Health Care Bill in the Supreme Court

[pinipig523]

With the bill presented to the Supreme Court - what should we be rooting for? Is it a good thing if the court strikes down the mandated portion of the bill - this will destabilize the entire health care bill...

Or do we root that it goes through unscathed?

Thoughts?

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[GeneralVeers]

It's absolutely a good thing if it goes down. Anything that gives the Federal government absolute power over every individual (which Obamacare does) should be dismantled.

 

[EctopicFetus]

The more of it that goes away the better IMO. A bad piece of legistlation. Insurance companies love it and a lot of docs (majority from the polls I have seen) hate it.. That should be all you need to know. Beyond the mandate the IPAB is what really needs to go. Truly the mandate is good for EM.. imagine if your uninsured rate dropped by 2/3s.. The problem is morally I oppose the mandate even though I think it would be good for my wallet.

 

[GeneralVeers]

The more of it that goes away the better IMO. A bad piece of legistlation. Insurance companies love it and a lot of docs (majority from the polls I have seen) hate it.. That should be all you need to know. Beyond the mandate the IPAB is what really needs to go. Truly the mandate is good for EM.. imagine if your uninsured rate dropped by 2/3s.. The problem is morally I oppose the mandate even though I think it would be good for my wallet.

It won't be good for all EM. It depends on your payor mix.

If you're at a grungy county facility with 80% no pay, then yes, Obamacare will probably increase your reimbursement.

The vast majority of us work at facilities with mostly insured patients. While we will probably see a drop in self pays as more of them get Medicaid (welfare, not real insurance), we will also see a decrease in private insurance as more of them get shifted to Medicaid from their employers. At best it's a wash, but I suspect we'll see reimbursement on average go down, as Medicaid in many states pays pennies on the dollar.

 

[Birdstrike]

.

 

[TeamZissou]

What does everyone predict WILL happen?

 

[Birdstrike]

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[GeneralVeers]

I predict it will be upheld.

I also predict that EPs will not make more money. It'll just mean a greater number of patients on gov't insurance that pays the same or less than self-pay. A wash at best. Crappy government insurance will pay less than just sending people a bill and getting what you can get.

It will also lead to a surge in ED visits. When you provide "free insurance" with no out of pocket expenses, and no disincentive to visit the ER, you will naturally increase demand. We'll see reimbursement remain flat (at best) while facing a greater shortage of EPs.

Overall the future is bleak for medicine in general.

 

[SepulvedaMD]

how is this bleak?

Even if reimbursements stay flat. Eps do ok in the house of medicine. And if demand goes up, wouldn't that be good for the specialty?

 

[GeneralVeers]

how is this bleak?

Even if reimbursements stay flat. Eps do ok in the house of medicine. And if demand goes up, wouldn't that be good for the specialty?

There aren't enough EPs already, and the government isn't providing any more funding for residency training.

Furthermore, since more people will be under government "insurance" we will be forced to obey their arbitrary edicts concerning "quality" more and more. The future is that the government will start paying us based on Press-Ganey, "quality measures" and other arbitrary ways to not pay us. There is no fighting the government, and while reimbursement per patient may stay the same, they will find new ways to withhold payment.

A good example is the new arbitrary edict that CMS will not pay for any charts that have blanks in the dictation. At sites like mine which use 100% dictation this is annoying, as about 10-20% of most physicians charts have at least one blank. Even if it's something irrelevent to billing/coding like the name of a PMD, they will refuse to pay.

 

[EctopicFetus]

Always looking for ways to screw us. My hope is it goes away (obamacare and obama for that matter), I am no legal eagle but it seems at best only a part will go away.

I dont see a full repeal. What we want the most is a repeal of individual mandate, IPAB (not even up for discussion here) but most importantly the expansion of medicaid. Thats the big wtf for us.

As others have mentioned it would run our system amok. Private insurers would be even more powerful, more people would have the crappy paying medicaid and it would be bad.

As a note here in AZ medicaid pays about 105% of medicare. In some states that number is like 60%. One of the benefits is that obamacare requires medicaid to pay at least at medicare rates. Could be a big bonus for some EPs.

 

[SepulvedaMD]

There aren't enough EPs already, and the government isn't providing any more funding for residency training.

