Medicare for all and physician salaries

Discussion in 'Topics in Healthcare' started by wimby2016, Feb 6, 2019.

  1. sb247

    sb247 Doer of things
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    You aren’t the only old one here

    Your prior post is the stereotype for the wide eyed young premed who has no concept about the effort, economics, and motivations of physicians. Working near doctors for a long time doesn’t relay that information either. Again, when you get farther along I think you will have some more context. No hard feelings, you just don’t know how much you don’t know
     
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  2. nimbus

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    No I absolutely would not have considered it if I couldn’t make a good living at it. Forget it. Life is too short to spend it struggling financially. If medicine all of a sudden paid 100k/year, I’d go find a better paying job.

    That said, I really enjoy the work. I would enjoy it a lot less if I had to worry about how I’m going to pay my bills.
     
    #252 nimbus, Feb 8, 2019
    Last edited: Feb 8, 2019
  3. doc05

    doc05 2K Member
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    Give me a break.
     
  4. RNthenDoc

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    Back on topic, I’d love to hear workable solutions to these problems. I have some solid local politicians who are surprisingly open to communication with constituents (aka I chat with my reps on social media regularly), and it would be great if I could present better options that are well-articulated.

    Like I said, it’s easy to point out problems, harder to propose workable solutions.
     
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  5. sb247

    sb247 Doer of things
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    Do you mean “workable” as in appropriate? Or “workable” as in would pass and still get someone elected?
     
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  6. aProgDirector

    aProgDirector Pastafarians Unite!
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    All proposals that I have seen / heard combine some mechanism for central funding with cost reductions. Usually the argument goes:

    We want to ensure that everyone has health care paid for.
    Other countries do this at lower cost, so there must be some way for us to do so.
    Creating a single payer system will generate cost savings, because less bureaucracy.
    We also have lots of waste/fraud/abuse in our system which can be cut.
    Better early healthcare is cost saving in the long run.
    The costs of most medical services is too high, and can be reduced.
    Combining these four (bureaucracy, waste, early care, and overall decreased costs), we save enough money to pay for everyone.

    Whether this is actually true is unclear. First, cutting "waste" or "bureaucracy" sounds like a good idea, but remember that any cut in healthcare spending is reducing someone's income somewhere. Perhaps it's not your income, so you don't care. But that person will care. Much like the coal industry collapsing.

    Decreasing costs is similar. If MRI costs decrease from $1000 to $350 (I made those numbers up), that loss of revenue has to come from somewhere.

    No matter what we do, any change will create winners and losers. This is always true. Hence it's hard to say whether any plan is "good" or "workable", it will totally depend upon where in the healthcare system you are.
     
  7. aProgDirector

    aProgDirector Pastafarians Unite!
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    There are two plans that, whether you agree with them or not, are at least published out there with enough detail to be worth discussing.

    Bernie Sander's Medicare for all: Medicare for All: Leaving No One Behind - Bernie Sanders
    Ryan Newhofel's PHA's:

    Sanders plan is the all-in Medicare for all. Private insurance could still exist, but everyone would still pay in to the new Medicare (so only the very wealthy could afford private insurance). His plan is somewhat vague on details -- he states that all co-insurance, deductibles, and donut holes would go away and medicare would pay for everything. As far as I can see in his plan, there would be no out of pocket costs for anyone. He states, with no plan how, that this would somehow cost less than current Medicare. I don't see how this is possible, other than large payment cuts.

    Newhofel's plan is interesting. He advocates for forcing everyone to save a least $2000 per year in a PHA -- those who were poor would have it funded by the gvernment, those more wealthy would fund personally / employer sharing. Then, all first-dollar costs come from your PHA. He would then add a medicare-for-catastrophic-for-all on top of this -- if your PHA runs out of money or your costs are high enough, it kicks in. There's also a deductible that's also means tested. The idea with this plan is to allow patients to shop around -- instead of medicare setting prices, individual physicians could charge whatever they wanted (theoretically). Ultimately medicare would need to decide how much they pay for any event (for those that have medicare kick in), that will still drive prices it seems. He also wants to renegotiate how specialty care is paid for (i.e. he wants to decrease payment). He's very vague on how much this will all cost, guesses that a 7% medicare tax would pay for it (unclear if this would also pay for funding all the PHA's). But he does have a nice section where he shows you who the winners and losers are likely to fall, and it does allow for some market competition because people will be saving their own money to spend. And this plan is likely to make everyone unhappy -- which actually IMHO is a good sign.
     
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  8. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    I posted Neuhofel's plan several days ago, are you doing this on purpose???

    Kidding of course, I'm just happy that someone outside of the DPC community has actually read and is familiar with his plan.
     
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  9. aProgDirector

    aProgDirector Pastafarians Unite!
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    Your post introduced me to his plan in the first place.

    His plan is interesting because it's the best/worst of a mix of socialist (every one gets health care for free provided by the govt) and capitalist (everyone buys health care on their own, the govt stays out of it). There's enough cost sharing that the far left will be unhappy, and enough universal coverage that the far right will be unhappy. Yet there's enough in it that many in the middle could be happy. And you can still but private insurance if you want to, or gap insurance.

    But there are all sorts of problems with it. I'm not convinced that he's really costed out the whole thing correctly. He's (vaguely) suggested that the tax rate would just float to keep the whole plan solvent -- which is an interesting idea but leave it open to attack that the tax rate could skyrocket. I'm not convinced that people will really manage this private spend account well -- they are likely to just spend it all, figuring that then the new Medicare plan would kick in (although the deductible might help prevent that). And would docs / hospitals really compete to lower prices? Or would this new Medicare simply define how much a colonoscopy would be paid (because they will need a rate for those people who spend down their PHA's) and hence fix prices, exactly what opponents of single payor are worried about.

    One problem with MFA that has been glossed over is that many hospitals lose money on Medicare patients. We had an initiative a number of years ago to "profit on Medicare pricing". Surprise, it was impossible -- unless we started slashing support staff and/or salaries.

    Another huge problem with Neuhofel's plan is that he tosses long term care costs to the states. This is a huge unfunded mandate.

    Sander's plan seems even more impossible financially -- costs less, yet wipes out all deductibles and copays, and covers more people, and more services.

