Thoughts on the election as it pertains to insurance

[DebtRising]

This is something that is all speculative at this point. The election is over, strong feelings on all sides, may very well continue for the next 4 years.

What is concerning to me are the proposals to change medicare, which aren't part of Trump's platform but are part of Paul Ryan's, and he has been talking about them more(ie either block grants for both M programs, or premium support instead of actual Medicare). If Medicare were to have significant payment changes, could radiation in its current form survive? The share of either primary or secondarily insured medicare patients we treat is large, and am starting to have some concerns that this may lead to a large cut for oncology care.

Of course this is theoretical - changing Medicare is the equivalent of political suicide, but the fact that it is being talked about is more concerning than a true public option / single payer model that Hillary may or may not have advocated.

Anyone have similar feelings? Any rumblings about the ASTRO PAC getting some early traction on this or at least starting an initiative for funding?

---

Members don't see this ad.

 

[thecarbonionangle]

Never underestimate how far out of touch the right-wing can be when it comes to these things. When Dubya won, they thought they would realise all their wet dreams and privatize SS. Paul Ryan is an absolute believer in everything he says and it would be a mistake not to take him at his word. Liberals made a mistake considering Trump a joke and they are now the real joke of a party, decimated at the state level losing almost all governorships and state houses, having followed two consecutive successful Democratic presidents with complete duds, now a minority party in all branches of government. I'd say they deserve everything they will get with DT and more. Just watch the SCOTUS be stacked with 4 Scalias. To answer your question regarding what will happen with insurance under trump? weren't you paying attention? something TERRIFIC. duh-uh.

 

[DebtRising]

The point here is that the general assumption, even from me, was that a Hillary presidency was worse for healthcare from all angles, with strong possibility of a public option.

With the unexpected result of the election we are now facing a potentially worse proposition. Paul Ryan does want to privatize Medicare- thats means freezing or decreasing the amount of Federal support for the program by offering premium support to private programs and shifting costs to beneficiaries. In any possible viewpoint that represents a real and potentially steep drop in health spending. The people who then cannot afford good plans with their own savings will then get limited benefit private plans. It's almost exactly like the ACA except for seniors, and it will lower costs to the government by directly rationing care.

Now as as I said, this is about as politically toxic as you can be - but it very well may happen. Trump said he would not cut Medicare, but there is no argument to make that believing his rhetoric is of any value.

If this is the path however, then the coming cuts may be much worse than what was predicted for public options. And I think if we aren't out lobbying against this now, or raising awareness, it will get swept up into the 'repeal ACA' bantor and only after it is enacted will people know what has happened.

I have wrote Paul Ryan about this. I have wrote the AMA about this. You of course have license to take my often fatalistic tone as alarmist on this. But if Paul Ryan's plan is enacted, then we (as healthcare providers, not Rad Oncs), and seniors, are going to be in a very difficult situation.

 

[thecarbonionangle]

Really? Worse for healthcare "from all angles" and "strong possibility of public option" under Hilary? what are you smoking? we must have seen completely different elections. Didn't know she could just snap her finger and the GOP controlled congress would pass such a thing. She argued against the public option during the primary with Sanders. She had no interest in it. Get ready for the Trump train and far right Ryan dictating economic policy and creepy Pence setting social policy. "I'm hearing" it is going to be TERRIFIC.

 

[medgator]

Like with most issues, trump has held every position imaginable. Probably comes from being both a democrat and a republican throughout his life.

Anyone who thinks they can predict how trump will affect healthcare should consider all of the potential positions he's had on the issue, including his open endorsement of government-run universal healthcare last year.

https://www.google.com/amp/www.cbsn...inutes-scott-pelley/?client=ms-android-att-us

Scott Pelley: What's your plan for Obamacare?

Donald Trump: Obamacare's going to be repealed and replaced. Obamacare is a disaster if you look at what's going on with premiums where they're up 45, 50, 55 percent.

Scott Pelley: How do you fix it?

Donald Trump: There's many different ways, by the way. Everybody's got to be covered. This is an un-Republican thing for me to say because a lot of times they say, "No, no, the lower 25 percent that can't afford private." But--

Scott Pelley: Universal health care?

Donald Trump: I am going to take care of everybody. I don't care if it costs me votes or not. Everybody's going to be taken care of much better than they're taken care of now.

Scott Pelley: The uninsured person is going to be taken care of how?

Donald Trump: They're going to be taken care of. I would make a deal with existing hospitals to take care of people. And, you know what, if this is probably--

Scott Pelley: Make a deal? Who pays for it?

Donald Trump: --the government's gonna pay for it. But we're going to save so much money on the other side. But for the most it's going to be a private plan and people are going to be able to go out and negotiate great plans with lots of different competition with lots of competitors with great companies and they can have their doctors, they can have plans, they can have everything.

 

[Burt Radnolds]

nm

 

[GranD14]

Does anyone have any idea what would happen to residencies if Medicare is privatized? Since Medicare currently pays for residency programs, who would pick up the bill? Would there be fewer residencies, residents go unpaid, or would they have to be privatized? Would the government continue to pay for this part alone? I tried reaching out to some people that might have some answers but have come back basically empty handed...

 

[medgator]

Does anyone have any idea what would happen to residencies if Medicare is privatized? Since Medicare currently pays for residency programs, who would pick up the bill? Would there be fewer residencies, residents go unpaid, or would they have to be privatized? Would the government continue to pay for this part alone? I tried reaching out to some people that might have some answers but have come back basically empty handed...

