Medical School Discrimination

[Mad Jack]

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BTW, I only shared all that because you said I was grinding your gears, which was grinding my gears.

I really just wanted to go on an anti-liberal tangent, what can I say. And I do get particularly unnerved by the great number of people who want to determine when, where, and for how much I practice without having ever had to give up what I'm giving up in the process.

 

[Nietzschelover]

Here's a hypothetical scenario with single payer. Your debt is wiped out, you start around 240K, progress to 320-350K, and then get a pension that pays you half of the last 3 years of your salary....let's say 170K per year until you die. And of course you have health care benefits for life. That's all for the average MD with some specialties making considerably more.

 

[Nietzschelover]

I made an informed decision with the debt and income factored in.

Now, I'll have invested 4 years of undergrad (really 6, I took my time, but I'll simplify it for the average undergrad student), 4 years of medical school, 3 years of residency, and 3 years of fellowship, along with $1,000,000 of debt and lost wages (excluding the amount undergrad cost me and the amount I'm losing from not being able to invest, which would substantially balloon the figure). 14 years and $1,000,000 is an investment I want to at least break even on lol.

And what part of all that sacrifice has to do with "the government"???

 

[Mad Jack]

Here's a hypothetical scenario with single payer. Your debt is wiped out, you start around 240K, progress to 320-350K, and then get a pension that pays you half of the last 3 years of your salary....let's say 170K per year until you die. And of course you have health care benefits for life. That's all for the average MD with some specialties making considerably more.

Can I opt out? If not, no deal.

 

[Nietzschelover]

I made an informed decision with the debt and income factored in.

Now, I'll have invested 4 years of undergrad (really 6, I took my time, but I'll simplify it for the average undergrad student), 4 years of medical school, 3 years of residency, and 3 years of fellowship, along with $1,000,000 of debt and lost wages (excluding the amount undergrad cost me and the amount I'm losing from not being able to invest, which would substantially balloon the figure). 14 years and $1,000,000 is an investment I want to at least break even on lol.

Well, here's the good news. You're only a couple of active threads away from hitting the 20K posts mark 😉.

 

[Nietzschelover]

Can I opt out? If not, no deal.

Fair enough. I'll take it instead.

 

[Mad Jack]

And what part of all that sacrifice has to do with "the government"???

I never said "the government" in my sacrifice. But what I want in return for that is two things: autonomy and enough renumeration to make it worthwhile.

 

[Nietzschelover]

I never said "the government" in my sacrifice. But what I want in return for that is two things: autonomy and enough renumeration to make it worthwhile.

You do realize that private sector pressures and practices could drive your income (AND autonomy) way down, right?

 

[ridethecliche]

Like I said, I'm down a million dollars on this investment. I expect to break even. Society owes me a million and some change if they want to talk about cutting my wages to benefit others. And even then I'd expect a pretty decent compensation package that congress wouldn't **** with every time a budget deal came along and the republicans felt like making some cuts- which, oh wait, will never happen.

The second you sign yourself over to the state, your salary becomes nothing more than a budget item to be slashed and a political football to be kicked about. Screw that, I'd sooner go cash only.

I hope the irony of your belief that society owes you over a million bucks because you're in debt isn't lost on you given your viewpoint that people aren't 'owed' healthcare they can't afford. These ideas are incommensurable.

To be the devils advocate, you seem to think that think that society owes you for taking on personal debt. Why is that society's problem? Society didn't force you into this path. You keep bringing up lost wages for a profession you're not even part of as well as lost wages from a previous position. All of these things should have been part of your calculations when you took on that debt. It seems like you're arguing against something for others when you kind of expect it for yourself.

Preventative care, when done right, is far cheaper than emergency care. The libertarian argument that seems most likely to make sense is a solution that saves both the government and society the most money. Ironically, that solution happens to be one in which people are covered.

The other thing buried in your argument is a different can of worms, which is that education in our country is hilariously overpriced. It seems that in cases like yours it brings about the mentality that you have.

 

[Mad Jack]

Well, here's the good news. You're only a couple of active threads away from hitting the 20K posts mark 😉.

I'll reach the top 20 post count board someday...

Fair enough. I'll take it instead.

This whole question of whether one can opt out seems to be academic and based upon principle, but really, it's not all that simple. See, if I can't opt out, getting a more flexible work arrangement becomes difficult to impossible. Let's say I want to work half the year and spend the rest of my time volunteering abroad- in many fields, that is totally an option, by either doing a shared working arrangement where two physicians split one full time job, or by having a flexible group that allows you to that sort of flexibility. Try doing that sort of thing in any government position- it ain't gonna happen. Once you hand over your career to them, they set the terms, and if you don't like them, you can walk. Right now, there's plenty of physician groups out there, and plenty of niches one can fill. That wouldn't really exist in a socialized system- then NHS, for instance, basically uses physicians as interchangeable cogs. If you're a unique cog, they won't bother trying to use you.

You do realize that private sector pressures and practices could drive your income (AND autonomy) way down, right?

That entirely depends. There is a lot of potential for both increased and decreased earnings, depending on how one does things. I've always been pretty damn good with business and finding opportunities, so I doubt I'll be hurting for income. Less savvy physicians do indeed suffer in a free market system, however. And it is very dependent upon your field- some fields are more amenable to small and medium sized group practice, while others are ripe for being swallowed by massive health care conglomerates. I've got to choose my opportunities wisely, basically.

As to your hypothetical physician salary, I highly doubt members of Congress will be all aboard for paying hundreds of thousands of physicians six figures more than they make without some market pressure to do so 😉

 

[Lucca]

I hope the irony of your belief that society owes you over a million bucks because you're in debt isn't lost on you given your viewpoint that people aren't 'owed' healthcare they can't afford. These ideas are incommensurable.

To be the devils advocate, you seem to think that think that society owes you for taking on personal debt. Why is that society's problem? Society didn't force you into this path. You keep bringing up lost wages for a profession you're not even part of as well as lost wages from a previous position. All of these things should have been part of your calculations when you took on that debt. It seems like you're arguing against something for others when you kind of expect it for yourself.

Preventative care, when done right, is far cheaper than emergency care. The libertarian argument that seems most likely to make sense is a solution that saves both the government and society the most money. Ironically, that solution happens to be one in which people are covered.

A truly hard-line libertarian argument would be that the government has absolutely nothing to do with healthcare and that everyone pays for themselves. The people who cannot are covered by acts of private charity. It's a far more impossible scenario than any of the other ones proposed in this thread.

 

[Mad Jack]

I hope the irony of your belief that society owes you over a million bucks because you're in debt isn't lost on you given your viewpoint that people aren't 'owed' healthcare they can't afford. These ideas are incommensurable.

