universal healthcare

[daact]

Will universal healthcare be beneficial for ophthalmologists?

Thanks

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[7ontheline]

Why, because Obama is the nominee?

In all likelihood, universal health care will be bad for medicine in general, and there's no reason to think ophthalmology will be an exception. Personally, I doubt a true universal health care system is coming because the American public is unwilling to make the concessions (rationing, etc.) that are necessary.

 

[orbitsurgMD]

Will universal healthcare be beneficial for ophthalmologists?

Thanks

No one has defined exactly what that term means; it is a buzzword for changing whatever is seen to be dysfunctional about the present system, but it clearly means different things to different people.

Does it mean insurance paid through taxes for every American, old and young, working and not working?

Does it mean mandated purchase of health insurance from private sources and only where that is impossible, from the government?

Does it mean care provided through government clinical facilities provided by government-employed professionals?


All of these exist in one form or another in other developed (and many not-so developed) countries. The election cry for "universal healthcare" really is an inchoate demand to "have what they're having" without much thought as to how other systems have developed or how the average citizen is expected to participate to make those systems come about (namely much higher taxes and all that follows from that, for one thing.)

Are we willing to pay much higher personal income taxes? Nearly all the countries that have these systems have high personal taxes. (Maybe not Switzerland.)

Are we willing to fully fund higher education, or at least to a degree that is comparable to those countries whose systems we think are worth copying?

Are we willing to give up the expensive torts liability system that adds expense in premium to the practices that provide care and even more expense in the way of overuse of testing and referral that is done in the way of defensive medicine?

Are we willing to have our government decide what we cannot have--for instance critical care or organ transplantation for the elderly or multiply co-morbid?

If we are willing to impose price controls on the providers of care and materials, are we likewise willing to subsidize wholly their costs? That goes for educating doctors as well, as our educations are one of the most significant investments in our professions.

It is easy to just complain and want things. Citing the millions of uninsured in the USA is no argument in and of itself; a country serious about addressing health care for its citizens has to be willing to answer serious questions.

 

[baya]

I completely agree that a serious solution to our health care issues requires more than an election buzzword.

Here's a summary of my post, for those of you who don't want to read the whole thing:
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I'm in favor of having a single-payer system because (if done right) it will be more efficient and less of a pain in the arse.

I'm in favor of health care for all Americans because I think it's ethical.

I expect to pay a little more for this, but not much.
-----------------------------------------------------------------------------------

What I want (under any name) is "health care paid for through taxes for every American, old and young, working and not working".

This is a slight modification of the first definition that you offered, because I don't think the concept of "insurance" is functional in the arena of health care -- insurance is for unexpected exigencies. This is a model that does not lend itself to preventive care or regular checkups. I'm not interested in either of the other two possible definitions you posed, although I know many other people are.

I would have no problem transferring what I currently pay in insurance premiums (or lost salary when my employer pays it), deductables, and copayments to the form of taxes. I don't find it inherently worse to give $ to the government than to an insurance company. And paying it once a year would probably be less of a pain in the arse than the current system of many payments in many forms each year.

Since the government would not be pulling a profit from that money, I would expect that they could do more with it for my health than the insurance company does. So for my own personal health, I should pay LESS in taxes than I currently pay for health care. (If I don't, the system was implemented VERY badly and should be fixed.)

Now, even given the expected increase in efficacy of the health care dollar if it's moved out of the private sector, we would still be trying to cover a lot of people who are currently under-insured and uninsured. I would be wiling to tolerate a modest increase in what I pay towards health care to make this happen, because I find the current state of health care intolerable.

Yes, this translates to much higher taxes, but not to much less disposable income because I would stop giving money to insurance companies. The election cry of "no new taxes" is even more tired than the "universal health care" cry.

Personally, I expect to enjoy my (future) job as a physician more if there is only one entity responsible for re-imbursing me, as it should require less time and energy devoted to paperwork. This should also translate to lower expenses in office-staff salary, since negotiating with insurance companies and keeping up with the many different systems of reimbursement is a large part of what they do.

Of course there would be caps on reimbursement, but that's already the case anyway, except for those of us treating the wealthy few who can pay whatever we say they should for their treatment. But if there's one payer, we could negotiate with them more effectively than the current morass of payers.