True, but this could be remedied by changing the tax structure for medicare. Why not just separate them?

Furthermore, since more people will be under government "insurance" we will be forced to obey their arbitrary edicts concerning "quality" more and more.

How is this different than the hoops private insurance sets-up?

Always looking for ways to screw us. My hope is it goes away (obamacare and obama for that matter), I am no legal eagle but it seems at best only a part will go away.

I dont see a full repeal. What we want the most is a repeal of individual mandate, IPAB (not even up for discussion here) but most importantly the expansion of medicaid. Thats the big wtf for us.

As others have mentioned it would run our system amok. Private insurers would be even more powerful, more people would have the crappy paying medicaid and it would be bad.

As a note here in AZ medicaid pays about 105% of medicare. In some states that number is like 60%. One of the benefits is that obamacare requires medicaid to pay at least at medicare rates. Could be a big bonus for some EPs.

Interesting. I have been trying to follow this issue. Its seems that the mandate will stand. The counter arguments are trying to frame this as an overreach by congress to regulate individual purchases. However, others have pointed out that nobody is actually outside the healthcare market. In fact, healthcare may be one of the few markets where choosing not to participate actually causes costs to go up for those in the market (as opposed to something like jeans).

 

[GeneralVeers]

Interesting. I have been trying to follow this issue. Its seems that the mandate will stand. The counter arguments are trying to frame this as an overreach by congress to regulate individual purchases. However, others have pointed out that nobody is actually outside the healthcare market. In fact, healthcare may be one of the few markets where choosing not to participate actually causes costs to go up for those in the market (as opposed to something like jeans).

While I disagree with this argument, I think it will prevail. The problem is that allowing the invidividual mandate to stand gives the government unrestricted authority to regulate, tax, and penalize everything you do! For example the government could state that fuel-ineffecient vehicles cause harm to everyone by creating greenhouse gases. In order to bring the price of the Chevy Volt down, they could mandate that you buy a Chevy Volt from GM. In order for them to force you to enter a contract with ANY private company all they have to do is demonstrate (or fabricate) an indirect harm to others or the economy.

 

[pinipig523]

I hope it goes down in flames then.

 

[SepulvedaMD]

I agree that the commerce clause presents a slippery slope. However, given the percentage of GDP healthcare amounts to, something had to be done. Additionally, the government has little recourse when having people not carry insurance causes a cost to system as a whole. The mandate may not be popular, but I don't see how you attack costs without getting more people into the pool. That, and the framework will look different (should it stand) in 10 years.

Also, there has to be a non-profit alternative to private insurance, a counterpoint to offset their use of premium dollars for non-healthcare-related endeavors.

 

[Postictal Raiden]

It will also lead to a surge in ED visits. When you provide "free insurance" with no out of pocket expenses, and no disincentive to visit the ER, you will naturally increase demand. We'll see reimbursement remain flat (at best) while facing a greater shortage of EPs.

Overall the future is bleak for medicine in general.

In another thread, I read that the specialty of EM is getting saturated due to the steep increase in EM residency positions over the last few years. This year, close to 2000 grads matched into allopathic and osteopathic EM. With this trend, the number of future EM physicians will exceed 50k (assuming 25-30 in practice).

http://forums.studentdoctor.net/showthread.php?t=896410
http://www.natmatch.com/aoairp/
http://www.nrmp.org/data/datatables2012.pdf

 

[boggvir]

There aren't enough EPs already, and the government isn't providing any more funding for residency .

I don't know who is paying for it but there has been a 20% increase in EM residency spots from 2008-2012. That's a pretty huge increase...

 

[Docuronium]

It's absolutely a good thing if it goes down. Anything that gives the Federal government absolute power over every individual (which Obamacare does) should be dismantled.

GeneralVeers, over the years (despite the tag, been around since 2005) I have generally seen eye to eye with you, but this statement makes me question whether the issue is that you simply hate Obama.

 

[Docuronium]

While obviously the argument is much more complicated than this, unfortunately this is the internet. The world hasn't collapsed since Auto Insurance became required, and that's far less important than insuring the health care of every person in the United States. Based on my studies in public health and policy, a system that mandates individuals and the group to buy-in is far more likely to succeed than the current one. While "ObamaCare" (dislike using the term because at this point it's meant to be derogatory) isn't perfect, it's better than the current "plan."

