Should Medicaid Patients be REQUIRED to Work?

Discussion in 'Pain Medicine' started by drusso, Apr 21, 2017.

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  1. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    News from The Associated Press

    Price, Verma Encourage Governors To Add Work Requirement To Medicaid Programs.
    The AP (4/20, Alonso-Zaldivar) “A simple question – should adults who are able to work be required to do so to get taxpayer-provided health insurance? – could lead to major changes in the social safety net.” Data show some 70 million Americans, or about 20 percent of the population, are on Medicaid, “including an increasing number of working-age adults.” The article says that in contrast to his predecessors, HHS Secretary Tom Price “has already notified governors it stands ready to approve state waivers for ‘meritorious’ programs that encourage work.” In a recent letter to governors, Price and CMS Administrator Seema Verma “suggested that work itself can be good for health.” They wrote, “The best way to improve the long-term health of low-income Americans is to empower them with skills and employment.” Yet, figures indicate about 60 percent of adults on Medicaid already have full- or part-time jobs.
     
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  3. ampaphb

    ampaphb Interventional Spine 10+ Year Member

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    The Trouble With Medicaid Work Requirements

    “Because Medicaid works as a work support, [a work requirement] would be a bit of a vicious cycle,” Katch told me. She outlined a scenario where a hypothetical poor coal miner in West Virginia suffers from two problems rather common to those in his occupation and region—back problems and associated opioid use. He fails to secure work thanks to the back troubles, the addiction, or lack of treatment for either. If he were subject to a work requirement, said coal miner might be kicked off the very program—Medicaid—that pays for treatment that might allow him to re-enter the workforce. That could lead to a downward spiral of sickness and poverty. Medicaid, like the rest of the American safety net, is intended as a failsafe for those not able to find work, and taking it away for those who cannot work subverts its purpose.

    Again, most people on Medicaid who can work do, and low-income people working demanding jobs often do so “until their bodies gave out on them,” Pavetti said. There isn’t much evidence that penalizing the Medicaid population for not working will improve the program, its outcomes, or job creation. Indeed, the only real outcome of a Medicaid work requirement is that fewer people will have access to Medicaid, which may be the point.
     
  4. drusso

    drusso Moderator Emeritus Lifetime Donor 10+ Year Member

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    In either case, Pain Management is a luxury for a Medicaid patient not an essential health benefit.
     
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  5. DrCommonSense

    DrCommonSense

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    Is there any evidence that giving them Medicaid allows them to work vs not having medicaid?

    I like that able bodied Medicaid people actually WORK or be put through job training for a future job.
     
  6. SeniorWrangler

    SeniorWrangler 5+ Year Member

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    In former Socialist countries in Eastern Europe, everyone was required to work, but they also created undemanding jobs for people to do. Expecting a broken-down coal miner with a bad back and no high school degree to retrain at 50 to become a paralegal or something seems pretty unrealistic and will just result in the guy NOT getting a job, NOT getting Medicaid, and then getting all his care through the ED, which will NOT get paid since the guy has no money.
     
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  7. DrCommonSense

    DrCommonSense

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    Oh so he can't learn how to type or be a secretary then?

    Or how about work at McDonald's?
     
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  8. BobBarker

    BobBarker Member 10+ Year Member

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    He is unemployable. You haven't been around very many washed up oil field, contractor's helper types. They don't have the people skills to work retail or in an office. Opioids and alcohol and some disability make it not feasible for legitimate employment in their former lines of work. Mowing yards is too much responsibility for most of them.
     
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  9. DrCommonSense

    DrCommonSense

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    Im not a fan of paying medical care to place him on opioids and alcohol while not working.

    How about working as a cashier at walmart, mcdonald's burger flipper, etc?
     
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  10. valhead

    valhead

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    Luckily here in FL they didn't expand Medicaid with the ACA and there are work requirements for those without young children. New legislation was just introduced this month as well that if working aged, able bodied adults will loose the ability to get benifits for 12 months if they don't meet work requirements within 60 days.
     