    Often claimed is that covering more people and getting them care earlier will save money because we'll treat things at an earlier stage and prevent complications. This is laughable, IMHO. We might make people healthier and improve their QOL -- and that's good. But there's no way this saves money. You end up spending more money than you save. And, even if you prevent someone from having a CVA because you anticoagulate their AF, or prevent colon cancer with a screening colo -- ultimately those people likely develop some disease later in life that's expensive to treat. So at best we're just pushing costs into the future.
     
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  10. sunshinefl

    sunshinefl All Gold Everything
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    Lmao... what??? Like I always say when this topic comes up... I did not choose to become a physician to get rich (and you won’t be anyway), but I absolutely do want to be compensated fairly for all of my training, education, expertise, sacrifice, opportunity costs, blood, sweat, and tears.

    Exactly!!!!!

    Lmao again.... what are you even going on about in your first paragraph? How do you simultaneously have the life experience to speak down to us about the “context of life” while also in the very next paragraph refer to you undergrad pre-health advisor? Not sure if you are a troll or just unbelievably self-righteous. But either come out from under the bridge or get off your high horse, as applicable.
     
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  11. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Not everyone would manage that private account well, but that's no different than lots of people who don't care about medical costs now. On the other hand, a lot of people would. Especially if the account rolls over.

    Pricing is already a thing. We know what Medicare charges for everything, but cash prices are usually a fair bit less than that. This wouldn't change under Neuhofel's plan.

    Agree with your last part completely. Pretty sure its been shown that not treating various conditions is actually cheaper because you die sooner.
     
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  12. sb247

    sb247 Doer of things
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    Not treating is absolutely cheaper, if you’re willing to not step back in later
     
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  13. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Even if you are it's still cheaper.
     
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  14. Nikj

    Nikj NigelWhiskers
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    There are a variety of problems with your arguments, which I'll be happy to address. Please bear with me as I explain how things really are, and why the argument for single payer is flawed.

    1. The biggest issue people have with the current healthcare system stems from 2 major issues, the first being costs, and the second being "poor outcomes compared to country xyz." While at face value these statements are true, the reasons behind them are very misunderstood.

    Costs are high for 5 major reasons: Government regulation (paper work etc), Administrative regulation (billing etc), Litigation (pervasive throughout all aspects of U.S life), CMGs'/Corporatization of medicine, end of life care, and R&D. Of these, and IMO, CMGs, and administrative costs are the major driver in the increased costs of healthcare. R&D is high because there is no other country that produces as much in quantity, and arguably quality, as the US, which affords our people, especially children, cutting edge technology and medical tx. There are ways to fix cost, like reducing the administrative costs and the burden that CMGs create.

    Poor outcomes are due to several reasons: A general lack of personal self care, a general distrust of the medical system, a massively diverse population, a disjointed EMR system, administrative/insurance/government regulation, and lack of access to care. Of these, IMO, general lack of personal care, a massively diverse population, and administrative/insurance/government regulations, are the biggest factors in poor outcomes. Especially detrimental are lack of self care and a diverse population.

    2. With the above in mind, let us address your viewpoint. You, and many who support a single payer system give the following reasons (at least the major reasons I can gather): "there will be reduced costs, there will be better outcomes, there will be better access to care, and people will know what they are paying for." Let's address why many of these will not be the case, or come with major drawbacks.

    "There will be reduced costs" : This is a very arguable point because many of the studies that suggest it will be lower are very flawed and exclude many factors. These factors include a rise in administrative costs (like every other government run system), a huge rise in end of life care since everyone would be technically "covered", rises in the number of people receiving care, extra billing done by expert CMG billers to squeeze more money from the government, and etc....

    "There will be better outcomes" : Absolute BS. As already mentioned, this is largely attributable to the very diverse population we have, and the lack of self care. This is not the fault of the healthcare system as much as it is societies/individuals. A majority of the costs of healthcare are associated with preventative diseases https://www.rand.org/content/dam/rand/pubs/tools/TL200/TL221/RAND_TL221.pdf. You can look through that PDF to get a better sense.

    You use the argument that other countries have better outcomes so they are somehow better. This is just nonsense. Many of those countries populations are much smaller, genetically and culturally homogenous, and have patients who actually take care of themselves.

    You want some interesting data? As an example the life expectancy of a White Woman in the United States is 81.4% (https://www.cdc.gov/nchs/data/nvsr/nvsr66/nvsr66_04.pdf) and the life expectancy of a Woman (the vast majority of which are white) in Norway is 83.7% (Life Expectancy in Norway) hardly significant when you account for lifestyle differences. The reason the overall rate in the U.S changes is because there is variation in the genetic makeup of the population which drastically alters disease risk and outcome.

    "There will be better access to care": Also BS. In the US doctors work on average 50 hours a week, with nearly 25% working 65 hours a week. In Norway, Doctors work on average 8 hours a day (translates to 40-45 hours a week), and anything beyond 40 hours a week is considered Overtime (Working Conditions for Medical Professionals in Norway | MediCarrera). A similar process will happen in the US to protect all healthcare workers, drastically reducing time to see patients. This will be compounded by the added strain of new patients in the system. The data is even more contrasting when you look at U.S Residents weekly hours worked versus those of Norwegian Doctors in training.

    Also, not only will Access decrease, but choice of provider will disappear.

    "Patients will have clarity for what they are paying for" : When has this ever been true with any government expense? To follow up, this is an unfair complaint people bring up. Lots of pro-Health care for all people claim that you can't ever get a true number when it comes to medical expenses, especially before tx. This IS true, but very few people ask why. Hip replacements are often cited in this argument, and how it might cost $10k in hospital 1 but $15k in hospital 2, and they ask why there is such a difference. It is because those are two different patients, receiving care for similar issues, but the medical/surgical management might be drastically different depending on etiology/severity/type of injury, interventions used, insurance reimbursement, drugs used, surgical instruments used, location of surgery, number of staff involved in patients care. But yes, this is probably one area where there could be some improvement in transparency, but it's not nearly as simple as many people make it out to be.

    I could keep going with counter arguments but I'll wait for your response. I am aware that not all the data is sufficient, so if there is anything you don't like I'll find another study/journal/etc. to back up the statements.

    Edit: Just want to mention that I am totally for ensuring everyone receives care, especially all children, but the currently proposed "solutions" would just make the system worse. Change is needed though.