 

[JacobMcCandles]

While obviously the argument is much more complicated than this, unfortunately this is the internet. The world hasn't collapsed since Auto Insurance became required, and that's far less important than insuring the health care of every person in the United States. Based on my studies in public health and policy, a system that mandates individuals and the group to buy-in is far more likely to succeed than the current one. While "ObamaCare" (dislike using the term because at this point it's meant to be derogatory) isn't perfect, it's better than the current "plan."

Surely you're not comparing the healthcare mandate to auto insurance. You only have to have auto insurance if you have a car. You aren't legally required to obtain a car. A car is a luxury.

The real issue here is that this will set a dangerous precedent for the government being allowed to require you to purchase something, which is what GeneralVeers is getting at. He's right in the fact that it would be a serious power grab by the government regardless of who's the President.

 

[GeneralVeers]

GeneralVeers, over the years (despite the tag, been around since 2005) I have generally seen eye to eye with you, but this statement makes me question whether the issue is that you simply hate Obama.

I was against the Patriot Act under Bush too. I am consistent with my belief in freedom. Just because a policy MIGHT increase health and wellness of the population, doesn't justify the taking of liberties from any citizen. Moreover the government is going to have to confiscate by force more private wealth in order to fund this power grab.

Do you really believe you should be thrown in jail if you don't buy health insurance? That's what this law amounts to. Don't pay health insurance? Then pay a fine/tax. Refuse to pay the fine/tax then go to jail. Great, huh?

 

[SepulvedaMD]

see next

 

[SepulvedaMD]

Surely you're not comparing the healthcare mandate to auto insurance. You only have to have auto insurance if you have a car. You aren't legally required to obtain a car. A car is a luxury.

The real issue here is that this will set a dangerous precedent for the government being allowed to require you to purchase something, which is what GeneralVeers is getting at. He's right in the fact that it would be a serious power grab by the government regardless of who's the President.

But the government has already done this. They have regulated how much wheat can be grown by farmers, and that growing personal marijuana can potentially impact interstate commerce. BTW, the argument cannot be that the government can make you enter a market like buying car, because unlike buying a car you cannot choose not to be in the healthcare market. this is because none of us knows when we will need care. This translates to everyone already being in the market, but in this market the non payers are causing the premiums for the payers to increase since our insurance model is based on pooled risk.

 

[boggvir]

Unless you argue that a person forfeits his right to medical care if he is in an accident if he chooses not to buy instance.

That can't happen because the first good looking person to die because the hospital left him or her to die outside after a car accident will be front page news with their parents and the obligatory outrage, etc and that law would be promptly changed. That ship has sailed, we as a society have already established that rule. It's like arguing against the sunset. The only thing left now is determining how to ration and pay for the care weve already established everyone should get.

 

[SepulvedaMD]

Do you really believe you should be thrown in jail if you don't buy health insurance? That's what this law amounts to. Don't pay health insurance? Then pay a fine/tax. Refuse to pay the fine/tax then go to jail. Great, huh?

I can appreciate the libertarianism, but it's just not pragmatic. Our current model is not sustainable for anyone. How is this not inline with personal responsibility? Should we just hope people buy insurance?

If you're in an accident and show up in the ED, you'll be treated on my dime because you don't have insurance. How is that fair? Surely you're not in favor letting that person die since they have no insurance? Or do you assume that said person will be a self-pay? BTW, who could afford such a charge?

 

[GeneralVeers]

People who use the Auto Insurance Argument demonstrate how little they understand the actual issue. Auto Insurance is mandated at the state level and is completely constitutional. The same with the individual mandate in MA. What we are discussing is whether or not a Federal mandate is constitutional. People don't understand that an individual state can compel you to do almost anything, so long as it doesn't conflict with the Constitution. The Feds meanwhile have very few powers that are spelled out quite clearly.

This makes sense in terms of the "laboratories of democracy". If you don't like a mandate in one state, like the one in MA, you can pick up and move to one that doesn't have one. In this way the best ideas will be supported and proliferate, and the states who make poor choices will have problems. When the Feds start taking your liberties, where can you go?