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  11. drpainfree

    drpainfree 7+ Year Member

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    yes, I agree. EVERYONE should be working, somehow, someway!
     
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  12. bedrock

    bedrock Member 10+ Year Member

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    disagree. these people don't want to work, because they can't imagine anything other than building houses or drilling holes in the ground. They still can learn simple new skills at 48 yrs old. It's not that hard to answer a phone, or work in simple retail jobs. These people just don't want to bother with some basic skill training.

    But instead of coddling them with SSI, medi-medi, and food stamps, what would happen if they were forced to work basic office/retail job or starve? They would get off their ass, work, and contribute to the economy for another 18 years instead of living off our taxes. This is why I will never certify someone for disability that isn't a quad, or suffered a severe stroke, etc.
     
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  13. BobBarker

    BobBarker Member 10+ Year Member

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    I agree with you in principle. But... they don't have (and will never have) the interpersonal skills to keep a job at Home Depot or McDonald's. The 30-55 year old FMSer I have a lot harder time rationalizing.
     
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  14. clubdeac

    clubdeac 7+ Year Member

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    I think you're making excuses for someone who just has a piss poor attitude.

    "Attitude Is Everything

    The longer I live, the more I realize the impact of attitude on my life. Attitude, to me is more important than the past, than education, than money, than circumstance, than failure, than success, than what other people think, say, or do. It is more important than appearance, giftedness, or skill. It will make or break a company... a church... a home.

    The remarkable thing is, we have a choice every day regarding the attitude we will embrace for that day.

    We cannot change our past; we cannot change the inevitable. The only thing we can do is play on the one string we have, and that is our attitude...

    I am convinced that life is 10 percent what happens to me, and 90 percent how I react to it.

    And so it is with you... We are in charge of our attitudes"
     
  15. ampaphb

    ampaphb Interventional Spine 10+ Year Member

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    What are work requirements good for?

    Stretching back to the establishment of welfare in the United States, politicians have debated both the practical and moral utility of requiring people to work in order to receive government benefits. Since welfare reform in the 1990s gave states wide latitude to create work requirements in the Temporary Assistance for Needy Families cash-assistance program, Republicans have hankered for a chance to extend those requirements to other safety-net programs, as part of their push to “require everyone who can to work.”

    The purpose of work requirements in welfare, according to the Congressional Research Service, is “to offset work disincentives in social assistance programs, promote a culture of work over dependency, and prioritize governmental resources,” in addition to helping lift people out of poverty.

    Now, Republicans could take one step closer to having that chance, thanks to a last-minute manager’s amendment that was attached to the GOP’s Obamacare repeal-and-replace bill by House Speaker Paul Ryan. In a fashion similar to TANF, the amendment would give states authority to mandate that “non-disabled, non-elderly, [and] non-pregnant” individuals enrolled in Medicaid engage in some amount of hours of “work activities.”


    The measure was put forth to appease party concerns about the legislation, before Thursday’s anticipated showdown between the Freedom Caucus and the bill’s backers on the House floor. But beyond the political motives for the Medicaid work requirement, the provision itself requires scrutiny. Do work requirements even do what Paul Ryan wants them to do, and would they work for Medicaid?

    The history of TANF doesn’t entirely conform to Ryan’s assertions that work requirements spur more people to find jobs or the larger goal of “promot[ing] a culture of work over dependency.” Most research does indicate that after the passage of the 1996 welfare-reform bill—the Personal Responsibility and Work Opportunity Reconciliation Act—the number of people receiving TANF plummeted, employment among recipients increased, and poverty rates did not increase on account of the requirement. But deeper analysis finds that the employment gains were ephemeral, inconsistent, and have often been questionably attributed to “welfare reform.”