    Edit 2: You made a comment on how it was ridiculous to say that our costs are so high because of obesity, diabetes, etc. Per the CDC, 90% of the 3.5 trillion we spend on healthcare is due to chronic disease, of which a significant majority is preventable. So yes, those factors do play a significant role, and in fact the primary role, in the costs associated with healthcare in this country.
     
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    #264 Nikj, Feb 10, 2019
    Last edited: Feb 10, 2019
  15. Boola Boy

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    Solution: Build bike lanes and tax high fructose corn syrup and fast food

    Thoughts??
     
  16. sb247

    sb247 Doer of things
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    why?
     
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  17. medschoolzombie

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    Don’t we already have bike lanes in most places? Also, taxing HFCS is likely never gonna happen since That defeats the purpose of the govt subsidizing corn. That’s probably one of the reasons why people’s concept of nutrition is messed up.

    I’m sure the fast food companies would lobby against that hard lol. Until the convenience and affordability factor of them change, they’re not going away
     
  18. jambro

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    Firstly I want to say thank you for youre response which is more level-headed than others and significantly less political. Still disagree with a lot of it too. I'm going to just quote the stuff that I wanted to counter.

    "R&D is high because there is no other country that produces as much in quantity, and arguably quality, as the US, which affords our people, especially children, cutting edge technology and medical tx."

    What good is the most cutting edge technology and medical tx if you can't afford it? http://www.nationalmemo.com/americans-dying-cant-afford-medicine/?cn-reloaded=1

    "These factors include a rise in administrative costs (like every other government run system), a huge rise in end of life care since everyone would be technically "covered", rises in the number of people receiving care, extra billing done by expert CMG billers to squeeze more money from the government, and etc...."

    The whole government-is-inefficient by its nature thing really doesn't make sense with healthcare. What is your counter to the fact that medicare has a 2% administration cost and yet private insurance has a 17% administration cost, AFTER Obamacare forced that to be at most 20%? Private insurers are more inefficient than medicare by a long shot.

    "A majority of the costs of healthcare are associated with preventative diseases.
    Many of those countries populations are much smaller, genetically and culturally homogenous, and have patients who actually take care of themselves."

    Arguing that we cannot compare outcomes because we have more people here just is not a good argument. Insurance works better with more people.

    In addition, so the argument goes that our healthcare costs more because we have worse preventative diseases, and therefore you can't compare it to other nations with single payer because they have a lower incidence of preventable diseases. Yeah, but doesn't it make sense that, maybe because healthcare is free at point of service, you could reduce the incidence of preventative diseases?

    "The reason the overall rate in the U.S changes is because there is variation in the genetic makeup of the population which drastically alters disease risk and outcome."

    Furthermore, in the study you cite, we see that non-hispanic whites have the highest incidence of chronic conditions. But, do they also have the lowest life expectancy? I don't think they do. So the question is: why is it that we don't have a perfect correlation between those with the highest incidence of chronic diseases and life expectancy? Probably because non-hispanic whites are wealthier than hispanics, and our healthcare system works much better for those who can afford it. So in what other ways is our healthcare system affecting the outcomes that we could be getting?

    Lastly, your argument that we are "diverse" therefore we will have worse outcomes naturally than other more homogeneous nations. I am assuming you are implying that because we have more hispanics, middle Easterners, African Americans, etc, who are unhealthier on average, its not apples to apples. But we also know that these groups on average have much less money than whites, for example. How do we know that diversity is not lowering our health outcomes because of their genetics, but rather because of confounding socioeconomic factors that hugely affect how they can utilize healthcare in this country?

    "Also, not only will Access decrease, but choice of provider will disappear."

    People cannot access physicians and medications regardless if they cannot afford them, so for many people this is a moot point. In addition, many people already can't choose their provider as they'd like to. Oh, this great doc is out of network? Shame, I would love to go but can't afford it.

    "It is because those are two different patients, receiving care for similar issues, but the medical/surgical management might be drastically different depending on etiology/severity/type of injury, interventions used, insurance reimbursement, drugs used, surgical instruments used, location of surgery, number of staff involved in patients care"

    I think another reason might be that Hospital A decided to charge 30k and Ambulatory Surgery Center B just decided to charge 45k.
     
  19. Nikj

    Nikj NigelWhiskers
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    Happy to respond--


    "What good is the most cutting edge technology and medical tx if you can't afford it? http://www.nationalmemo.com/americans-dying-cant-afford-medicine/?cn-reloaded=1"


    This is honestly a matter of personal opinion. It comes down to thought process and inherent American ideals. The U.S has always been a country of innovation, spurred on by free market trade and competition.


    If we were to set this aside for a moment, your counterpoint is flawed, in that it precludes the possibility that R&D could lead to massive reduction of preventable disease, and in the long term reduction of costs and the advancement of humankind. As examples, advancements in vaccine technology, Bioinformatics and Genomics, nutrition, and aging, are all fields that the U.S spends lots of money on, and have already gleamed tremendous advances, or at least set the stage for advances. As a specific example the CRISPR-CAS9 study that examined whole Genome editing was conducted through a U.S institution (yes other countries had done other research with other aspects before this, but they didn't conduct this specific study), and I would think it received some funding from some U.S sources. That single study is already and will lead to the greatest changes mankind has ever seen.


    "The whole government-is-inefficient by its nature thing really doesn't make sense with healthcare. What is your counter to the fact that medicare has a 2% administration cost and yet private insurance has a 17% administration cost, AFTER Obamacare forced that to be at most 20%? Private insurers are more inefficient than medicare by a long shot."



    I would need to see the studies that show that the cost is only 2%, and I would want to also know the reimbursement rates compared to private insurance, as well as quality and quantity of care, and finally approval rates of Medicare vs private. Additionally I'd like to see the number of individuals who are on medicare compared to similarly placed individuals who have private insurance, and compare all of the above numbers of both groups. I ask because I suspect this information would yield a better picture of relative costs.


    I do generally agree though that private insurers are inefficient and have high administrative costs because it benefits their bottom line, and protects them legally. This is a large part of problem that causes high healthcare costs.


    "Arguing that we cannot compare outcomes because we have more people here just is not a good argument. Insurance works better with more people.



    In addition, so the argument goes that our healthcare costs more because we have worse preventative diseases, and therefore you can't compare it to other nations with single payer because they have a lower incidence of preventable diseases. Yeah, but doesn't it make sense that, maybe because healthcare is free at point of service, you could reduce the incidence of preventative diseases?"