 

[JacobMcCandles]

But the government has already done this.

Then why let them continue to do it and expand their power?

If you're in an accident and show up in the ED, you'll be treated on my dime because you don't have insurance. How is that fair? Surely you're not in favor letting that person die since they have no insurance? Or do you assume that said person will be a self-pay? BTW, who could afford such a charge?

You're trying to base your example off of an extreme case. Nobody is going to deny care in a life or death situation but for those without insurance that come in with a non-emergent complaint, it should be allowed to turn them away.

 

[EctopicFetus]

Again as has been mentioned.. Auto insurance isnt the same as health care. Anyone who uses this argument doesnt understand what is going on in this case.

On another note giving a bunch of people health care makes no sense.

If you're in an accident and show up in the ED, you'll be treated on my dime because you don't have insurance. How is that fair? Surely you're not in favor letting that person die since they have no insurance? Or do you assume that said person will be a self-pay? BTW, who could afford such a charge?

And who is paying for Obamacare? Those people being insured? NOPE.. it is the same people already paying taxes.

Where are these doctors gonna show up to care for these people? For those who are in favor of Obamacare.. have you seen the cost overruns in Mass? BMC suing the state after initially supporting it. Wait times to see docs are through the roof and Mass is in the top 2-3 in docs per capita. Whats gonna happen to everyone else? If obamacare stays intact costs will go through the roof..

 

[EctopicFetus]

Then why let them continue to do it and expand their power?


You're trying to base your example off of an extreme case. Nobody is going to deny care in a life or death situation but for those without insurance that come in with a non-emergent complaint, it should be allowed to turn them away.

Shoudl be allowed but EMTALA is not involved in this.. this is off topic.

 

[boggvir]

Then why let them continue to do it and expand their power?


You're trying to base your example off of an extreme case. Nobody is going to deny care in a life or death situation but for those without insurance that come in with a non-emergent complaint, it should be allowed to turn them away.

The problem is many many complaint often require a lot of money to determine if it's actually non emergent.

I personally don't have a problem with requiring the purchase of an insurance. We are forced to pay for schools, police departments etc. The difference is one is public vs one is private and if you feel that strongly, then it should be via a single payor so public only. Many would rather purchase a private plan.

Without making sure everyone has some personal responsibility you can't have the type of care people expect.

 

[GeneralVeers]

Again as has been mentioned.. Auto insurance isnt the same as health care. Anyone who uses this argument doesnt understand what is going on in this case.

On another note giving a bunch of people health care makes no sense.

And who is paying for Obamacare? Those people being insured? NOPE.. it is the same people already paying taxes.

Where are these doctors gonna show up to care for these people? For those who are in favor of Obamacare.. have you seen the cost overruns in Mass? BMC suing the state after initially supporting it. Wait times to see docs are through the roof and Mass is in the top 2-3 in docs per capita. Whats gonna happen to everyone else? If obamacare stays intact costs will go through the roof..

Exactly. The vast majority of the "insured" will really just be put on a welfare program that I am paying for. The bill will in fact shrink the insurance pool and drive up the cost of private insurance.

 

[GeneralVeers]

The problem is many many complaint often require a lot of money to determine if it's actually non emergent.

I personally don't have a problem with requiring the purchase of an insurance. We are forced to pay for schools, police departments etc. The difference is one is public vs one is private and if you feel that strongly, then it should be via a single payor so public only. Many would rather purchase a private plan.

Without making sure everyone has some personal responsibility you can't have the type of care people expect.

Great! Then go live in a state that forces people to buy insurance like NY or MA. I'll choose libertarian states like TX or NV. We'll see who is better off in 20 years....

Again, if this is really a vital thing to have, then states are free to do it. The Feds should not be involved at all.

 

[EctopicFetus]

The problem is many many complaint often require a lot of money to determine if it's actually non emergent.

I personally don't have a problem with requiring the purchase of an insurance. We are forced to pay for schools, police departments etc. The difference is one is public vs one is private and if you feel that strongly, then it should be via a single payor so public only. Many would rather purchase a private plan.

Without making sure everyone has some personal responsibility you can't have the type of care people expect.

Is this a serious post? SMDH..