To be the devils advocate, you seem to think that think that society owes you for taking on personal debt. Why is that society's problem? Society didn't force you into this path. You keep bringing up lost wages for a profession you're not even part of as well as lost wages from a previous position. All of these things should have been part of your calculations when you took on that debt. It seems like you're arguing against something for others when you kind of expect it for yourself.

Preventative care, when done right, is far cheaper than emergency care. The libertarian argument that seems most likely to make sense is a solution that saves both the government and society the most money. Ironically, that solution happens to be one in which people are covered.

If they were to turn my potential career from an entrepreneurial endeavor into a public one, yes, they would owe me, as they would be literally stealing my profession from me. In the current system, they owe me in the sense that I will charge them enough to make it worth my while, and if they aren't willing to pay, I'll exit the field, and that is fine. To more appropriately state things, if the public wants my services as a physician, I expect renumeration that will make those services worthwhile to me. And that renumeration would include making up for what I've lost, just as a man who builds a home charges the cost of materials in addition to the amount he values his services to be worth.

And if they would opt not to pay, then I'll go elsewhere, and that's fine. I've got plenty of options outside of being a physician, and outside of health care entirely. If a few people don't get care because society didn't view my services to be worth paying for, that's on them, not me.

 

[Nietzschelover]

As to your hypothetical physician salary, I highly doubt members of Congress will be all aboard for paying hundreds of thousands of physicians six figures more than they make without some market pressure to do so 😉

Why? I think congresspersons know physicians (in general) should be making more than them. Physicians make more than many executives in health care companies. There are physician employees that make more than their bosses. Pro athletes in general make more than their coaches.

 

[Lucca]

If they were to turn my potential career from an entrepreneurial endeavor into a public one, yes, they would owe me, as they would be literally stealing my profession from me. In the current system, they owe me in the sense that I will charge them enough to make it worth my while, and if they aren't willing to pay, I'll exit the field, and that is fine. To more appropriately state things, if the public wants my services as a physician, I expect renumeration that will make those services worthwhile to me. And that renumeration would include making up for what I've lost, just as a man who builds a home charges the cost of materials in addition to the amount he values his services to be worth.

And if they would opt not to pay, then I'll go elsewhere, and that's fine. I've got plenty of options outside of being a physician, and outside of health care entirely. If a few people don't get care because society didn't view my services to be worth paying for, that's on them, not me.

This concept really seems antithetical to my concept of a physician who I view from the beginning as a public servant. Physicians already don't set their own prices outside of cash-only practice dont they? You can choose your payer mix but the payers provide you with the payment amounts, you dont dictate them -- or am I misunderstanding?

 

[Nietzschelover]

And if they would opt not to pay, then I'll go elsewhere, and that's fine. I've got plenty of options outside of being a physician, and outside of health care entirely. If a few people don't get care because society didn't view my services to be worth paying for, that's on them, not me.

No worries on the latter. Like we hear in almost every pre-med lamenting thread.....there are more than enough folks wanting a seat who would be glad to take your spot.

 

[Mad Jack]

Why? I think congresspersons know physicians (in general) should be making more than them. Physicians make more than many executives in health care companies. There are physician employees that make more than their bosses. Pro athletes in general make more than their coaches.

Tell that to the pundits that advise them.

 

[Nietzschelover]

Tell that to the pundits that advise them.

I've always hated Duke. Damn Christian Laettner.

 

[Mad Jack]

No worries on the latter. Like we hear in almost every pre-med lamenting thread.....there are more than enough folks wanting a seat who would be glad to take your spot.

Yeah, but I'll have already completed a residency and used up an entire spot in the training pathway. In a system with finite capacity, losing a physician is losing a person with the capacity to care for a panel of roughly 2,000 patients. That's 2,000 people without care for every fully-trained doctor the system drives away. Worse still, I'm likely going to be practicing in a subspecialty which already has a shortage (critical care), for which there is a proven loss of life if non-fellowship trained personnel move in to replace fellowship-trained physicians.

It's easy to say "oh we don't need you anyway." But when we've got research that shows we do, in fact, need someone and there is no one to replace them, driving them out of the field isn't exactly the best way to approach things. And I'm sure I'd be far from the only person to bail. If you drive away 3 critical care doctors, you just cost an entire unit coverage for a week. 30 doctors, 10 units. 300 doctors, 100 units. Actions have consequences, and driving doctors away from medicine by making the conditions untenable- well, those consequences can be measured in lives. Specifically, intensivist staffed critical care units reduce mortality by 40%- that's a huge number when you've got 5.7 million ICU admits a year.

 

[Mad Jack]

This concept really seems antithetical to my concept of a physician who I view from the beginning as a public servant. Physicians already don't set their own prices outside of cash-only practice dont they? You can choose your payer mix but the payers provide you with the payment amounts, you dont dictate them -- or am I misunderstanding?

Your concept of a physician is your personal concept, not what we must be. You want to be a public servant, that is your prerogative. As to set their own prices, no, you have to negotiate with all of your insurers when you request to join their panel. The larger your physician group, the more bargaining power you have to increase the rates you will accept. If they don't pay enough, you scrap them. That's one of the advantages of joining a large physician group- more bargaining power with insurers.

 

[ridethecliche]

I guess my issue with this is that I see the cost issues more related to education, administration, and CYA medicine than related to physician reimbursement. Reimbursement is an infathomably small part of the puzzle. The lack of an acting physician union makes it easy to eat into that but if you really want to put a dent in the costs you have to start with the other stuff because just like with college costs, it's the administration cost that is making everything so ridiculously expensive.

I guess I see the issue from the societal standpoint of a disconnect between people trying to run a business without understanding how it really works.

This is obviously an issue that is way more complicated than any of us can really flesh out on SDN, but I see the complications and the costs having risen on the provider side also due to increased bureaucracy with insurance. Some places will actually straight up tell you that they make it hard for physicians to get their patient services so they give up and save the company money. I'm not saying that I have all the answers, but I think there are ways in our society to address the health inequality via primary care while also keeping the rest of the system in line and making the delivery more efficient.

Part of me thinks we should just burn everything to the ground and start over because I think it's pretty bloody ridiculous how things are run right now. Making physicians do the sheer amount of administrative tasks they do is a pretty gross misuse of resources.

Your concept of a physician is your personal concept, not what we must be. You want to be a public servant, that is your prerogative. As to set their own prices, no, you have to negotiate with all of your insurers when you request to join their panel. The larger your physician group, the more bargaining power you have to increase the rates you will accept. If they don't pay enough, you scrap them. That's one of the advantages of joining a large physician group- more bargaining power with insurers.

Yeah, I'm pretty into the entire social justice thing too, but realistically being a doctor is a job. At the end of the day everyone wants to go home to their family and have a decent quality of life. Again, I think these two things can be commensurable.