    There already famous studies that show the effects of people moving from other countries where the general population is considered very healthy, to the United States, and subsequent generations developing chronic preventable disease prevalent here in the U.S, attributable to cultural and life style choices. To put it to you in another way, using your argument, It would be like saying that it should be acceptable to compare the healthcare outcomes in the United States to that of Sierra Leone, even though the two countries are vastly different in a variety of parameters. This is of course absolutely ridiculous to do, and thus it is reasonable to say that it would be disingenuous to compare two different countries.


    Quite honestly as someone involved in the scientific field, I would think that you would see the fallacy in trying to equate two things which operate under immensely different conditions, and not offering up any studies that can account for these differences (Don't think I've come across a single one that does this and is able to still coincide with your viewpoint.)


    To your point that healthcare being free at point of service would reduce the incidence of preventative disease, is a great talking point, but in practice is flawed, and has either already been disproven, or would simply not work. How? Because for years preventive care has been at the forefront of healthcare, but not much has changed, and thus to think that somehow something drastic will come about when people are covered under a universal system is just not the case.


    It goes back to the point that there seems to be a focus on trying to fix the healthcare system and those who work in it, instead of stepping back and saying —-hey wait a second, what if all these people who don’t exercise, don’t eat well, don’t listen to their care provider, don’t take their recommended medications, continue to smoke, continue to drink, and don’t have a general sensibility of their well being, might actually be the root cause of the problem?


    Additionally, that argument also relies on the belief that whatever preventative care is rendered is either efficacious or potent in treatment, when in fact resources available in such a system would be stressed and rationed, as already seen in the U.K. system, and they would at best be “band-aids.”

    This again comes back to an ideological and ethical question of “Is it right for some people to get timely effective treatment, or is it right for a larger number of people to get intermittent stop-gap treatment.”


    “Furthermore, in the study you cite, we see that non-hispanic whites have the highest incidence of chronic conditions. But, do they also have the lowest life expectancy? I don't think they do. So the question is: why is it that we don't have a perfect correlation between those with the highest incidence of chronic diseases and life expectancy? Probably because non-hispanic whites are wealthier than hispanics, and our healthcare system works much better for those who can afford it. So in what other ways is our healthcare system affecting the outcomes that we could be getting?”



    Presence of chronic disease does not necessarily correlate with disease severity or relative amounts of money spent on care, it just indicates that those people qualified as having had the disease. I do agree that better care is afforded to those that can pay for it, but how is that a bad thing, that people with money can spend it on themselves to improve their health? And what do you consider preventative care because I believe that to be an issue more related to education, and personal choices/culture/environment than it does to healthcare.




    “Lastly, your argument that we are "diverse" therefore we will have worse outcomes naturally than other more homogeneous nations. I am assuming you are implying that because we have more hispanics, middle Easterners, African Americans, etc, who are unhealthier on average, its not apples to apples. But we also know that these groups on average have much less money than whites, for example. How do we know that diversity is not lowering our health outcomes because of their genetics, but rather because of confounding socioeconomic factors that hugely affect how they can utilize healthcare in this country?”


    Let me start by saying that I’m not saying any particular group is outright “unhealthy” because they are of a particular race.


    Have you experienced any clinical medicine, or studied any pathology or epidemiology? It is very well know that minorities are at risk for several preventable disease simply due to genetics. As an example, African Americans are at risk for cardiovascular disease, and this predisposition is worsened when you put that individual in an environment where a Western diet is followed.


    Socioeconomic status IS also a factor, which also is another reason why you cannot simply compare two different countries, when they are also different in the societal structure of different socioeconomic classes.


    “People cannot access physicians and medications regardless if they cannot afford them, so for many people this is a moot point. In addition, many people already can't choose their provider as they'd like to. Oh, this great doc is out of network? Shame, I would love to go but can't afford it.”


    You say this as if vast swathes of people are unable to see a PCP. Can you be more specific and provide data for what you mean?


    I do agree to a certain extent that drug prices are high and unobtainable for patients. No argument there.


    Thats only true for an HMO, PPO’s can choose. Even within an HMO, you can still have choice and latitude in who is your physician. Under a universal system, you would literally have no choice, and unlikely any options to change if you were not happy.


    “I think another reason might be that Hospital A decided to charge 30k and Ambulatory Surgery Center B just decided to charge 45k”


    What? That not how billing works. This is not even an argument you are making, it literally just a random comment.

    I’d ask you reexamine my statements as I do not believe you fully answered/responded to them. I’ll be happy to again respond to any questions in this post.
     
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  20. jambro

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    "As a specific example the CRISPR-CAS9 study that examined whole Genome editing was conducted through a U.S institution (yes other countries had done other research with other aspects before this, but they didn't conduct this specific study), and I would think it received some funding from some U.S sources. That single study is already and will lead to the greatest changes mankind has ever seen."

    I'm a little confused what this has to do with what we're talking about... did this study happen because we have private insurance and profit motives? Or just because the United States spent money on research? Which of course I'm not opposed to...

    "I do generally agree though that private insurers are inefficient and have high administrative costs because it benefits their bottom line, and protects them legally. This is a large part of problem that causes high healthcare costs."

    This is the main reason why I think that our current system just philosophically is not a good idea.

    "To your point that healthcare being free at point of service would reduce the incidence of preventative disease, is a great talking point, but in practice is flawed, and has either already been disproven, or would simply not work. How? Because for years preventive care has been at the forefront of healthcare, but not much has changed, and thus to think that somehow something drastic will come about when people are covered under a universal system is just not the case."

    How can we say this has honestly been tried when many people cannot afford a 400 dollar emergency, copays can range from 20-75 dollars, and deductibles can reach in the thousands of dollars? All of these things completely disincentivize people from getting care at early stages.

    "Presence of chronic disease does not necessarily correlate with disease severity or relative amounts of money spent on care, it just indicates that those people qualified as having had the disease. I do agree that better care is afforded to those that can pay for it, but how is that a bad thing, that people with money can spend it on themselves to improve their health? And what do you consider preventative care because I believe that to be an issue more related to education, and personal choices/culture/environment than it does to healthcare."