I think questions about subsidizing or fully funding higher education, including medical education, can be a separate discussion. However, yes, I think it's reasonable to subsidize medical school, as the current debt expectancy deters potential applicants and has an overly strong impact on choice of specialty. With little educational debt and reimbursement caps, our financial situations would be somewhat normalized, which I think would be better than the current roller-coaster.

Thanks for raising these important topics. I think a rational discussion is essential to solving our health care problems in this country.

And believe it or not, I'm open to changing my mind about the opinions I expressed above, if an opposing opinion is well-reasoned.

No one has defined exactly what that term means; it is a buzzword for changing whatever is seen to be dysfunctional about the present system, but it clearly means different things to different people.

Does it mean insurance paid through taxes for every American, old and young, working and not working?

Does it mean mandated purchase of health insurance from private sources and only where that is impossible, from the government?

Does it mean care provided through government clinical facilities provided by government-employed professionals?


All of these exist in one form or another in other developed (and many not-so developed) countries. The election cry for "universal healthcare" really is an inchoate demand to "have what they're having" without much thought as to how other systems have developed or how the average citizen is expected to participate to make those systems come about (namely much higher taxes and all that follows from that, for one thing.)

Are we willing to pay much higher personal income taxes? Nearly all the countries that have these systems have high personal taxes. (Maybe not Switzerland.)

Are we willing to fully fund higher education, or at least to a degree that is comparable to those countries whose systems we think are worth copying?

Are we willing to give up the expensive torts liability system that adds expense in premium to the practices that provide care and even more expense in the way of overuse of testing and referral that is done in the way of defensive medicine?

Are we willing to have our government decide what we cannot have--for instance critical care or organ transplantation for the elderly or multiply co-morbid?

If we are willing to impose price controls on the providers of care and materials, are we likewise willing to subsidize wholly their costs? That goes for educating doctors as well, as our educations are one of the most significant investments in our professions.

It is easy to just complain and want things. Citing the millions of uninsured in the USA is no argument in and of itself; a country serious about addressing health care for its citizens has to be willing to answer serious questions.

 

[Mirror Form]

Any form of socializing healthcare would be bad for doctors, and bad for the majority of patients. The people it would benefit are the minority who do not have insurance and don't pay much in taxes.

Regardless, it will never happen. The democratic politicians get WAY too much money for ATLA to ever do anything beyond just talking about socializing medicine.

BTW, a single payer system would be a nightmare. At least with a normal socialized system we still have some freedom. A single payer system is stalin's version of socialism.

 

[baya]

Can you add some explanations to support your claims? I'm seriously open to changing my mind, but what you've said so far doesn't say much.

Any form of socializing healthcare would be bad for doctors, and bad for the majority of patients. The people it would benefit are the minority who do not have insurance and don't pay much in taxes.

Regardless, it will never happen. The democratic politicians get WAY too much money for ATLA to ever do anything beyond just talking about socializing medicine.

BTW, a single payer system would be a nightmare. At least with a normal socialized system we still have some freedom. A single payer system is stalin's version of socialism.

 

[7ontheline]

Trust me, as a medical student you don't really know $%#!. I don't say this to offend - I was one not very long ago.

Changing to single-payer government funded healthcare would be very bad for physicians. Expect to be paid a lot less. Expect to jump through a lot more hoops. Expect more restrictions placed on which tests/medications you can order. Thinking that the government is going to be more efficient is a fantasy - look no further than the veteran's system and Medicare. Once you start dealing with these things, the reality will quickly become apparent to you.

FWIW, I am an Obama supporter and generally liberal politically, so it's not just anti-government ideology talking here.

 

[baya]

Trust me, as a medical student you don't really know $%#!. I don't say this to offend - I was one not very long ago.

Changing to single-payer government funded healthcare would be very bad for physicians. Expect to be paid a lot less. Expect to jump through a lot more hoops. Expect more restrictions placed on which tests/medications you can order. Thinking that the government is going to be more efficient is a fantasy - look no further than the veteran's system and Medicare. Once you start dealing with these things, the reality will quickly become apparent to you.

FWIW, I am an Obama supporter and generally liberal politically, so it's not just anti-government ideology talking here.

I'm not offended, and I'm well aware that as a med-student I don't know that much about the realities of re-imbursement. (Gee, wish they covered that in med school. Wouldn't that be nice.)