Also, I don't think medicine as a calling and as a job are incommensurable with the idea of health equality. Though I guess motivations can be different.

I don't think you'd be opposed to more access and care if it didn't really change things for you. Like reimbursements from different insurances to different providers are different already. I think the biggest impact from something like single payer would be to private practice, but nothing is stopping people from paying extra to get that better insurance. And people WILL do that for the convenience factor.

I guess I just buy into the idea that a more educated and healthier populace is better for society as a whole. Personally, that's something I think is worth paying for though I guess people do disagree with that. I think it makes for better workers that can take bigger risks because they're not scared of their world falling apart if they get sick.

I've been unemployed essentially due to being disabled for a year. I had to have one surgery but I was between jobs and would have been totally screwed. Now I'm in medical school and that was because my surgeon waived his fees and I live in a state that offers that coverage. I'm a bit of an extreme example, but I think that will all pay for itself over the course of my career.

I don't want to be seen as a bernie fanboi so I'll just let it be known that I didn't vote in my state's primary, but our corporate tax code is pretty atrocious. I also think that there's a lot of untapped money there as well. If corporations are allowed to have the rights of people, shouldn't they pay taxes like we have to as well?

*sorry for the ninja edits*

 

[Lucca]

I guess my issue with this is that I see the cost issues more related to education, administration, and CYA medicine than related to physician reimbursement. Reimbursement is an infathomably small part of the puzzle. The lack of an acting physician union makes it easy to eat into that but if you really want to put a dent in the costs you have to start with the other stuff because just like with college costs, it's the administration cost that is making everything so ridiculously expensive.

I guess I see the issue from the societal standpoint of a disconnect between people trying to run a business without understanding how it really works.

This is obviously an issue that is way more complicated than any of us can really flesh out on SDN, but I see the complications and the costs having risen on the provider side also due to increased bureaucracy with insurance. Some places will actually straight up tell you that they make it hard for physicians to get their patient services so they give up and save the company money. I'm not saying that I have all the answers, but I think there are ways in our society to address the health inequality via primary care while also keeping the rest of the system in line and making the delivery more efficient.

Part of me thinks we should just burn everything to the ground and start over because I think it's pretty bloody ridiculous how things are run right now. Making physicians do the sheer amount of administrative tasks they do is a pretty gross misuse of resources.



Yeah, I'm pretty into the entire social justice thing too, but realistically being a doctor is a job. At the end of the day everyone wants to go home to their family and have a decent quality of life. Again, I think these two things can be commensurable.

Also, I don't think medicine as a calling and as a job are incommensurable with the idea of health equality. Though I guess motivations can be different.

I don't think you'd be opposed to more access and care if it didn't really change things for you. Like reimbursements from different insurances to different providers are different already. I think the biggest impact from something like single payer would be to private practice, but nothing is stopping people from paying extra to get that better insurance. And people WILL do that for the convenience factor.

I guess I just buy into the idea that a more educated and healthier populace is better for society as a whole.

It's true. In any other industry you wouldn't have your 250k employee doing what we would consider 60k work (administrative tasks) but with the way things are organized right now the administrative tasks are the cash cow worth milking and patient care takes the backseat. How ridiculous would it be if you had your lead engineer whom you pay 200k spending most of his day checking a series of boxes about what he did that day instead of actually accomplishing more things?

I understand my views are personal @Mad Jack and I dont have a problem with other people having views that challenge or oppose mine. However, I still believe that you have to start designing a system from principles first. One of those principles I feel strongly about is that every citizen deserves access to adequate healthcare (and adequate is not some nebulous term, otherwise we wouldn't use phrases like "standard of care"). However, things like professional autonomy and other negative rights are important as well. Again, I want to highlight that given the choice most people would choose to have a system where every individual is medically covered but what they really take issue with is how the healthcare system is organized.

After @ridethecliche 's summary remarks, however, I am happy to end the discussion here.

 

[ridethecliche]

I think that the same end goal can be reached without being preachy. The 'this is a calling' blah blah blah preachers really really piss me off because at the end of the day no one really gives a rats ass what your motivations are if you get the job done.

At the same time, I think we're smart enough and capable enough to advocate for a system where these basic needs are met and still fairly compensate those that have spent so much time and energy to work for something like a medical license.

I like medicine because it poses complex problems, allows me to work with and care for people, and is something I think will give me satisfaction at the end of the day. It also happens to pay pretty well which is important for me given that I'm a first generation immigrant that's likely going to have to support his parents given all the things that they have sacrificed for affording me the opportunities that I have today.

Are my motivations inferior to those that think medicine is a calling? I still care about the people that will be my patients and feel fortunate that I get to play the role that I will play eventually, but I'd like to say that I think that I'm not better than anyone else. The 'calling' stuff just comes off as overly sentimental, hokey, and preachy to me. I just think that the actions and goals should take priority over the motivations. I can't imagine myself being in the OR someday and yelling at my partner for not thinking that medicine is a calling. I'd probably yell at them for being a bonehead though.

I've just found that as I've gotten older, I like things to be simpler. There's enough stuff to worry about without adding another layer of crud for everyone to have to pass through.

Regarding the bit about adequate care bit, I just think it's cheaper as a society to pay for preventative medicine instead of the sexy crazy life saving insane things we do to people who often don't have access. As of right now we're going to be paying for the latter as a society and it's realistically not going away no matter how opposed to it people are so I'd just prefer to spend the money differently for better results. What we're doing now clearly isn't working out so well for us.

 

[Mad Jack]

It's true. In any other industry you wouldn't have your 250k employee doing what we would consider 60k work (administrative tasks) but with the way things are organized right now the administrative tasks are the cash cow worth milking and patient care takes the backseat. How ridiculous would it be if you had your lead engineer whom you pay 200k spending most of his day checking a series of boxes about what he did that day instead of actually accomplishing more things?

I understand my views are personal @Mad Jack and I dont have a problem with other people having views that challenge or oppose mine. However, I still believe that you have to start designing a system from principles first. One of those principles I feel strongly about is that every citizen deserves access to adequate healthcare (and adequate is not some nebulous term, otherwise we wouldn't use phrases like "standard of care"). However, things like professional autonomy and other negative rights are important as well. Again, I want to highlight that given the choice most people would choose to have a system where every individual is medically covered but what they really take issue with is how the healthcare system is organized.

I guess my visceral reaction against a national health care plan is largely the result of everything I've dealt with regarding Physicians for a National Health Plan. PNHP specifically wants to ban private options, private hospitals, and private practice, because they believe these things would harm a single-payer system. I'm ethically opposed to any system that bans one from being able to earn a living on their own terms- I earned a medical degree, and whether I want to charge a person peanuts and coffee for my services in a shack or hundreds of dollars an hour out of a high-rise and people are willing to agree to either terms, I should be able to do so. Many of the proposed single-payer systems have this issue- generally they go Medicare-only (which would murder wages). The only way one would be able to make decent money under such a system would be to bail out, but many proposals do not allow one to do so, which I view as a violation of the basic human right to economic self-direction.