    Of course people with money can spend money on themselves, that makes sense. But what I am getting at is your implication that the vast amounts of money and resultant outcomes in america are due to patients' poor overall health rather than the nature of our healthcare system. And yet, when you look at people with the most chronic diseases (proxy for overall health), we see that their overall health is not as bad as we would think when compared to those with less chronic diseases, implying that there must be something else resulting in the observations we have. As a result, I think it makes sense that, even with relatively poor health, changing the healthcare system to give everyone the benefit that those of higher socioeconomic status have currently would result in improved outcomes.

    "Have you experienced any clinical medicine, or studied any pathology or epidemiology? It is very well know that minorities are at risk for several preventable disease simply due to genetics. As an example, African Americans are at risk for cardiovascular disease, and this predisposition is worsened when you put that individual in an environment where a Western diet is followed."

    I am aware of this but I still believe that our insane healthcare spending is not due to the increased likelihood of disease of a small percentage of our population, and rather due to the nature of the system itself.

    "You say this as if vast swathes of people are unable to see a PCP. Can you be more specific and provide data for what you mean?"

    Poll: 44% Of Americans Skip Doctor Visits Because Of Cost

    In particular though I am talking about those who can afford to see a physician BUT cannot see the one they prefer because they were out of network, etc. This can happen all the time and all the fragmentation from insurance agreements, in network/out of network drastically cuts down on actual competition and free choice that could result in better service and preferred choices.

    "Under a universal system, you would literally have no choice, and unlikely any options to change if you were not happy."

    Who would have no choice? Physicians or patients? Physicians could opt out although that probably wouldn't make a lot of sense, but patients would be able to see nearly any physician they wanted without fear of insurance agreements, in network status, etc. It would be the ultimate choice for patients.

    "What? That not how billing works. This is not even an argument you are making, it literally just a random comment."

    What are you talking about? For instance, if you are out of network, you choose the amount that you bill the insurance company. Not that you're going to get that of course, but you can send it. And there is nothing stopping one surgeon from valuing their services at 25k and another at 30k. And then of course the negotiation begins. I worked at a private practice that changed prices all the time based on what they thought they could get away with.
     
  21. sb247

    sb247 Doer of things
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    Some of your overhead numbers are a bit misleading...

    Redirect Notice
     
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  22. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    It all boils down to this: will increasing people's ability to go to the doctor affordably impact health measures.

    Best answer we have so far seems to be no:

    Oregon Health Study — Results

    People felt healthier and had less depression, but no improvement in BP, A1c, or cholesterol levels.
     
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  23. Little Green Mensch

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    Lifestyle is probably the most important determinant of health, and getting people to see the doctor more often doesn't really improve the underlying causes of their risk factors for chronic disease.

    If you look at the Cochrane review on motivational interviewing, for example, it becomes pretty clear that we as a profession don't have a really reliable means of persuading patients to actually implement changes in their habits.

    Circling back to the topic, the more health insurance is expected to spend on routine health maintenance, the more we destroy the ability of pricing to efficiently allocate resources, substantially increasing costs in the arena where demand is actually elastic. What's worse, it's not clear that spending more money on routine care improves even risk factors, let alone actual outcomes. In life-threatening situations, however, people tend not to ask about cost - insurance for catastrophic health events makes a bunch of sense, and distorts the rest of the market less.

    With respect to the Constitutionality of universal healthcare, Congress arguably should not have even been able to legislate Medicare/Medicaid into existence. It's not in the enumerated powers, despite the historically over-broad interpretation of the Commerce Clause. States, however, are not thus restricted. If we're going to have universal healthcare, it should happen on a state-by-state basis; let federalism work for us, and let states find solutions that work for themselves. This also, happily, preserves the right of exit - while it's inconvenient to move, people can vote with their feet (if nothing else) by leaving states whose health insurance laws they find intolerable.
     
  24. Nikj

    Nikj NigelWhiskers
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    "I'm a little confused what this has to do with what we're talking about... did this study happen because we have private insurance and profit motives? Or just because the United States spent money on research? Which of course I'm not opposed to..."

    This issue here that I'm trying to point out is that the method and systems in place that allow for such research to be conducted would be drastically changed, and for the worse under the system you are espousing. Just like what happened with NASA, funding would become tightly controlled, and the R&D the U.S is so well respected for would be dismantled as soon as it is realized that there is not enough money to support such a system.

    "This is the main reason why I think that our current system just philosophically is not a good idea."

    Looking at the information from @sb247 's article, here is a quote the explains why your information is misleading
    “Medicare’s administrative cost percentages look illusorily low in large part because they are percentages of per-capita expenditures that are atypically high, relative to those seen in the private sector,” said Charles Blahous, a former public trustee for Medicare and Social Security. “Seniors have higher health expenditures per capita than the younger individuals insured in private sector plans. Thus, the lower administrative cost percentages in Medicare don’t by themselves imply that extending a Medicare-style system to participants of all ages would produce a system with similarly low administrative costs. In fact, one can predict fairly certainly that wouldn’t be the case.”

    I still agree though that administrative costs are playing a huge role in the cost of healthcare, and I think I can say confidently that most people here, would agree. But to suggest that universal care will fix the problem is just false, disingenuous, and is just being used as a way to trick people.

    "How can we say this has honestly been tried when many people cannot afford a 400 dollar emergency, copays can range from 20-75 dollars, and deductibles can reach in the thousands of dollars? All of these things completely disincentivizes people from getting care at early stages."

    @VA Hopeful Dr 's post shows an article that suggests that even more access does not change physical health outcomes, which obviously means there would be relatively little change in a majority of preventable disease. That same article does suggest some improvement in particular mental health issues, but when you factor in the rationing of care in a universal system, I again doubt that access would increase, and in fact would have a negative impact on most health measures. The question is why was that the case? The answer comes back to the fact that in many cases, health outcomes are the direct result of the patients choices, or societal/environmental influences. While anecdotal, I've been guilty of this myself.

    You still haven't completely addressed this point, and I'm waiting for you to show me evidence that this is not the case. Btw, when I say the patients choices, I recognize that it is not always a choice, or they have not received proper education on a particular issue, which is more the fault of our education system (run by gov cough cough) than their lack of self care.