    For starters, research from LaDonna Pavetti of the liberal Center on Budget and Policy Priorities indicates that while TANF’s work requirements did translate over the first two years to increased employment or work activity—including volunteer work, community service, and some limited combinations of training, work, and job-seeking—those gains diminished after five years. “You see an initial increase in work, but then people who are not subject to work requirements, their employment rates actually come together,” said Pavetti, who is vice president for family income-support policy at the center. In other words, people who were on TANF and not subject to work requirements saw their employment rates rise in the long-term, even as the people with work requirements lost jobs.


    The initial spike from work requirements probably followed proponents’ plan: In the face of pressure—and sometimes aided by state-sponsored training and placement programs—people sought jobs. But those jobs were often low-paying, meaning they could not lift people from poverty as desired, and the newly employed workers were very soon sloughed from employment rolls anyway.

    These losses occurred even as employment among people exempt from TANF’s requirements increased over time. That indicates that there were other economic factors that helped sustain long-term employment more than work requirements—including a strong Bill Clinton-era job market and major federal investments in the safety net via Medicaid, the Children’s Health Insurance Program, and child-care grants. The few work requirements that did have some enduring, robust effects, like those in Portland, Oregon, and some communities in California, were coupled with strong training, subsidized work, and placement programs that invested significant time and resources into securing just those results.

    Pavetti explained what she described as the central failure of work requirements. “Getting people into the labor system quickly doesn’t necessarily have long-term benefits,” she said. And the reasons are pretty obvious. Low-paying and part-time jobs are usually unstable to begin with, and the vast majority of low-income people who can secure steady employment, including those on Medicaid, already do work.


    The remainder of people subject to TANF’s work requirements tend to have major barriers in their lives to employment—including single mothers with young or disabled children, people with mental-health or addiction issues, those who act as primary caregivers to older relatives, or those with functional physical or mental disabilities that don’t meet thresholds to qualify for supplemental insurance. Research from Harvard Medical School researchers in 2006 suggests that at least some of the TANF requirements’ success at shrinking welfare rolls came from simply pushing people already unable to work out of the program and into an even lower rung of poverty.

    The only indisputable national success of the TANF work requirement—its reduction of people on welfare rolls—came at a significant cost to millions of people. Today, often because of their lack of access to cash assistance, millions of families and children live in deep poverty, or around $2 a day per person or less, according to researchers Kathryn Edin of Johns Hopkins and H. Luke Shaefer at the University of Michigan. As my colleague Alana Semuels reported last year on Wisconsin’s TANF program, job training and meaningful opportunities for advancement are rare among the program’s recipients, let alone those who become unenrolled from lack of work. In essence, some of the successes attributed to welfare reform in reducing enrollment and costs came from simply making the program less and less accessible for those who fall behind, not from helping people find jobs or lifting them from poverty.


    Reports on the application of a TANF-like work requirement for Medicaid forecast some similar effects, but also identified a host of new potential complications given the program’s size, diversity, and complexity. First, research from Hannah Katch, an analyst also at CBPP, indicates that the effect on jobs would be just as inconclusive—or perhaps more so—as the effect with TANF. The economy is much less healthy than it was during the Clinton heyday, and the number of Medicaid enrollees is many times greater than that of TANF. There isn’t a guarantee that the economy could even create long-term stable jobs for the population of Medicaid enrollees, and Medicaid covers people with the kinds of medical issues and disruptions that create job instability in the first place.

    Additionally, the AHCA manager’s amendment doesn’t fund any training or placement programs, not to mention the kinds of rigorous initiatives found in the successful TANF work programs in Oregon and California. Without that funding, states may have little incentive to create those programs. Katch believes “there’s actually a disincentive, since the bill itself is reducing overall funding for Medicaid.”

    likely employment options; work requirements will only hurt their prospects of ever making it out of poverty.


    Individuals who qualify for Medicaid because of a disability, or who receive federal disability payments, are exempted from the AHCA work requirement. But that doesn’t cover every worker with disabilities: The Kaiser Family Foundation reports that many adults covered as “able bodied” under Medicaid nevertheless report significant impairments or disabilities and can’t work. They may be waiting for decisions from the federal government on their disability status or may have a disability that interferes with their line of work but doesn’t qualify for insurance—for example, computer users with severe, chronic migraines triggered by computer use.