Problems with single payer? Look no further than PNHP's own FAQ:

Why shouldn’t we let people buy better health care if they can afford it?
Whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers. If the wealthy are forced to rely on the same health system as the poor, they will use their political power to assure that the health system is well funded. Conversely, programs for the poor become poor programs. For instance, because Medicaid doesn’t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered politically important. Moreover, when the wealthy jump the queue, it results in longer waits for others. Studies in New Zealand and Canada show that the growth of private care in parallel to the public system results in lengthening waits. Additionally, allowing the development of a parallel, private system for the wealthy means the creation of a permanent lobby for underfunding public care. Such underfunding increases the demand for private care.

Basically, no private options for you. And if there's no private options for you, then there's no private practice for physicians.

How will we keep doctors from doing too many procedures?
This is a problem in any system that reimburses physicians on a fee-for-service basis. In today’s health system, another problem is physicians doing too little for patients. So the real question is, “How do we discourage both overcare and undercare?”

One approach is to carefully control new capital expenditures. Once a hospital or imaging center purchases a multimillion-dollar CT scanner, it will try to generate enough scans to pay off the fixed cost. Explicit health planning should be done to assure that expensive machines and facilities are sited where they are needed and not where they are redundant and likely to generate overuse.

Another approach is to compare physicians’ use of tests and procedures to their peers with similar patients. A physician who is “off the curve” will stand out. A related approach is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from colleagues.

In addition, expert guidelines by groups like the American College of Physicians, etc., can help shape professional standards - which will certainly change over time as treatments change. This really gets to the heart of “how do you improve the quality of health care,” which is a longer topic. Suffice it to say that single-payer, universal coverage provides a framework for achieving thoughtful quality improvement.

This is where we get back into "evidence" based medicine and rationing of care. They propose punishing physicians that order more tests and procedures than others, or by limiting spending in different areas. Do something that there is evidence for but isn't "standard of care" yet? You get dinged. Seeing too many patients or doing too much work? Dinged. Have an unusually bad run of complicated patients that require extra testing (because you may have two people that look similar on a page at a glance, but the actual patient sitting in front of you may be very different than the guy next door with similar comorbidities because people don't work like statistics would have you believe)? Dinged.

So my problem less comes with "should we do this" and more with "how can we do this and make it reasonable for everyone involved?" In the United States, I can see no way of making that happen, largely because of all of the competing interests and political shenanigans inherent in our system.

 

[ridethecliche]

Yeah, I think the two systems can be run concurrently. I don't agree with removing the private options.

I'd also think that if you have a private insurance in that kind of system then:
Single payer should cover their base and the rest should come out of pocket/private insurance.

I would only agree if these things were for elective procedures that didn't tax the rest of the system too much. Like.... I don't think that waiting a month or two for a hip replacement is a big deal given the natural history and pathology of that issue, but if you have severe bone loss and have a high risk of a femoral fracture then you should probably be an emergent case even if you don't have private insurance. I'm a bit of a research junkie though. I like my risk scores etc.

 

[Lucca]

I guess my visceral reaction against a national health care plan is largely the result of everything I've dealt with regarding Physicians for a National Health Plan. PNHP specifically wants to ban private options, private hospitals, and private practice, because they believe these things would harm a single-payer system. I'm ethically opposed to any system that bans one from being able to earn a living on their own terms- I earned a medical degree, and whether I want to charge a person peanuts and coffee for my services in a shack or hundreds of dollars an hour out of a high-rise and people are willing to agree to either terms, I should be able to do so. Many of the proposed single-payer systems have this issue- generally they go Medicare-only (which would murder wages). The only way one would be able to make decent money under such a system would be to bail out, but many proposals do not allow one to do so, which I view as a violation of the basic human right to economic self-direction.

Problems with single payer? Look no further than PNHP's own FAQ:

Why shouldn’t we let people buy better health care if they can afford it?
Whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers. If the wealthy are forced to rely on the same health system as the poor, they will use their political power to assure that the health system is well funded. Conversely, programs for the poor become poor programs. For instance, because Medicaid doesn’t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered politically important. Moreover, when the wealthy jump the queue, it results in longer waits for others. Studies in New Zealand and Canada show that the growth of private care in parallel to the public system results in lengthening waits. Additionally, allowing the development of a parallel, private system for the wealthy means the creation of a permanent lobby for underfunding public care. Such underfunding increases the demand for private care.

Basically, no private options for you. And if there's no private options for you, then there's no private practice for physicians.

How will we keep doctors from doing too many procedures?
This is a problem in any system that reimburses physicians on a fee-for-service basis. In today’s health system, another problem is physicians doing too little for patients. So the real question is, “How do we discourage both overcare and undercare?”

One approach is to carefully control new capital expenditures. Once a hospital or imaging center purchases a multimillion-dollar CT scanner, it will try to generate enough scans to pay off the fixed cost. Explicit health planning should be done to assure that expensive machines and facilities are sited where they are needed and not where they are redundant and likely to generate overuse.

Another approach is to compare physicians’ use of tests and procedures to their peers with similar patients. A physician who is “off the curve” will stand out. A related approach is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from colleagues.

In addition, expert guidelines by groups like the American College of Physicians, etc., can help shape professional standards - which will certainly change over time as treatments change. This really gets to the heart of “how do you improve the quality of health care,” which is a longer topic. Suffice it to say that single-payer, universal coverage provides a framework for achieving thoughtful quality improvement.

This is where we get back into "evidence" based medicine and rationing of care. They propose punishing physicians that order more tests and procedures than others, or by limiting spending in different areas. Do something that there is evidence for but isn't "standard of care" yet? You get dinged. Seeing too many patients or doing too much work? Dinged. Have an unusually bad run of complicated patients that require extra testing (because you may have two people that look similar on a page at a glance, but the actual patient sitting in front of you may be very different than the guy next door with similar comorbidities because people don't work like statistics would have you believe)? Dinged.

So my problem less comes with "should we do this" and more with "how can we do this and make it reasonable for everyone involved?" In the United States, I can see no way of making that happen, largely because of all of the competing interests and political shenanigans inherent in our system.