    "Of course people with money can spend money on themselves, that makes sense. But what I am getting at is your implication that the vast amounts of money and resultant outcomes in america are due to patients' poor overall health rather than the nature of our healthcare system. And yet, when you look at people with the most chronic diseases (proxy for overall health), we see that their overall health is not as bad as we would think when compared to those with less chronic diseases, implying that there must be something else resulting in the observations we have. As a result, I think it makes sense that, even with relatively poor health, changing the healthcare system to give everyone the benefit that those of higher socioeconomic status have currently would result in improved outcomes."

    This argument has too much fluff. The problem stems from the fact that our education system fails at teaching children how to properly take care of themselves nutritionally and physically.

    If you want my take on it, the way to fix our system going forward is to
    #1 ensure all children from ages 0-18 receive FREE comprehensive health coverage using a very similar model to MEDICARE. After that they would get a 1-2 year buffer period to get coverage, by getting a job, through their parents, through their college, through the military, etc. This would foster better self care, prevent early bad habits, and lead to an overall positive influence in all aspects of U.S life. This also would not be as ridiculously expensive as what you are proposing. Please note though, that I am only for this plan if government stays out of the actual healthcare process and medical decision making process, where they have no right to be making any decision for a patient (obviously emergency and life saving situations excluded where children SHOULD be saved no matter what.) Under this system parents should still be able to choose a private plan for their children if they wish, and if they did they would receive a slight benefit of some sort. Of course, this would result in an influx of patients, and training of Pediatric/Family Physicians would have to increase to meet the demand, but thats a whole other topic.

    If you look at studies only ~8.4% of ALL healthcare spending goes towards treating children. (Spending on Children’s Personal Health Care in the United States) It doesn't take much to realize that the major issue issues in healthcare must therefore start in childhood, and the causative factors are lack of education on self care, early intervention,

    #2 Keep the current overall framework, with some obvious fixes in administrative costs, reduction in stringent regulations, reduction in drug prices, reduction in corporatization of medicine, and a return to where Healthcare providers are in charge of running Medicine. ADULTS SHOULD PAY FOR THEMSELVES, and while Medicare and Medicaid should stay in place for adults, just because an adult is negligent in their self care, other adults should not have to pay for it.

    That is why I see your plan as as wrong, because it puts in place an action that does not focus on the root problem, and only worsens the problem by spreading resources thin.

    If someone has a study on why free care for children would not work, I'd also be happy to read it to understand why.


    "I am aware of this but I still believe that our insane healthcare spending is not due to the increased likelihood of disease of a small percentage of our population, and rather due to the nature of the system itself."

    I've addressed this issue and don't see us agreeing. Again I feel the major costs of healthcare are hugely due to preventable disease, in all races, and all socioeconomic class, but obviously at differing rates/severities/costs. To suggest preventable disease is not the driving cause in the high cost of healthcare is to completely ignore the data.


    "Poll: 44% Of Americans Skip Doctor Visits Because Of Cost

    In particular though I am talking about those who can afford to see a physician BUT cannot see the one they prefer because they were out of network, etc. This can happen all the time and all the fragmentation from insurance agreements, in network/out of network drastically cuts down on actual competition and free choice that could result in better service and preferred choices."


    I've also addressed this comment by citing other posters on this forum. While what you post might be true, even when costs is taken out of the equation, health measures do not change given increased access.

    "Who would have no choice? Physicians or patients? Physicians could opt out although that probably wouldn't make a lot of sense, but patients would be able to see nearly any physician they wanted without fear of insurance agreements, in network status, etc. It would be the ultimate choice for patients."

    This is not the case because under such a system, as I've mentioned many times, drained resources and lack of providers would prevent any actual benefit.
    You can look at the failures of the NHS in U.K to understand this issue, and especially how many people who are less educated and do not have money have very little choice, and when they are given a choice, they are unable to determine if it is better to get one service over another, because there is so much complexity in care.

    "What are you talking about? For instance, if you are out of network, you choose the amount that you bill the insurance company. Not that you're going to get that of course, but you can send it. And there is nothing stopping one surgeon from valuing their services at 25k and another at 30k. And then of course the negotiation begins. I worked at a private practice that changed prices all the time based on what they thought they could get away with."

    Yes but they are not randomly throwing a dart at a board and saying "Ohhhh dammmm it hit 30k" or "Crap it hit 10k". You yourself said in not so many words that those practices charged based on what they legally thought they could, so essentially based on what they did with the patient. How would these billing practices be curtailed in your universal care plan?

    The answer is that they wont, and practices will conform to the new rules, but just still bill the maximum they can for the work they do. The difference is that the government won't be able to deny them payment like insurance can, and you might actually see a rise in costs. Why do you think many Physicians are pro-Single payer? Because they get more money out of it.

    And before you answer to this point, I can already predict that you counter will be that the prices will be negotiated down, but that will be based on false numbers that would not account for the decrease in denied payments, and actual real costs of everyone being covered. This would also lead to a collapse of the system, the shuttering of many community hospitals and clinics, people loosing work secondarily, Providers not working because they aren't getting paid, and in the end a complete failure of all of Healthcare. The U.K is not too far from this scenario.
     
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  25. Dr G Oogle

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    A single payer system would create more bureaucracy not less since it will be government run.

    To answer your question about salaries they will not go up because reimbursement will go down per RVU; Medicare already pays 50% of what private insurance does for the same kind of work so even if there are more patients to see you will get paid less to see them and worst case scenario will have to do more work to make less money. Hospitals may want to see more patients but there are only so many docs out there and a big shortfall is predicted really really soon. What might then happen is that many docs will go open concierge or cash only practice and the Medicare for all people are seen predominantly by mid levels and if they need non emergency surgery (which includes cancer surgery) will have to wait months to get on the waiting list. So while access might improve there will be a two-tiered system with the bottom tier potentially getting substantially lower quality care then the top tier. And while some might argue at least there’s access I would float the point that sometimes a bad “provider” is worse than no provider at all.
     
  26. jambro

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    "This issue here that I'm trying to point out is that the method and systems in place that allow for such research to be conducted would be drastically changed, and for the worse under the system you are espousing. Just like what happened with NASA, funding would become tightly controlled, and the R&D the U.S is so well respected for would be dismantled as soon as it is realized that there is not enough money to support such a system."