But still, I form opinions based on the information I have, and do the best I can with that.

So basically you're saying "our government sucks so badly that they would do even worse than they current system", yeah?

That's a pretty sucky government, 'cause what we have now stinks.

And you don't think there's any chance we can improve the set-up, if physicians were actively involved in the process?

What about a non-profit organization that got a "contract" to provide insurance to all Americans? So that the government isn't actually running the organization, but channels funds to it? Would that make it better?

 

[orbitsurgMD]

. . . .
What about a non-profit organization that got a "contract" to provide insurance to all Americans? So that the government isn't actually running the organization, but channels funds to it? Would that make it better?

The Blues stated out that way, as a "non-profit" carrier that provided coverage to low-paid working people, nurses, schoolteachers and public employees who could not afford medical indemnity offered by typical private companies. Now with their several generations' protection from taxes and special status, these carriers behave little differently from for-profit corporations, except they don't have to account to their shareholders. They advertise, they invest (in profit-making enterprises), they pay huge salaries and bonuses to their senior management, they compete with for-profits for the same customers, and recently, they have tried to convert to stockholding companies and go public with management-privileged IPO schemes, all taking advantage of the taxpayers who underwrote their expansion and huge growth to their dominant market positions.

Those "non-profits"? No thanks.

 

[7ontheline]

And you don't think there's any chance we can improve the set-up, if physicians were actively involved in the process?

Good thought. But. . .do you think physicians are truly actively involved? The whole thing is set up by politicians who are not going to be necessarily familiar with the workings of real medical care. Doctors who help set policy tend to be a very political sort as well - your rank-and-file docs don't have the time or clout to be involved at those levels.

 

[baya]

Yeah, well non-profits that are actually for profit don't quite fit the bill, do they.

Maybe what we need is just much tighter regulation of the health insurance industry.

No profits. Not allowed to reject applicants for pre-existing conditions. Not allowed to cancel someone's insurance as soon as they're diagnosed with cancer.

The Blues stated out that way, as a "non-profit" carrier that provided coverage to low-paid working people, nurses, schoolteachers and public employees who could not afford medical indemnity offered by typical private companies. Now with their several generations' protection from taxes and special status, these carriers behave little differently from for-profit corporations, except they don't have to account to their shareholders. They advertise, they invest (in profit-making enterprises), they pay huge salaries and bonuses to their senior management, they compete with for-profits for the same customers, and recently, they have tried to convert to stockholding companies and go public with management-privileged IPO schemes, all taking advantage of the taxpayers who underwrote their expansion and huge growth to their dominant market positions.

Those "non-profits"? No thanks.

 

[baya]

Good thought. But. . .do you think physicians are truly actively involved? The whole thing is set up by politicians who are not going to be necessarily familiar with the workings of real medical care. Doctors who help set policy tend to be a very political sort as well - your rank-and-file docs don't have the time or clout to be involved at those levels.

True, and it's a problem. Members of other professions work to better their working conditions and so should we. We're screwing ourselves over and then wondering what happened.

 

[Lovologist]

I'm all in favor in socialized medicine because....

I love big brother

 

[baya]

I'm all in favor in socialized medicine because....

I love big brother

See, not so much with the rational discussion here. Moving along...

 

[KHE]

See...the notion of not being able to reject something for a pre-existing condition is completely counter to the idea of "insurance." That's like saying that State Farm MUST provide you with auto insurance no matter how many DUIs or speeding tickets you have. It just doesn't work.

I grew up in Canada, though I live and practice here now. No...I did not come here to escape the evil socialized system. I married an American and she didn't want to move to Canada. I have experienced the Canadian system as a patient. I have experienced the American system as both doctor and patient.

I'm really torn on this issue. It's tough. I think I probably lean towards a single payor system however. (note that single payor does NOT have to mean "goverment run.")

I recall reading a public health article when I was in school that stated that from 1977 to 1997, the number of doctors and nurses in the USA increases 11%. The number of health care administrators increased 2600%. (twenty six hundred percent.) I don't know how anyone can argue that THAT is an efficient use of resources.

Medicare has a 98% participation rate amongst those eligible. If 98% of people are participating, then to me that sort of signals that government health care can't be all that bad if 98% of people are participating.