I'm younger and more optimistic than you, "should" is still very important to me. My own experience has been colored by being an immigrant from a socialist country that went to **** in a red state. I'm very sympathetic to ideas like private property, competitive markets, autonomy and I understand how important they are for a society. I was old enough when I came to this country to remember being poor and not having anything but a couple of plates and cups, a couch we picked up from a dumpster, and an 8'' television and sleeping on the floor and going to a school that couldnt afford doors on the classrooms or nets on the basketball hoops so I also understand how much harder life is in this country for those at the bottom. To me, the concerns of the poor are more important than the concerns of the wealthy because there is always a way to opt out of a problem for the wealthy, not for the poor. That's my personal view and I don't expect others to adopt it or consider it legitimate. That being said, when, as a physician, asked the question "do you think healthcare is a human right" I do assert that the correct answer is "Yes" or "Yes, but" *insert your views here* and not simply "No".

I don't agree with some of the PNHP's views but I do agree that healthcare systems are better with 100% participation. Competition should be at the level of providing services, not at the level of actually being able to get any services at all.

 

[Mad Jack]

I think that the same end goal can be reached without being preachy. The 'this is a calling' blah blah blah preachers really really piss me off because at the end of the day no one really gives a rats ass what your motivations are if you get the job done.

At the same time, I think we're smart enough and capable enough to advocate for a system where these basic needs are met and still fairly compensate those that have spent so much time and energy to work for something like a medical license.

I like medicine because it poses complex problems, allows me to work with and care for people, and is something I think will give me satisfaction at the end of the day. It also happens to pay pretty well which is important for me given that I'm a first generation immigrant that's likely going to have to support his parents given all the things that they have sacrificed for allowing me the opportunities that I have today.

Are my motivations inferior to those that think medicine is a calling? I still care about the people that will be my patients and feel fortunate that I get to play the role that I will play eventually, but I'd like to say that I think that I'm not better than anyone else. The 'calling' stuff just comes off as overly sentimental, hokey, and preachy to me. I just think that the actions and goals should take priority over the motivations. I can't imagine myself being in the OR someday and yelling at my partner for not thinking that medicine is a calling. I'd probably yell at them for being a bonehead though.

I've just found that as I've gotten older, I like things to be simpler. There's enough stuff to worry about without adding another layer of crud for everyone to have to pass through.

Regarding the bit about adequate care bit, I just think it's cheaper as a society to pay for preventative medicine instead of the sexy crazy life saving insane things we do to people who often don't have access. As of right now we're going to be paying for the latter as a society and it's realistically not going away no matter how opposed to it people are so I'd just prefer to spend the money differently for better results. What we're doing now clearly isn't working out so well for us.

My idealism died with my 20s, as did my faith in any system built by the US government to be sustainable or efficient.

Primary care sounds like a fantastic way to reduce all sorts of spending issues. But there's this big problem- patients. Most patients are not active participants in their own health care. Half of all early deaths and a great deal of our disease burden are lifestyle related. All the primary care in the world can't force a person to put down the bottle and the smokes, or to stop swinging by Wendy's on the way home from work. Primary care is only as effective as your patients, and you can only do so much in a system that gives you 12 minutes with them, hardly enough time to show them you care, let alone to make a difference.

 

[ridethecliche]

My idealism died with my 20s, as did my faith in any system built by the US government to be sustainable or efficient.

Primary care sounds like a fantastic way to reduce all sorts of spending issues. But there's this big problem- patients. Most patients are not active participants in their own health care. Half of all early deaths and a great deal of our disease burden are lifestyle related. All the primary care in the world can't force a person to put down the bottle and the smokes, or to stop swinging by Wendy's on the way home from work. Primary care is only as effective as your patients, and you can only do so much in a system that gives you 12 minutes with them, hardly enough time to show them you care, let alone to make a difference.

This is definitely true, but we also have a real problem of food desserts in places that are lower income. There also aren't really any gyms there. These things add up. Have you read nudge? It's a book on choice architecture and I think it's important to add that framework to the discussion about these issues in medicine. You can design a system that makes it easier for people to access the things that are good for them too. If you make it hard it's much harder to overcome the resistance. I like a 10 minute walk from the school gym and balk about going when it's raining out... We had a professor talk about one of her patients that was doing very well with weight loss when she had a friend driving her to the gym, but the stigma of being on public transportation (she needed 2 seats) and the 2+ hr round trip on said transport was a barrier to her access. When her friend stopped going to the gym, she quit soon after...

As noble as we think our capitalist society is, we've really preyed on lots of minority populations and still do to be honest. Saying that already disenfranchised people should be able to look out for their own interests when you have a bunch of smart people figure out the perfect way to screw them is kind of disingenuous imho.

I think this kind of idea is much harder to pull off in the US since we're not as homogeneous a population as the scandinavian countries that are often used as an example for these sorts of things.

 

[Mad Jack]

This is definitely true, but we also have a real problem of food desserts in places that are lower income. There also aren't really any gyms there. These things add up. Have you read nudge? It's a book on choice architecture and I think it's important to add that framework to the discussion about these issues in medicine. You can design a system that makes it easier for people to access the things that are good for them too. If you make it hard it's much harder to overcome the resistance. I like a 10 minute walk from the school gym and balk about going when it's raining out... We had a professor talk about one of her patients that was doing very well with weight loss when she had a friend driving her to the gym, but the stigma of being on public transportation (she needed 2 seats) and the 2+ hr round trip on said transport was a barrier to her access. When her friend stopped going to the gym, she quit soon after...

As noble as we think our capitalist society is, we've really preyed on lots of minority populations and still do to be honest. Saying that already disenfranchised people should be able to look out for their own interests when you have a bunch of smart people figure out the perfect way to screw them is kind of disingenuous imho.

I think this kind of idea is much harder to pull off in the US since we're not as homogeneous a population as the scandinavian countries that are often used as an example for these sorts of things.

Oh, I totally agree that people get screwed left and right. I mean, look at food subsidies... And I've made many-an-argument about why we shouldn't deregulate drugs and such, because people are easy to manipulate into buying **** they don't need or that will actively harm them.

But here's the thing- many of the solutions you're talking about wouldn't be solved, or even approached, by a national health system. All the primary care access in the world doesn't fix food deserts, a lack of gyms, or predatory marketing and terrible subsidies that lead poor people to buy Doritos instead of vegetables.

 

[ridethecliche]

Oh, I totally agree that people get screwed left and right. I mean, look at food subsidies... And I've made many-an-argument about why we shouldn't deregulate drugs and such, because people are easy to manipulate into buying **** they don't need or that will actively harm them.

But here's the thing- many of the solutions you're talking about wouldn't be solved, or even approached, by a national health system. All the primary care access in the world doesn't fix food deserts, a lack of gyms, or predatory marketing and terrible subsidies that lead poor people to buy Doritos instead of vegetables.

Which is why access to care is only a part of the solution towards equitable health.

I think I've said all that I have to on this, but what I'm hearing from you is that you're not so opposed to the idea if it's done the right way, i.e. in a manner that is fair to both patients and providers and cuts down on some of the waste that we both agree is pretty commonplace in the system.