    Beyond the TANF comparisons, Katch points out that one component in particular makes Medicaid a potentially fraught target for work requirements: Medicaid is itself already a work-support program for low-income people. One of the basic underlying premises of providing public health insurance to is that keeping people healthy, able, and out of the hospital is a pretty good way of ensuring that they show up to work. The bottom line is that people need to be healthy to work, and people who aren’t healthy can’t.

    “Because Medicaid works as a work support, [a work requirement] would be a bit of a vicious cycle,” Katch told me. She outlined a scenario where a hypothetical poor coal miner in West Virginia suffers from two problems rather common to those in his occupation and region—back problems and associated opioid use. He fails to secure work thanks to the back troubles, the addiction, or lack of treatment for either. If he were subject to a work requirement, said coal miner might be kicked off the very program—Medicaid—that pays for treatment that might allow him to re-enter the workforce. That could lead to a downward spiral of sickness and poverty. Medicaid, like the rest of the American safety net, is intended as a failsafe for those not able to find work, and taking it away for those who cannot work subverts its purpose.

    Again, most people on Medicaid who can work do, and low-income people working demanding jobs often do so “until their bodies gave out on them,” Pavetti said. There isn’t much evidence that penalizing the Medicaid population for not working will improve the program, its outcomes, or job creation. Indeed, the only real outcome of a Medicaid work requirement is that fewer people will have access to Medicaid, which may be the point.
     
    Last edited: Apr 22, 2017
  16. DrCommonSense

    DrCommonSense

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    Good work Republicans!
     
  17. cowboydoc

    cowboydoc

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  18. GH253

    GH253 7+ Year Member

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    some people are on medicaid because they cant work and don't qualify for disability/medicare for reasons like not having paid into it
     
  19. DrCommonSense

    DrCommonSense

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    Everyone is able to do some level of work unless they are terminal, super young, or paralyzed. Even some paralyzed people are able to do certain jobs.
     
  20. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    You realize that working minimum wage at walmart and McDonald's still qualifies you to receive Medicaid, right?

    Currently, right off the cuff, I can personally identify 3 patients working at Walmart, 4 working at expressMart like gas stations (one as manager), and 2 working at autozone, 1 at McDs that are all on Medicaid, working at least 30 hours a week.


    Now, there is dis incentive to make more than minimum wage over $16,600 because you have to either buy expensive insurance or pay the tax penalty, unless you are going to make substantially more than minimum wage... hopefully at that level, employee benefits kick in to include insurance coverage - but not all big corporations do not (Walmart was a big player in this).

    (And FYI, at least 40% of walmarts workforce is part time -34 hours or less- and do not qualify for employee covered health insurance)


    Sent from my iPhone using SDN mobile
     
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  21. DrCommonSense

    DrCommonSense

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    I agree. That is why Obamacare is a joke and is making things far worse.

    However, most Medicaid people should still work.
     
  22. bedrock

    bedrock Member 10+ Year Member

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    Exactly. I have two such friends, both paralyzed from waist down who completed medical school after their injury, one became a radiologist, the other a physiatrist.

    Also have a good friend who had a stroke at 23, partially but notably affecting his speech and motor function. He also completed med school and residency after his CVA.

    So when these former construction workers try to say they can't work at all because their back hurts, I say BS. They can answer phones, work basic retail, and other jobs, and contribute to society and the tax base, not suck away from it.

    This is also why I don't write opioids for people who don't work, but are of working age but on disability from another physician.
     
    Last edited: Apr 22, 2017
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  23. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    one cannot make the blanket statement that someone on Medicaid is disabled or has filed for disability. in fact, ampha's article posits that most people on medicaid still work.

    filing for and/or getting SSD is different, imo. and i agree, the current level for qualifying for SSD is far too easy, especially since one of the most common reasons for disability approval is psychiatric.




    and drc, Obamacare actually provided an avenue for healthcare for the displaced group of individuals i discussed - those who made too much for Medicaid but couldnt get employer covered insurance or couldnt pay for an individual policy, because insurance is too expensive. imo, the problem isnt obamacare - it is because of the exhorbitant cost for insurance that covers very little yet makes huge profits for insurance companies and their executives.

    kind of opposite the point you are trying to make.
     