Over half of all bankrupticies in the USA are caused by unpaid medical bills and of those, over half are happening to people who are actually insured. One of the biggest problems that people run into here is that many people THINK that they have great insurance because their copayments for visits are low, and their birth control pills and antibiotics are covered, but then just wait until dad has a heart attack, your child gets leukemia, or grandma has to go in a nursing home and you realize just how little coverage you have.

The head of my local Blue Cross was paid $15 million last year. That's ONE GUY who heads up ONE HMO in one SMALL CORNER OF THE COUNTRY. Anyone want to guess how much the head of the medicare program made last year? Hint: It's a lot LESS than $15 million.

So...I advocate for some for of single payor. Again, does not mean the government "runs it." The government is the largest customer of both Raytheon and Boeing corporations however I don't think that anyone would make the case that the government "runs" Boeing or Raytheon. I believe that there is enough money floating around in the flotsam and jetsam of the current system to provide full coverage to all people.

The Canadian system is not utopia by any stretch of the imagination. However, the myth is that the streets of Canada are littered with dead Canadians who died waiting to have their heart attacks fixed. That's not the case. If you're not going to die, there probably is going to be some wait. Here in the USA, I can send someone to a cataract surgeon and have a cataract removed within a week. In Canada, it's probably gonna be a couple of months. But if you have cancer, or a heart attack, you're going to get fixed quickly. I know I got fixed quickly when I had serious problems that required surgical intervention.

Always an interesting debate.

 

[Chorizo Bandito]

Great subject for a debate! Maybe I'm just a crazy liberal, but I'd love to have a single payer system. Here's why:

1) It seems like alot of our compensation is pegged near medicare rates anyway, and having a single payer that pays on time is better then chasing multiple insurance companies around for reimbursements that may be collected months after the point of care. And, if having a single payer means less overhead (ie fewer employees to chase down reimbursements), the pay cut to the doc in the end may not be all that significant.

Caveat: I'm a medicine intern going in to ophtho residency in july. Never had to try collecting a dime from the middleman and haven't practiced in ophtho yet.

2) What's wrong with rationed health care? Is it really that big of a calamity to wait a few weeks to have your cataract removed? Last time I checked, nuclear sclerosing cataracts didn't develop overnight... Heck, I'd wait 6 weeks for elective knee surgery if it was free! In America we spend the most, per capita, on health care but we're far from the most healthy population. One couldn't really argue that the system we have now is superior to other developed nations.

3) Sure we may make less, but it's not just about our paycheck. How much is it worth to not have to worry about your granddparents, parents, brothers, sisters and kids getting health care? Alot of Americans pay more for their health insurance than they do for their mortgage...and that's before they get sick. I think for alot of docs, the benefit to those they care about would more than make up for the pay cut.

On a related note, has anyone seen Michael Moore's "Sicko"? It may just soften your opinion on single payer systems.

 

[baya]

See...the notion of not being able to reject something for a pre-existing condition is completely counter to the idea of "insurance." That's like saying that State Farm MUST provide you with auto insurance no matter how many DUIs or speeding tickets you have. It just doesn't work.

Absolutely true. Which is part of why I think "health insurance" is a bad paradigm for health care payment. People do have chronic conditions, and a system that bankrupts them for it just isn't all that functional. If you develop Diabetes Mellitus Type I at age 11, then you pretty much have to be continually employed by a company who includes good health insurance as part of your employment benefits your entire adult life until you hit Medicare age, unless you're lucky enough to be wealthy.

I grew up in Canada, though I live and practice here now. No...I did not come here to escape the evil socialized system. I married an American and she didn't want to move to Canada. I have experienced the Canadian system as a patient. I have experienced the American system as both doctor and patient.

I'm really torn on this issue. It's tough. I think I probably lean towards a single payor system however. (note that single payor does NOT have to mean "goverment run.")

Good point, which again brings up whether we could have non-profits that STAY non-profits. If they were well regulated, I could be in favor of this solution.

I recall reading a public health article when I was in school that stated that from 1977 to 1997, the number of doctors and nurses in the USA increases 11%. The number of health care administrators increased 2600%. (twenty six hundred percent.) I don't know how anyone can argue that THAT is an efficient use of resources.

Medicare has a 98% participation rate amongst those eligible. If 98% of people are participating, then to me that sort of signals that government health care can't be all that bad if 98% of people are participating.