Is that accurate?

 

[Mad Jack]

Which is why access to care is only a part of the solution towards equitable health.

I think I've said all that I have to on this, but what I'm hearing from you is that you're not so opposed to the idea if it's done the right way, i.e. in a manner that is fair to both patients and providers and cuts down on some of the waste that we both agree is pretty commonplace in the system.

Is that accurate?

If it protects physician and patient autonomy, reduces waste, and doesn't hit wages all that hard, I'd be fine with it, but only if one also has the option, as a physician, to opt out.

 

[hopefulERdoc251]

Not to jump in unnecessarily and sort of change the topic, but everything boils down to lifestyle. There are obviously certain diseases that are independent of that, but many many many diseases can be prevented by lifestyle changes. For instance, cardiac disease. Risk factors are DM, HTN, Obesity. All of those are lifestyle based for the most part. Cardiac disease is exacerbated by all of that, and then you're in a medication cascade. Here's a statin for your lipids, here's a pill for your BP. Here's a pill for your DM. Ect.

Much of this starts in the school system in my opinion. For instance, my HS has vending machines for soda, candy, ect. All unhealthy crap that they make tons of money from. The other problem is the quality of food. When schools offer buy 2 get 1 free hot dogs, 2 for 1 pizza day, 2 for 1 burger day ect, it's a no brainer that our society is growing up unhealthy. A simple sign on the cafeteria wall saying milk makes stronger bones is not sufficient enough. A friend of mine is an international student, he had his secondary education in a country in Asia and he said that they regularly provided healthier, leaner choices of food. Not only does that help improve health outcomes, but it also improves cognitive function. Now everybody will not appeal to such a system. I understand that. But it has to be a start. Habits can be formed when you're young and at this age.

When I did a public health internship, I created a curriculum that taught elementary students the importance of eating healthy. Sure most of the students didn't change their habits, but starting at 25% is well, a start. Parents came up to me and my fellow interns saying how they made a simple lifestyle change, like not eating potatos and rice every meal, or drinking fat free milk, using fat free yogurt. It's a start. And that's where I think America is at crossroads.

 

[ridethecliche]

If it protects physician and patient autonomy, reduces waste, and doesn't hit wages all that hard, I'd be fine with it, but only if one also has the option, as a physician, to opt out.

Yup. Like I said, I don't understand the need to remove choice from the equation. If a patient wants to pay extra for concierge primary care or expedited elective surgery/bigger hospital rooms etc, then that's their right. This is assuming that the base level of care is comparable and they're paying extra for amenities and access to their physician. If a patient and physician decide to do something like this, it's their right and their money.

Not to jump in unnecessarily and sort of change the topic, but everything boils down to lifestyle. There are obviously certain diseases that are independent of that, but many many many diseases can be prevented by lifestyle changes. For instance, cardiac disease. Risk factors are DM, HTN, Obesity. All of those are lifestyle based for the most part. Cardiac disease is exacerbated by all of that, and then you're in a medication cascade. Here's a statin for your lipids, here's a pill for your BP. Here's a pill for your DM. Ect.

Much of this starts in the school system in my opinion. For instance, my HS has vending machines for soda, candy, ect. All unhealthy crap that they make tons of money from. The other problem is the quality of food. When schools offer buy 2 get 1 free hot dogs, 2 for 1 pizza day, 2 for 1 burger day ect, it's a no brainer that our society is growing up unhealthy. A simple sign on the cafeteria wall saying milk makes stronger bones is not sufficient enough. A friend of mine is an international student, he had his secondary education in a country in Asia and he said that they regularly provided healthier, leaner choices of food. Not only does that help improve health outcomes, but it also improves cognitive function. Now everybody will not appeal to such a system. I understand that. But it has to be a start. Habits can be formed when you're young and at this age.

When I did a public health internship, I created a curriculum that taught elementary students the importance of eating healthy. Sure most of the students didn't change their habits, but starting at 25% is well, a start. Parents came up to me and my fellow interns saying how they made a simple lifestyle change, like not eating potatos and rice every meal, or drinking fat free milk, using fat free yogurt. It's a start. And that's where I think America is at crossroads.

For all the things we do really well, we do this kind of stuff very well. It's the ugly side of capitalism I think. Corporate interests and health often don't go together. Schools are under funded and get money they desperately need out of the deals that end up doing quite a disservice to those that can't really argue against it.

I guess it's also the flip side of the rugged individualism that's pushed down our throats. I guess I see the irony of it better at times since I wasn't brought up here and can question what people seem to take for granted. But it's often hard to see how things are stacked against certain segments of the population from a time when they are most impressionable.

 

[NeuResurgens]

I actually predict that most people would be willing to participate. If other countries are any evidence, a public system, well-subsidized and which provides affordable care to all of its patients alongside a medical education system which is also heavily subsidized produces happier physicians with more professional satisfaction, a system with better measurable outcomes, and can still provide a salary well-above the national median for those countries. The quality of the employer and the work will be more important to 99% of physicians than ideology (just as it is now) and I, unlike you and Womb I suspect, believe that most people would be happy with what the healthcare market deems as "enough" payment for medical service.

If you look at the military med forums, most military docs will list "not having to worry about the cost of treatment" as a strong pro. One American physician I know (who is very, very conservative by most standards, run-of-the-mill by Texas standards) worked for the NHS in England for 5 years because of a faculty appointment at a school there and said he strongly preferred it to our system here and would go back in a heartbeat if given the opportunity. N=1 though.

Personally, however, I believe medicine is a service profession in the way joining the Peace Corps or Americorps or the military is a service profession (to a lesser extent than the military though since military service is a far bigger commitment). That's just me. I dont expect people to agree with me on that.

This part is all a matter of perspective though, I've heard of plenty of English doctors who are very disappointed in their system, so it can go both ways.

Personally, I like the thought of a two tiered system, a public general system and a privatized system. Loan forgiveness incentives and some protections from litigation for the public system, higher pay but more risk in the private system. Theoretically it balances out, but it'd be hard to implement.

 

[Instatewaiter]

I understand what you mean, but I think you are missing the point.

If people have a right to bear arms protected under the law by laws such as concealed carry for example then you can carry a concealed arm on your person. If I am a small business owner I have a right to refuse weapons - concealed or not - being present on my property. Are anyone's rights being violated? No. People with concealed weapons can go to another store or leave their weapon at home or in the car when visiting this business.

If people have a right to access healthcare then they have a right to receive affordable care when they need it. If a physician does not want to provide care at the price which was determined fair and affordable by a governing body (it can be a hospital system, it can be the government, it can be a committee of insurance providers -- it is not necessarily the government who has to determine this) then they do not provide care for that patient. However in a system where healthcare is a human right, there is an affordable and accessible option for every citizen. It might not be you, but they will get it somewhere. No one's rights are being violated.