    How does going to a single payer system change current funding for research? One is about our healthcare system and the other is about funding and research. They're different. I am assuming that your general argument is that if you decrease Pharma profits there will be less research which is overall worse for the consumer than not being able to afford the medications in the first place. This assumes that all the profit we have now is contributing to research and any decrease in profit will absolutely lead to significant decreases in research... This isn't necessarily true. It is possible that profits are so high right now that they can be drastically cut and yet we still have significant research incentives. Best thing I can equate is that the marginal tax rate in the United States used to be vastly higher and yet we did not have people stop working which many believe would happen if we put them at the same rates now.

    "It all boils down to this: will increasing people's ability to go to the doctor affordably impact health measures.

    Best answer we have so far seems to be no:

    Oregon Health Study — Results"

    So you're looking 3 things as a proxy for health, and I'm looking at actual health. What do you say to this?

    New study finds 45,000 deaths annually linked to lack of health coverage


    "Looking at the information from @sb247 's article, here is a quote the explains why your information is misleading
    “Medicare’s administrative cost percentages look illusorily low in large part because they are percentages of per-capita expenditures that are atypically high, relative to those seen in the private sector,” said Charles Blahous, a former public trustee for Medicare and Social Security. “Seniors have higher health expenditures per capita than the younger individuals insured in private sector plans. Thus, the lower administrative cost percentages in Medicare don’t by themselves imply that extending a Medicare-style system to participants of all ages would produce a system with similarly low administrative costs. In fact, one can predict fairly certainly that wouldn’t be the case.”

    So here is the argument: I realize that medicare has extremely low administration costs, but you have to take into account the fact that they are covering the sickest, most difficult patients in america. Huh? So they have the toughest patient population and STILL do better? How is that an argument against them?

    And Charles Blauhous is saying one can predict fairly certainly that WOULDN'T be the case? How can you do that? Is there any evidence or data? And lets keep in mind Charles Blauhous is a right-wing free-market conservative who is bankrolled by other laissez-faire groups who pay him to spread these opinions. Fact is the only evidence we have says that medicare has much lower admin costs and to imply there would be anything other than savings is completely based in fiction.

    "ADULTS SHOULD PAY FOR THEMSELVES, and while Medicare and Medicaid should stay in place for adults, just because an adult is negligent in their self care, other adults should not have to pay for it."

    They are paying for themselves in a medicare for all system? It's called payroll taxes and medicare taxes and income taxes. They pay it so they have healthcare. Everyone does. What is idea that if you have something provided via taxes it means no one is paying for it themselves ??

    "Yes but they are not randomly throwing a dart at a board and saying "Ohhhh dammmm it hit 30k" or "Crap it hit 10k". You yourself said in not so many words that those practices charged based on what they legally thought they could, so essentially based on what they did with the patient. How would these billing practices be curtailed in your universal care plan?"

    Under the plan rates are negotiated in a government body... so if you take medicare then you agree to the rates that have been negotiated. Simple as that... there is no "out of network" status where you bill whatever you think you're worth. Either you take the plan and its reimbursements or you dont, simple.

    "The difference is that the government won't be able to deny them payment like insurance can, and you might actually see a rise in costs. Why do you think many Physicians are pro-Single payer? Because they get more money out of it."

    Why would an insurance company have more power than the government... ? Like I said, either you take the plan or you don't. And physicians are pro-single payer?? Have you read this thread? Everyone here but me thinks providing healthcare to everyone like the rest of the world would lead to physician salaries cut into a third and worse patient outcomes and wait lines.

    "A single payer system would create more bureaucracy not less since it will be government run."

    No having thousands of insurance plans, outsourcing of authorizations, etc results in significantly more bureaucracy. The idea that government run things by definition are more bureaucratic is a right-wing talking point that is not born out by the data that I have already cited several times.

    "To answer your question about salaries they will not go up because reimbursement will go down per RVU; Medicare already pays 50% of what private insurance does for the same kind of work so even if there are more patients to see you will get paid less to see them and worst case scenario will have to do more work to make less money. Hospitals may want to see more patients but there are only so many docs out there and a big shortfall is predicted really really soon. What might then happen is that many docs will go open concierge or cash only practice and the Medicare for all people are seen predominantly by mid levels and if they need non emergency surgery (which includes cancer surgery) will have to wait months to get on the waiting list. So while access might improve there will be a two-tiered system with the bottom tier potentially getting substantially lower quality care then the top tier. And while some might argue at least there’s access I would float the point that sometimes a bad “provider” is worse than no provider at all."

    The plan that everyone is talking about, H.R. 676 that most progressives want, does not say that under the new system old Medicare rates will be used. It says there has to be a negotiation. And if you think that physicians will refuse to accept too low rates and that patients will be forced to see midlevels and wait months, well I think that sounds like physicians have a lot of bargaining power and that everyone here shouldn't think that such a system would destroy the medical profession after all...
     
  27. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Jesus H. use the forum quote feature, that post is an unreadable mess.

    That article doesn't tell us much about the study. Post the actual study perhaps?

    But I'll go ahead and make a few guesses: its a lot of statistics for something we can't actually measure. That's why the Oregon study is valuable. It isn't perfect, but it does show that even with essentially free health care, people's blood pressure and diabetes don't do any better than without free health care. We have measurable markers of health that did not improve when people got more medical care.
     
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  28. Nikj

    Nikj NigelWhiskers
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    There is still so much that you are either misinterpreting, misrepresenting, or outright not addressing. This has gotten too long to make into a written argument, and would need to be continued in an open conversation.

    Though to address a couple things, there is a difference between a single payer system like Canada, and a universal care system like the NHS of U.K.

    Under a single payer system, Physicians can benefit because of a reduction in administrative costs, as well as increase in the number of reimbursements given out (at the expense of government). Additionally, PCP's would probably see an increase in salary due to higher reimbursements, while Specialists would see a decrease. Generally though, this would be seen as an average increase. There is another thread on the forums talking about this topic as it relates to Canada. Now there are other problems with single payer that I still have an issue with, so I'm not necessarily supporting it.

    Then there is a universal care plan, which is what many left leaning people are hoping for. This type of system is absolutely horrible, and would be bad for everyone involved. From your arguments it seems like this is what you would support. Read this article and some of things faced in that system in the U.K Doctors Who Support Single-Payer Should Seek A Second Opinion.

    Also, one aspect I'd ask you to address which I brought up earlier, was that either single payer or universal care, would create a domino effect, resulting in the closure of many community hospitals and clinics, which a huge portion of our population relies on. Many of those places are already struggling to stay afloat, and introduction of one of those plans would cause them to sink, and result in millions of people having to search for care in other places, drastically exacerbating lack of access to care.
     