 

[boggvir]

Great! Then go live in a state that forces people to buy insurance like NY or MA. I'll choose libertarian states like TX or NV. We'll see who is better off in 20 years....

Again, if this is really a vital thing to have, then states are free to do it. The Feds should not be involved at all.

I personally don't have a problem with it but I never said its necessarily constitutional - though I suspect that it is.

I personally trust the fed more than I trust my state government but that's again a personal preference.

 

[boggvir]

I guess it comes down to the good old commerce clause. In my opinion, states rights effectively died with the 16th and 17th amendments. Now the fed can officially tax at will and representation at that body (congress) is no longer decided by the states. So the interests of the state are going to be protected by...?

Now starting with the Rhenquist court, some of that power under the commerce clause began to be restricted again but it's peripheral. The federal government isn't dependant on states for its revenues, doesn't have to appropriate it based on any state based criteria and the members are answerable only to the people not the states.

So the guardians of state rights are actually the individual people electing politicians who willingly abrogate their power to the states. But picking a candidate based on that might require at least a cursory understanding and appreciation for the articles of confederation vs the modern constitution, he purpose of the federalist papers etc and good luck with that. I'm not saying they should know who Publius was or even be able to identify the federalist papers by name but I just think a basic understanding of what the purpose of having states and a separate federal government (instead of central govt with administrative regions) just doesn't exist.

 

[boggvir]

Err I apologize - the above may or may not have had a point. I'm a history/politics guy and sometimes I ramble on theoretical points.

 

[Apollyon]

In my opinion, states rights effectively died with the 16th and 17th amendments. Now the fed can officially tax at will and representation at that body (congress) is no longer decided by the states. So the interests of the state are going to be protected by...?

How do you figure? Direct election of senators, incidentally, to which I am opposed and would be quite in favor of repeal of that amendment, still leaves the vote in the hands of the people. If I recall, at least 2 states were electing their senators popularly when the 17th amendment was ratified, and made every state do it that way.

 

[Docuronium]

Surely you're not comparing the healthcare mandate to auto insurance. You only have to have auto insurance if you have a car. You aren't legally required to obtain a car. A car is a luxury.

The real issue here is that this will set a dangerous precedent for the government being allowed to require you to purchase something, which is what GeneralVeers is getting at. He's right in the fact that it would be a serious power grab by the government regardless of who's the President.

The government has set a legal precedent requiring you to do something? Like that has never happened before?

I'll be honest, I see very few scenarios where the new system ends up being worse than the previous system.

Finally, regarding the auto insurance statement, pretty sure the first line of that post read: "While obviously the argument is much more complicated than this..."

 

[EM2BE]

Also regarding the auto insurance statement - how many people out there do not have insurance but once a year? I knew of plenty of people in undergrad who would pay for one month of car insurance then cancel the policy until it was time to renew tags / pay taxes again. If they get pulled over, of course they go to court, but that again costs the system more money as the person is likely not paying into the system.

 

[Redrox]

Why not make the Social Security or better yet the Medicare argument? It's essentially a health insurance policy with delayed benefits that all citizens in all states are required to buy into. Can't see how this is constitutional but absolutely nobody today cares if it isn't.

 

[GeneralVeers]

Also regarding the auto insurance statement QUOTE]

Why not make the Social Security or better yet the Medicare argument? It's essentially a health insurance policy with delayed benefits that all citizens in all states are required to buy into. Can't see how this is constitutional but absolutely nobody today cares if it isn't.

Actually a lot of people do, they just can't voice their opinion without being demonized.

Rick Perry had it right: Social Security IS a Ponzi scheme. It promises way more in benefits than it can ever hope to deliver.

Medicare is just a welfare program for rich seniors. It transfers wealth from the young and poor, in order to give a free benefit to the old and rich. It should be abolished.

 

[Lokhtar]

Why not make the Social Security or better yet the Medicare argument? It's essentially a health insurance policy with delayed benefits that all citizens in all states are required to buy into. Can't see how this is constitutional but absolutely nobody today cares if it isn't.

A lot of people say that medicare is a bad idea. I don't know of anyone that says medicare is unconstitutional. Why would anyone think it is unconstitutional?