A law and a right are two separate things. So in your example, the law allowing concealed to carry is not a right. The business owner has autonomy over his property (his business) so he has the ability to bar weapons on his premises. Your parallel is not an accurate one because the patron has no right to bring a weapon onto private property.

In our society you have few positive rights- ie those that must be provided. This is nicely evident in our right to life. You have a right to life such that no one can take it away from you without just cause. You however do not have a right to life such that others must provide it to you. Similarly, you do not have a right to access to health care such that somone should provide it for you. Perhaps you have a right to access to healthcare such that no one can keep you from it (falls under right to liberty).

You most definitely do not have a right to health care being provided for you for many reasons. First, a right cannot be denied. However with healthcare, if someone doesn't want to provide the care to you, they must be forced. This is a violation of autonomy and liberty. This would force your right to healthcare to be above my right to liberty and self-determination. This is the crux of why socialism ends up being inherently immoral.

 

[ridethecliche]

You most definitely do not have a right to health care being provided for you for many reasons. First, a right cannot be denied. However with healthcare, if someone doesn't want to provide the care to you, they must be forced. This is a violation of autonomy and liberty. This would force your right to healthcare to be above my right to liberty and self-determination. This is the crux of why socialism ends up being inherently immoral.

But, I like totally don't want to fulfill the services required of me given the job I do.

I'm just waiting for you to compare this to slavery.

I'm also curious how just like not seeing patients who weren't insured in all situations would affect medical education. I.e. a large part of our learning comes from interactions with patients that aren't insured or are incredibly under insured given the nature of academic institutions. Some of those patients pose the best learning scenarios given the myriad complications they often have.

 

[Instatewaiter]

BTW, @Mad Jack, you think getting a Ph.D. doesn't involve any sacrifices? Took me 11 years (post-undergrad) to get that, and for my troubles I've made half or less than half of what a psychiatrist makes for the past 25+ years.

Well financially that was not a very sound decision. Either you didn't think this through or more likely, you are benefitting in other ways (enjoyment)...

 

[Nietzschelover]

Well financially that was not a very sound decision. Either you didn't think this through or more likely, you are benefitting in other ways (enjoyment)...

I thought we were all done.

I didn't intend to give an impression of complaining. Simply was trying to verify with Mad Jack that I am of the same planet.

And yes, I have benefited in some other ways. In addition to having a reputation as one of the very top people in my specialty area in my state, I was able to coach my kids' soccer teams, attend dance recitals, blog and post a lot on internet forums, and attend the greatest game in college basketball history with my father (and hence the Laettner reference). I also get to drink some pretty good wine when my wife isn't paying too much attention without getting called to a hospital in the middle of the night.

 

[Nietzschelover]

You most definitely do not have a right to health care being provided for you for many reasons. First, a right cannot be denied. However with healthcare, if someone doesn't want to provide the care to you, they must be forced. This is a violation of autonomy and liberty. This would force your right to healthcare to be above my right to liberty and self-determination. This is the crux of why socialism ends up being inherently immoral.

Had to do a double take. Socialism is "inherently immoral"? Since when did a person's rights (or lack thereof) become the cornerstone of morality? Are you suggesting that capitalism is "moral"??? And how did you determine that your right to refuse treatment is greater than a person's right to receive treatment? Why do you have a right to a gun any more than you have right to own property, a right to education, a right to live your sexuality as it is rather than as other believe you should live it?

As to your rhetoric about "forced," we do all kinds of things because we are "forced." Try refusing treatment to 10 patients tonight in the ER to ANYONE, or because they are Muslim or Christian or black or because they smoke and you're disgusted that they aren't taking more responsibility for their health. Sure, you can walk off the job and increase the likelihood that you won't work in the field again, but you're probably going to "choose" to provide the services even if you're mumbling under your breath for the whole shift.

 

[Nietzschelover]

But, I like totally don't want to fulfill the services required of me given the job I do.

I'm just waiting for you to compare this to slavery.

I'm also curious how just like not seeing patients who weren't insured in all situations would affect medical education. I.e. a large part of our learning comes from interactions with patients that aren't insured or are incredibly under insured given the nature of academic institutions. Some of those patients pose the best learning scenarios given the myriad complications they often have.

Yeah, the quickness with which a few posters have dissembled to slavery has been disturbing.

 

[Nietzschelover]

Does anyone have a link to the letter Harvard med school profs and students put out stating that single payer is absolutely the right way to go?

 

[Instatewaiter]

Had to do a double take. Socialism is "inherently immoral"? Since when did a person's rights (or lack thereof) become the cornerstone of morality? Are you suggesting that capitalism is "moral"??? And how did you determine that your right to refuse treatment is greater than a person's right to receive treatment? Why do you have a right to a gun any more than you have right to own property, a right to education, a right to live your sexuality as it is rather than as other believe you should live it?

As to your rhetoric about "forced," we do all kinds of things because we are "forced." Try refusing treatment to 10 patients tonight in the ER to ANYONE, or because they are Muslim or Christian or black or because they smoke and you're disgusted that they aren't taking more responsibility for their health. Sure, you can walk off the job and increase the likelihood that you won't work in the field again, but you're probably going to "choose" to provide the services even if you're mumbling under your breath for the whole shift.

That is right. Socialism is inherently immoral. It stands under the guise of morality but truly is the opposite. It takes property from people. It steals services from people. It violates autonomy, liberty, property and many other inviolable and inalienable rights. Violating these is inherently immoral. I am not suggesting capitalism is moral or immoral but at least what you produce isn't stolen from you and your labor and effort are your own.

You do not have a right to education as it is provided by others. It is a priveledge provided that could be taken away. For this very reason, no one has a right to receive treatment. It relies on someone elses autonomy and liberty. Your right to property is inherent. Your right to sexuality falls under liberty. To create a parallel with a right to receive treatment let's take sexuality. How come no one has to provide you with a sexual partner? I'd argue sex is more essential than healthcare. If someone has to provide treatment, why not sex? Oh that's right liberty and autonomy...

Now as to your second point, I would not discriminate on those parameters because I am not a bigot. You are creating a straw man by inferring that I am. Second, if someone in the ED doesn't need emergency care, I by law (and by rights) do not have to give them care if I don't want to (also I am not an emergency medicine physician). However, in the ED, I don't spend the time figuring out who can pay and who can't nor do I care who is compliant and who isn't. Their ER visit is their warning shot across the bow. It's their chance to become compliant. However, in clinic, if you're non-compliant you can be damn sure I will fire them as a patient.

