one-size-fits-all Federal government entitlement system. It would also bring a degree of market competition as different states would try out different methods, and some would be more successful than others.
The biggest problem we have with healthcare is not cost, but rather consumption. To say you want to decrease costs means that you would have to halt medical innovation, and decrease interventions. By necessity the newest treatments cost more. Sure we could regress to the 1950's cost structure of medical care, but say goodbye to imaging, interventional techniques, advanced surgeries and effective chemotherapies.
The current bill does nothing to address consumption of services, and in fact will make it worse. If you give 10-20 million more people free medical care, of course they are going to use it, and we all will have to pay for it. To address consumption we need to have a user co-pay structure for all Medicare and Medicaid (as well as all private insurance). If Joe Six-Pack has to spend $5 out of pocket on his ER visit for a runny nose, he may think twice about going. Will it deter people from going when they are really sick? I highly doubt it.
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deleted65604
Have you ever hung around orthopedic residents? Those guys study incessantly. They are expected to digest and know 5 times the amount of imformation that we are as emergency physicians. Yes, I too love the old joke about an orthopod needing to be as strong as an ox and twice as smart. The reality is that they have a much more demanding (Intellectually, Physically, and Mentally) residency than an ER doctor's worst nightmare.
What you are advocating is PCP's to get paid more money at the expense of sub-specialties. I disagree.
The other day, I had a testicular torsion come in. My town was snowed in, and the weather was too bad for a helicopter to fly. While I was able to detorse him, I was having nightmares about the possibility of not having access to a urologist. Luckily, a local urologist was able to come in and take him to surgery.
As a medical student, I don't think you quite grasp the dependence that we as ER doctors and PCP's have on the sub-specialties and the predicament that we would have trying to adhere to standard of care without prompt access to these guys.
Again, be careful what you ask for primary care physicians... while you would love a chunk of change taken from the sub-specialists and put in your pocket, you may not understand how that would affect medicine.
You might find yourself in my position, watching a young man writhe in pain as his testicle infarcts and having no sub-specialist to call on.
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deleted65604
The problem is that increasingly, PCP's are not diagnosticians. Chest-pain? Shortness of breath? Abdominal Pain? Headache? Nosebleed that won't stop? Blood in the stool? Nausea/Vomiting/Diarrhea? Abscess? Trauma? Head injury? Need stitches? Think you broke a bone?
Again and again, the answer is the same, go to the ER, we can't help you here. We don't start IV's, we don't administer medications, we don't do stitches, we don't have x-ray, we don't have splinting material, etc. If you need to be admitted, the hospitalist will take care of you.
PCP's in my area rely on the hospitalists to admit their patients. Half of them aren't even on call for patient questions off hours. They truly lead the life of Reilly, 9-5, Mon-Thurs, with a full 1hour break for lunch. They get paid well over $100,000/year for this ridiculous schedule, and lack of sacrifice on their part for their patients.
We don't need the government re-distributing wealth across specialties.
I'm with you on this one. Although instead of joe six-pack it'll be Mrs. Fatty mcfatpants who might spend her 5 bucks on the ER visit instead of Big Value Meal #1.
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I just wish you would be at least honest when you discuss these things. This, specifically, stands out: a 220-215 vote is not a "foregone conclusion". Other, more astute commentators called it a "close vote". Also commented was how deals had to be made just to get that passed (like the abortion amendment).
I really don't see health reform with a public option passing the Senate.
I keep hoping that the we'll see a last minute insertion of true and meaningful tort reform (i.e. a no-fault system like NZ) combined with repeal of the SGR and a mandated co-pay up front for non-emergent ED visits.
If the Dems did this it would put the Republicans in a very nasty spot, politically, and put forward a bill that can have some lasting impact.
No need to tell me how this will never happen, how the Dems are in the pockets of the trial lawyers or how neither party wants to repeal the SGR when they know medicine can keep being blackmailed for campaign contributions year after year. I know this as well as you do.
The least you can do is let me keep dreaming the good dream...
Take care,
Jeff
If the Dems did this it would put the Republicans in a very nasty spot, politically, and put forward a bill that can have some lasting impact.
No need to tell me how this will never happen, how the Dems are in the pockets of the trial lawyers or how neither party wants to repeal the SGR when they know medicine can keep being blackmailed for campaign contributions year after year. I know this as well as you do.
The least you can do is let me keep dreaming the good dream...
Take care,
Jeff
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deleted109597
Except
Heaven forbid we do anything to the other medical costs. I mean those guys support the democrats. We have to take it from those fat cat doctors.
Actually the dealmaking and the reason for specific votes was quite complex. The reason so many "Blue Dogs" voted agains the bill was that they knew it would have enough votes to pass, but Pelosi is trying to protect them in their own conservative districts by allowing them to vote against it. Pelosi made deals with the various elements of her party to pass healthcare legislation (by a slim majority) while protecting as many incumbents as she can in 2010.
Maybe we should just quit practicing medicine for a few days. Maybe that'll draw attention to the malpractice issue.
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