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  24. valhead

    valhead

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    From personal experience while in school I have to agree with Ducttape. I was going to school full time while husband worked. We had 2 kids then. He got laid off in thelate 90's for about 6 months. We couldn'tafford cobra even back then so we applied for and got short term Medicaid and food stamps. We were honest and reported every time he got side jobs or day labor and every single time the very small benefits were reduced. 6.25/hr 20 hours a week we would loose $100 in FS and the shared cost of the kids medicaid would go up. We didn't apply for ourselves because we didn't want to be those people and we're healthy then. It is a vicious cycle that seems to reward those who know how to work the system and penalize those who are honest. Now disability also doesn't guarantee medicaid. Depends on your worth and how much SSD you receive. My mother had a major heart attack 2 years ago. Her cardiologist said even though she was 60 if she worked anymore she would die. Her heart can't take any stress, she's a nurse and let a STEMI go on for 8 hours before calling me for help. Anyway she finally qualified for SSD, not SSI because she had a nice salary for 20+ years in LTC. So she certainly doesn't receive a livable amount she does have a decent check each month compared to most. Her income from this is still below the 138% of poverty line but she doesn't qualify for Medicaid of any kind and SS benefits don't kick in for 2 years. So she paid outrageous cobra rates until open enrollment for aca almost a year later and those premiums for what she needs are still half of her check. So grateful for Obamacare for her. I know for others it's a nightmare but she did have the double rate hikes everyone has been talking about. If not for us she would definitely fall in the cracks and receive subpar medical care.

    Huge employers are notorious for limiting workers to part time and offering horrible insurance for anyone who is part time. My son worked retail during college and management had a chart to see how many weeks in a row he put in over 38 hours and would cut him to 20 every 16th week so he wouldn'tbe full time and qualify for benefits. Obviously as a clege student we covered him but he worked with many adults trying to get buy.
    I'm also going to look up the rest of the video that posted about low IQ and being able to have a job. I'd like to know the answer. Do these manual laborers have the ability to learn these skills? If they did and could make a living wage wouldn'tthey have preferred working in an air conditioned office all these years and save their bodies? Who knows. It's just not so black and white to me.
     
  25. GH253

    GH253 7+ Year Member

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    If you have an impairment that cuts you off from the only kind of work you have the skills to do or are suited for, you can't work. I also find this statement and the sentiment behind it deeply concerning coming from a pain management specialist as it shows you do not appreciate what the conditions you supposedly treat actually do to people.
     
    Last edited: Apr 23, 2017
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  26. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    In my life I have been a lifeguard, camp counselor, insurance biller, score keeper for church league basketball, opthalmic tech, research assistant, chemistry tutor, lawn mower, and doctor. Tell me, what type of injury would prevent all of those jobs.
     
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  27. GH253

    GH253 7+ Year Member

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    Do you realize a lot of people don't have the aptitude for some of those jobs regardless of health? Any serious orthopedic injury, arthritis or other degenerative condition could easily prevent someone from working on his feet. Any sufficiently painful condition can prevent one from working at a job that demands concentration and performance. Don't pretend you can make a living as a church score keeper.
     
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  28. Disciple

    Disciple Senior Member 10+ Year Member

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    Important to define the term "able bodied" here.

    Work requirements can have value if there is a good way to separate "can't work" from "don't want to".
     
  29. bedrock

    bedrock Member 10+ Year Member

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    Not that hard to work off your feet answering phones. Lots of jobs fit that category with no or modest training needed.
     
  30. drpainfree

    drpainfree 7+ Year Member

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    You can find a million ways to not ever work if you do not have the will, the interest, the motivation, the necessity to work.