 

[Nietzschelover]

That is right. Socialism is inherently immoral. It stands under the guise of morality but truly is the opposite. It takes property from people. It steals services from people. It violates autonomy, liberty, property and many other inviolable and inalienable rights. Violating these is inherently immoral. I am not suggesting capitalism is moral or immoral but at least what you produce isn't stolen from you and your labor and effort are your own.

You do not have a right to education as it is provided by others. It is a priveledge provided that could be taken away. For this very reason, no one has a right to receive treatment. It relies on someone elses autonomy and liberty. Your right to property is inherent. Your right to sexuality falls under liberty. To create a parallel with a right to receive treatment let's take sexuality. How come no one has to provide you with a sexual partner? I'd argue sex is more essential than healthcare. If someone has to provide treatment, why not sex? Oh that's right liberty and autonomy...

Now as to your second point, I would not discriminate on those parameters because I am not a bigot. You are creating a straw man by inferring that I am. Second, if someone in the ED doesn't need emergency care, I by law (and by rights) do not have to give them care if I don't want to (also I am not an emergency medicine physician). However, in the ED, I don't spend the time figuring out who can pay and who can't nor do I care who is compliant and who isn't. Their ER visit is their warning shot across the bow. It's their chance to become compliant. However, in clinic, if you're non-compliant you can be damn sure I will fire them as a patient.

Gonna take a pass on this one. Thanks for playing.

 

[Mansamusa]

You do not have a right to education as it is provided by others. It is a priveledge provided that could be taken away. For this very reason, no one has a right to receive treatment. It relies on someone elses autonomy and liberty.

Just one thing on this. Higher education receives funding that comes from my money in the form of taxes. I think it is immoral for schools to create an arbitrary monopoly on education and randomly decide that if I don't receive a degree, that I don't know something even though I can teach myself independently of the schools. I think it is immoral for schools to take my money and then price me out of them.

And actually, if you want to take it further, wouldn't it also be immoral to make it illegal for me to perform surgery without a license? Shouldn't I and anyone who wants to be serviced by me have the liberty and autonomy to chose to have me operate on them knowing that I don't have the government approved license? I think it would be immoral if there were no gov't sponsored health program (like medicaid/medicare) because the gov't made standards where we don't have the liberty to see the healthcare providers we want unless they have an exclusive license. Basically, the fact that I need to see a MD/DO to have surgery violates my autonomy, so since we violated everyone's autonomy in making this system, healthcare is subject to a different set of "liberty" rules. I would think it is a violation of liberty to force all doctors into a gov't system, but it is not immoral to establish a gov't system.

Different ways of looking at things

 

[qwert876]

Here's a hypothetical scenario with single payer. Your debt is wiped out, you start around 240K, progress to 320-350K, and then get a pension that pays you half of the last 3 years of your salary....let's say 170K per year until you die. And of course you have health care benefits for life. That's all for the average MD with some specialties making considerably more.

And after 75% taxes and a reduced income because you're no longer having to pay for your own education, you will be making $75,000.

 

[qwert876]

You do realize that private sector pressures and practices could drive your income (AND autonomy) way down, right?

Do you really think monopolies drive wages up? No! Once the government monopolizes, they will pay however many peanuts they want.

 

[Instatewaiter]

Just one thing on this. Higher education receives funding that comes from my money in the form of taxes. I think it is immoral for schools to create an arbitrary monopoly on education and randomly decide that if I don't receive a degree, that I don't know something even though I can teach myself independently of the schools. I think it is immoral for schools to take my money and then price me out of them.

And actually, if you want to take it further, wouldn't it also be immoral to make it illegal for me to perform surgery without a license? Shouldn't I and anyone who wants to be serviced by me have the liberty and autonomy to chose to have me operate on them knowing that I don't have the government approved license? I think it would be immoral if there were no gov't sponsored health program (like medicaid/medicare) because the gov't made standards where we don't have the liberty to see the healthcare providers we want unless they have an exclusive license. Basically, the fact that I need to see a MD/DO to have surgery violates my autonomy, so since we violated everyone's autonomy in making this system, healthcare is subject to a different set of "liberty" rules. I would think it is a violation of liberty to force all doctors into a gov't system, but it is not immoral to establish a gov't system.

Different ways of looking at things

Your paralells are not entirely accurate. First, schoolS of higher education are not a monopoly (you know because there are multiple, autonomous entities). Nor are they an oligopoly. Second, it is not immoral to have standards. There are standards for a degree which you agree upon with your major. Their entire mission is to teach and evaluate that you have understood the content.

Finally, as to your last argument that because there are standards set for who can practice, it necesitates gov't sponsored health programs- that is nonsense and illogical. Were this argument true, because you need a gov't license to open a movie theatre, a beauty shop, a grocery store, a butcher shop and many others the gov't would have to provide you a gov't program for movies, hair care, groceries, meat products and the like. We can discuss whether the gov't should be in the business of licensure but that they are doesn't impact whether or not they should be creating other social programs.

 

[Instatewaiter]

Gonna take a pass on this one. Thanks for playing.

Well I guess you realize the immorality of your ways. Perhaps a more apt analogy would really hit home:

Your insistance on your (and others') right to my labors is no different than some republican's insistance he can legislate away a woman's right to make decisions about her own body

 

[Nietzschelover]

Well I guess you realize the immorality of your ways. Perhaps a more apt analogy would really hit home:

Your insistance on your (and others') right to my labors is no different than some republican's insistance he can legislate away a woman's right to make decisions about her own body

Ummm, not exactly. I was trying to be polite and mature by not replying. I've heard more rational rants from adults talking to themselves on the side of the street.

I think you have a bizarre understanding of both morality and what single payer would look like. We would still live in th USA, where all of the legislative branches would remain intact, where you could protest and tweak via your professional bodies, the media, etc. You wouldn't wake up in the morning and see Stalin on state TV for heavens sakes. And there is nothing to say that physicans couldn't play a major and even guiding role in how single payer would work and how their interests would be protected. There's nothing to prevent an implementation being reversed or substantially revised if all or certain aspects don't end up working. I don't think the citizens of Canada and the European countries believe they are living in gulags or in societies that are immoral by virtue of socialized medicine. I've heard that a group of Harvard MDs and med students have taken a stand in favor of single payer. Do you know anything about that?

 

[Med Ed]

I don't think the citizens of Canada and the European countries believe they are living in gulags or in societies that are immoral by virtue of socialized medicine.

Most people don't understand the distinction between socialized medicine and socialized insurance.

 

[Mad Jack]

Most people don't understand the distinction between socialized medicine and socialized insurance.

Socialized insurance that disallows private insurance and is where 100% of physician wages come from is socialized medicine in all but name. The only difference is that you get to fight with hospital administrators instead of government officials about the size of the slice of pie you receive.