Congress clearly has the power to levy a tax and give out services. I'm "required" to buy into my local police department, the defense budget, NASA, the NIH, etc....

 

[GeneralVeers]

A lot of people say that medicare is a bad idea. I don't know of anyone that says medicare is unconstitutional. Why would anyone think it is unconstitutional?

Congress clearly has the power to levy a tax and give out services. I'm "required" to buy into my local police department, the defense budget, NASA, the NIH, etc....

It's unconstitutional based on the "enumerated powers". The Constitution lays out the specific powers granted to the Fed government. All other powers are delegated "to the states and to the people".

Healthcare is not one of the powers specifically granted to the Feds. Technically it is a power granted to the individual states. It's just that states have been eager to wash their hands of expensive things like medical care, and are completely willing to allow their rights as states to be trampled on, as long as the Feds pay for it.

 

[Lokhtar]

It's unconstitutional based on the "enumerated powers". The Constitution lays out the specific powers granted to the Fed government. All other powers are delegated "to the states and to the people".

Healthcare is not one of the powers specifically granted to the Feds. Technically it is a power granted to the individual states. It's just that states have been eager to wash their hands of expensive things like medical care, and are completely willing to allow their rights as states to be trampled on, as long as the Feds pay for it.

Well I'm definitely a Hamiltonian in terms of the General Welfare clause. There is 200 years of precedent there that's been well accepted.

 

[zinjanthropus]

http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-398-Monday

audio and transcript from today's arguments

 

[GeneralVeers]

Well I'm definitely a Hamiltonian in terms of the General Welfare clause. There is 200 years of precedent there that's been well accepted.

I construe the Constitution narrowly. A broad definition of the General Welfare clause renders the rest of the document essentially void, and gives the Feds unlimited power to do anything they want, as long as it's for the "General Welfare".

"Dr. Veers, I'm sorry, but things just haven't been working out in Washington. We'll have to confiscate all of your earning for the last three tax years. Don't fret about it too much, it's all for the General Welfare of the country!"

 

[Lokhtar]

I construe the Constitution narrowly. A broad definition of the General Welfare clause renders the rest of the document essentially void, and gives the Feds unlimited power to do anything they want, as long as it's for the "General Welfare".

"Dr. Veers, I'm sorry, but things just haven't been working out in Washington. We'll have to confiscate all of your earning for the last three tax years. Don't fret about it too much, it's all for the General Welfare of the country!"

Well you don't need to go to the General Welfare clause for that. The 16th amendment gives Congress the power to tax - there is no limit percentage wise anywhere in that amendment.

 

[GeneralVeers]

Well you don't need to go to the General Welfare clause for that. The 16th amendment gives Congress the power to tax - there is no limit percentage wise anywhere in that amendment.

And you're not frightened by your own statement?

 

[SepulvedaMD]

I construe the Constitution narrowly. A broad definition of the General Welfare clause renders the rest of the document essentially void, and gives the Feds unlimited power to do anything they want, as long as it's for the "General Welfare".

"Dr. Veers, I'm sorry, but things just haven't been working out in Washington. We'll have to confiscate all of your earning for the last three tax years. Don't fret about it too much, it's all for the General Welfare of the country!"

Little extreme, don't you think?

The beauty of the constitution is that is living, and can be interpreted many ways. Even if interpreted narrowly, the mandate seeks to legitimize itself by regulating interstate commerce as an enumerated power, no?

Things get more complicated because the country is not only larger, but inextricably intertwined with global commerce. I still haven't seen a reasonable alternative to a mandate. unless of course nobody intends to increase healthcare coverage.

BTW, it was referenced earlier that the states are the laboratories of democracy. That's true according to the 10th amendment, but we've been at this healthcare business for a century. How long are we to give the states to get it right?

 

[Lokhtar]

And you're not frightened by your own statement?

I am not sure what you mean.

Your scary scenario, if Congress wished to do it, would not require them to to advocate an expansion of the General Welfare clause. They have every right to tax you at 100% if they wish under the 16th Amendment - there is nothing in the text nor in the precedent that places an upper limit. They don't tax people at 100%, obviously, for good reason but that's got nothing to do with its constitutionality. Like Medicare. It may not be a great idea, but it's a separate issue compared to its legality.