    You can find a billion ways to work, if you have the will, the interest, the motivation, the necessity to work.

    Or you simply have to work, because you don't have any other means to survive!

    Wait, I take that back, you can always be a bum on the street!

    Welfare system is a cancer, the more you feed to it, the bigger it grow!

    Yes, we can pity and treat a patient with a cancerous condition, but we have to acknowledge it first: cancer is a disease, is pathological, despite of its inevitability.
     
    Last edited: Apr 24, 2017
  31. Ducttape

    Ducttape SDN Lifetime Donor Lifetime Donor 5+ Year Member

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    are they going to have to work in India or the Phillipines?
    http://www.latimes.com/business/la-fi-philippines-economy-20150202-story.html


    Forcing people to work still does not address the fact that, apparently, most people on Medicaid are, in fact, working...
     
  32. DrCommonSense

    DrCommonSense

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    You have a problem with a pain physician wanting people to work?

    Maybe its you who has the problem
     
  33. VA Hopeful Dr

    VA Hopeful Dr Senior Member 10+ Year Member

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    I don't expect everyone to make a full living at their job if they're "disabled", but its been well documented that having a job (even just part time) improves pain and depression.
     
  34. lonelobo

    lonelobo PAIN DOC 10+ Year Member

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  35. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    Just saw a 62 yo back today for neck problems. Legally blind. Strabismus. I treat for c spondy, ddd, radic. On opiates within cdc guidelines. Disabled since birth for congenital blindness. Thinks he can drive, but doesn't. Owns small specialty contracting company. Just hime and his wife. Lists disabled on my paperwork. Has commercial insurance. Works 4 days per week.
     
  36. ampaphb

    ampaphb Interventional Spine 10+ Year Member

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    If he is working and collecting disability, he is committing fraud

    Sent from my SAMSUNG-SM-G930A using SDN mobile
     
  37. bedrock

    bedrock Member 10+ Year Member

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    great example of why just having low back pain, headaches, FMS, etc is not an excuse not to work and support yourself and the tax base.
     
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  38. lobelsteve

    lobelsteve SDN Lifetime Donor Lifetime Donor 10+ Year Member

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    He is not. Commercial insurance, works full time. Sees himself as disabled as blind since birth. But has nothing to do with anything other than he wants to drive but they call him disabled and won't give him a license.
     
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  39. DrCommonSense

    DrCommonSense

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    This is ANOTHER example of evidence that you can work if you want to unless you are literally paralyzed or have terminal cancer.
     
  40. bronchospasm

    bronchospasm Junior Member Lifetime Donor 10+ Year Member

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    Love it. I do not prescribe controlled substances to young patients on disability.
     
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  41. ampaphb

    ampaphb Interventional Spine 10+ Year Member

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    Absolute rules are silly.

    What if they don't have the smarts to be a doc? What if they don't have the smarts to do simple repetitive tasks?

    What if there are no jobs in the area? What if the jobs in the area don't match the skill sets patients have developed?

    Young patients on disability? What about a vet with a TBI? What about an oil worker or construction worker with a history of a significant fall, necessitating a multilevel fusion?
     
  42. bedrock

    bedrock Member 10+ Year Member

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    The smarts to do simple repetitive tasks? I'm sure your average construction worker can do simple repetitive tasks.

    No jobs in the area? so move to another area. Regular people do it all the time.

    No jobs that match their specific skills like drilling holes for oil..... learn some new ones. You can learn basic computer/office skills in a month, and lots of retail, customer service jobs will train you.

    Vet with TBI, depends on severity. I know many vets with TBI who just can't be bothered to work, but its true some are so severe they can't work. Only a physiatrist should make that distinction. No other doc is qualified.

    Oil/construction worker s/p fall and fusion, likely can't continue their current physical job, but that doesn't mean they can't do anything at all. They can answer phones, work retail, customer service etc.
     
  43. SSdoc33

    SSdoc33 10+ Year Member

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    im pretty liberal, but we cant pay these guys to sit around and play video games.
     
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