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  29. sb247

    sb247 Doer of things
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    sir/ma'am,

    I can't make any sense of what in that wall of text is you speaking and what was a quote
     
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  30. jambro

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    Sorry, it’s kind of tedious to use the quote feature rather than simply copy pasting. But if you read it, everything in quotes is NOT me and everything after it is me. It essentially goes quote, response, quote, etc.

    Nikj, I’ve laid out my arguments so if you want to disagree with what you think are poor arguments you have to argue against them, doesn’t work to just say they’re misunderstood, misrepresented, etc. but I hear you, I myself didn’t address some of your arguments because I only have so much desire and time to go into everything I disagree with.

    I also hear your discussion of universals healthcare and single payer, which are not necessarily the same thing. I understand that single payer is the funding type, universal healthcare is the goal. However, this IS what is seen in Canada.

    Domino effect of what? Seeing more patients...? Can you give me any argument for why community hospitals or clinics would close under a single payer, universal healthcare program? That’s complete conjecture. These clinics would be paid under a capitation agreement with the US gov who presumably would not want vast swathes is the population to go without medical care.
     
  31. sb247

    sb247 Doer of things
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    1. Do the work of posting properly. It makes everything easier to understand.
    2. Once the govt becomes the sole (or such a high percentage that they might as well be the sole) source of payment, they get too dictate salaries at will because the only other option then become leaving medicine or taking an unfairly lowered salary that doesn't reflect market value.
     
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  32. atomi

    atomi Member
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    More importantly the government gets to dictate quality of care for the poor (hint: it’s not going to be good).

    If anyone has a breakthrough on how to effectively communicate to leftists that entitlement spending is morally repugnant and harms vulnerable populations, please otherwise it’s like arguing against a “We demand free stuff!” wall.

    I find their love of mental walls somewhat ironic.
     
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  33. jambro

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    Not really sure how spending money to give healthcare hurts poor people who don’t have it in the first place, but considering how many agree with that statement it’s kind of pointless to continue any discussion.
     
  34. Boola Boy

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    Because it will be low-quality, box-checking care provided by overworked, undercompensated, and under-appreciated medical staff that are drowning in student debt.

    Look no further than the Denver teacher strikes and the low morale of physicians in the UK. Those are two prime examples of what will happen to the medical profession if we start “giving away” healthcare.

    Worker morale will suffer, and there will be an even greater shortage of physicians as people realize what a ****ty deal a medical career is. This will undoubtedly lead to worse care.

    Also, more care does not necessarily mean better outcomes...
     
  35. atomi

    atomi Member
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    We have modern democrats not just saying, but actually putting proposals in writing that say things like:

    “provide economic security to all those who are unable or unwilling to work"

    Adopt a marginal tax rate of 70% at the highest levels. Ignoring the fact that the vast majority of the highest earners only pay an effective rate around 20% as their income comes from capital gains.

    Replace all air travel with rail travel in 10 years.

    Confiscate all cars and upgrade every building in America in 10 years.

    And other loony childish low-level-thinking nonsense to appeal to the lowest common denominator in a desperate grab for votes.

    Medicare for all falls right in line.

    It’s basically a blueprint for how to bankrupt America and increase poverty.

    But what it’s really doing is creating a surefire path to make sure cheetoface is re-elected.

    I mean, you guys do nothing but complain about him 24/7 even though his presidency has not affected your lives negatively AT ALL, and all you had to do was literally nothing and run a moderate with populist appeal in the next election to make sure it would be a landslide.

    The Democratic Party is mentally insane.
     
  36. drtribbiani

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    Can someone explain to me why a single payer healthcare system necessarily results in low doctor salaries? Is there any way to implement it that doesn't screw doctors over? I've always strongly agreed with the notion that healthcare should be accessible to all, but the whole thing about cutting doctor wages by that much really drives me away from the idea...
     
  37. sb247

    sb247 Doer of things
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    1. If the govt controlled all of the customers/money in medicine and therefore had complete control of salaries, how can you not think salaries go down?

    2. Why would you think everyone has a right to all of the expensive labor/materials in healthcare?
     
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  38. medschoolzombie

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    Even if the government controlled salaries, they can’t force doctors to work right? If anything, this sounds like it would push more doctors out of the coasts and into the center of the country since they would use higher salaries to entice them.

    Would this not also mean that admin salaries are cut along in hospitals along with the number of admin people employed? I get that govt means more beurocracy but there’s no way the govt would take every single person employed in this process currently so it would have to be downsized at least somewhat
     
  39. KeikoTanaka

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    Doctors aren't allowed to unionize right? I think if salaries dropped over night, there would be huge / immense backlash.. I'm not sure in what form it would take.. but something would have to give lol maybe it would come in the form of loan reimbursement or something
     
  40. sb247

    sb247 Doer of things
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    You don’t have to pay more in the midwest if you just pay even less in the desirable areas. There are two ways to create that pay gap
     
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  41. medschoolzombie

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    That already happens, yet it hasn’t changed much. People on the coasts get paid less compared to people in the middle of country yet a lot of doctors still flock to the coasts
     
  42. medschoolzombie

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    I don’t see why not? I don’t remember ever hearing about a law or rule that says they can’t. I think it’s one of those things that is ‘frowned’ upon. Nurses unionize all the time so there’s no reason that doctors cant.

    I do think that if that happened, a lot more people would hate/drop out of the AMA though. It would be even more useless
     
  43. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Private practice doctors can't unionize. Employed ones can.
     
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  44. medschoolzombie

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    Is that by law? Also, do private practice doctors even need to unionize? Don't they have more ability to control their salaries compared to employed ones?
     
  45. VA Hopeful Dr

    VA Hopeful Dr Senior Member
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    Yes, depends who you ask, reimbursement is set by people who aren't the doctors so while there is more control it ultimately comes down to what you get paid for certain procedures.
     
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  46. Black Coffee 24/7

    Black Coffee 24/7 Probationary Status

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    As a moderate voter, I hate Don Trump with a passion. But, if the Dem Party nominee is challenging Trump with these bs promises, I would rather have Trump for 4 more yrs than some of these garbages that literally promote bad behavior.
     
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