Medicare funding for residency spots froze at the current level a couple of decades ago iirc. I think hospitals have been funding growth since then, in part.

 

[GranD14]

Medicare funding for residency spots froze at the current level a couple of decades ago iirc. I think hospitals have been funding growth since then, in part.

I believe that is incorrect. If you look at the AAMC, Medicare is the biggest funding for residencies:

Page 3:
Does Medicare have a role in financing graduate medical education?

Yes. Medicare is the largest single program providing explicit support for graduate medical education (GME). In federal fiscal year 2011, the Medicare program paid hospitals that train residents approximately $3.2 billion dollars in direct graduate medical education (DGME) funds, out of approximately $15 billion in DGME-related costs.1 DGME payments cover a portion of the direct costs of training residents, such as residents’ stipends and benefits, teaching physicians’ salaries, other direct costs (e.g., a GME office to administer programs, accreditation fees, educational space, etc.), and related overhead expenses. The amount of Medicare DGME payments a teaching hospital receives is related to the share of the hospital’s inpatients who are Medicare beneficiaries. All Medicare payments for DGME are paid directly to hospitals that train residents; none are made to the residents themselves.


https://members.aamc.org/eweb/upload/Medicare Payments for Graduate Medical Education 2013.pdf

Edit: I don't mean for growth...I mean for continuation. What incentive would hospitals have for residencies if it comes at a huge financial burden for them?

 

[medgator]

I believe that is incorrect. If you look at the AAMC, Medicare is the biggest funding for residencies:

Page 3:
Does Medicare have a role in financing graduate medical education?

Yes. Medicare is the largest single program providing explicit support for graduate medical education (GME). In federal fiscal year 2011, the Medicare program paid hospitals that train residents approximately $3.2 billion dollars in direct graduate medical education (DGME) funds, out of approximately $15 billion in DGME-related costs.1 DGME payments cover a portion of the direct costs of training residents, such as residents’ stipends and benefits, teaching physicians’ salaries, other direct costs (e.g., a GME office to administer programs, accreditation fees, educational space, etc.), and related overhead expenses. The amount of Medicare DGME payments a teaching hospital receives is related to the share of the hospital’s inpatients who are Medicare beneficiaries. All Medicare payments for DGME are paid directly to hospitals that train residents; none are made to the residents themselves.


https://members.aamc.org/eweb/upload/Medicare Payments for Graduate Medical Education 2013.pdf

That doesn't indicate whether funding has been growing or not.

Apparently it's been frozen at 1997 levels

http://www.fiercehealthcare.com/finance/aha-urges-congress-to-fund-gme-funding-expand-residencies

 

[GranD14]

That doesn't indicate whether funding has been growing or not.

Apparently it's been frozen at 1997 levels

http://www.fiercehealthcare.com/finance/aha-urges-congress-to-fund-gme-funding-expand-residencies

My concern is not whether funding is growing, but rather if it's continuing.. If Medicare is privatized, I am sure private insurance companies will not be paying for medical education....so who would?

 

[medgator]

My concern is not whether funding is growing, but rather if it's continuing.. If Medicare is privatized, I am sure private insurance companies will not be paying for medical education....so who would?

Probably the same sources that have been funding all the new slots in multiple specialties over the last two decades, including in radiation oncology.

Clearly the 1997 freeze has not stopped rad onc spots increasing over 50% in the last decade

 

[GranD14]

Probably the same sources that have been funding all the new slots in multiple specialties over the last two decades, including in radiation oncology.

Clearly the 1997 freeze has not stopped rad onc spots increasing over 50% in the last decade

Maybe you're right, but I'm hoping that's not something we allow ourselves to sit back and expect. Most other specialties are not as lucrative and might not have the funds, or might put the burden on the residents themselves.

 

[DebtRising]

Does anyone have any idea what would happen to residencies if Medicare is privatized? Since Medicare currently pays for residency programs, who would pick up the bill? Would there be fewer residencies, residents go unpaid, or would they have to be privatized? Would the government continue to pay for this part alone? I tried reaching out to some people that might have some answers but have come back basically empty handed...

I think the terminology needs to be clarified slightly. Medicare would effectively be privatized. Meaning there would still be a medicare tax and fund of some sort, but that money would then handed to a private company who administers a plan. No elderly patient is going to be able to self fund / start an HSA. So there could still be some funds that would be earmarked for education.

But yes this could mean big cuts in the education fund and residency slots would just decrease, because the money needed for premium support is likely much higher than what is needed for running medicare, with the underlying assumption that the insurance company who administers the plan would want a true profit margin, which can be 10% under a current part of the ACA I believe. Of course that could change as well. Who knows if its a bad thing if the residency pool contracts as the baby boomer explosion is already upon us - but a major disruption would just mean physician shortages and a lot of angry people who opened new medical schools. The government could always combat with limits on IMG physicians in the residency system and then force American grads into whatever slots are left / open.

If hospitals had to fund all education, on top of charity care and loss of volume from the ACA, there would be wave of bankruptcies and patients would suffer. But turning Medicare into a premium based support plan will make seniors who don't have the means suffer, and that is being talked about as serious policy, so who knows.

 

[medgator]

. The government could always combat with limits on IMG physicians in the residency system and then force American grads into whatever slots are left / open.

Already happening now in the "free market." Once upon a time several decades ago, rad onc was primarily filled by FMGs. More recently that had been happening in psych, path, FP.

But with the explosion of medical schools all over the country, American MD and DO students have been filling pretty much any U.S. residency spot open.

There are horror stories now of AMGs not matching in an acgme accredited residency. You can imagine how img/fmg numbers look given that