Over half of all bankrupticies in the USA are caused by unpaid medical bills and of those, over half are happening to people who are actually insured. One of the biggest problems that people run into here is that many people THINK that they have great insurance because their copayments for visits are low, and their birth control pills and antibiotics are covered, but then just wait until dad has a heart attack, your child gets leukemia, or grandma has to go in a nursing home and you realize just how little coverage you have.

Yup. Sucks like a hoover. Hmm... maybe we should try to change the system!

The head of my local Blue Cross was paid $15 million last year. That's ONE GUY who heads up ONE HMO in one SMALL CORNER OF THE COUNTRY. Anyone want to guess how much the head of the medicare program made last year? Hint: It's a lot LESS than $15 million.

So...I advocate for some for of single payor. Again, does not mean the government "runs it." The government is the largest customer of both Raytheon and Boeing corporations however I don't think that anyone would make the case that the government "runs" Boeing or Raytheon. I believe that there is enough money floating around in the flotsam and jetsam of the current system to provide full coverage to all people.

The Canadian system is not utopia by any stretch of the imagination. However, the myth is that the streets of Canada are littered with dead Canadians who died waiting to have their heart attacks fixed. That's not the case. If you're not going to die, there probably is going to be some wait. Here in the USA, I can send someone to a cataract surgeon and have a cataract removed within a week. In Canada, it's probably gonna be a couple of months. But if you have cancer, or a heart attack, you're going to get fixed quickly. I know I got fixed quickly when I had serious problems that required surgical intervention.

And the bit about not having to wait here is really just if you're wealthy. Those who are not on the top of the financial food chain do quite a bit of waiting for their medical care here in the good ol' U S of A. (I did med school at a county hospital, so I've seen plenty of this.)

Always an interesting debate.

Indeed. Hopefully it will progress from debate to some sort of a solution soon.

 

[baya]

Great subject for a debate! Maybe I'm just a crazy liberal, but I'd love to have a single payer system. Here's why:

1) It seems like alot of our compensation is pegged near medicare rates anyway, and having a single payer that pays on time is better then chasing multiple insurance companies around for reimbursements that may be collected months after the point of care. And, if having a single payer means less overhead (ie fewer employees to chase down reimbursements), the pay cut to the doc in the end may not be all that significant.

Caveat: I'm a medicine intern going in to ophtho residency in july. Never had to try collecting a dime from the middleman and haven't practiced in ophtho yet.

2) What's wrong with rationed health care? Is it really that big of a calamity to wait a few weeks to have your cataract removed? Last time I checked, nuclear sclerosing cataracts didn't develop overnight... Heck, I'd wait 6 weeks for elective knee surgery if it was free! In America we spend the most, per capita, on health care but we're far from the most healthy population. One couldn't really argue that the system we have now is superior to other developed nations.

3) Sure we may make less, but it's not just about our paycheck. How much is it worth to not have to worry about your granddparents, parents, brothers, sisters and kids getting health care? Alot of Americans pay more for their health insurance than they do for their mortgage...and that's before they get sick. I think for alot of docs, the benefit to those they care about would more than make up for the pay cut.

On a related note, has anyone seen Michael Moore's "Sicko"? It may just soften your opinion on single payer systems.

Hi Chorizo Bandito! Nice to have another liberal on this thread with us.

Agree with (most of) above.

I agree that waiting a few weeks for elective surgery isn't the end of the world. But what people always seem to leave out in this part of the debate is how much waiting for urgent medical problems to be addressed currently goes on in this country. (It just doesn't happen to rich people.)

For example, when on my core surgery rotation I saw a patient in the county ED who had a inguinal hernia. His scrotum was somewhat smaller than a soccer ball - I couldn't fully encircle it with both hands (and I wear size 7s), that's how big it was. The ED's "jock bag" that's supposed to help this guy out by supporting his scrotum for him didn't fit -- it was too small. But it wasn't incarcerated or strangulated, so we didn't consider it emergent. We told him we'd call him when the OR had an opening for an elective case. The residents and the surgical coordinator all told me that'd probably be in 4-5 months. Or if it became incarcerated or strangulated before then, he should come back and we'd fix it emergently. He left, and then I saw him again exactly one week later with the same complaint, and we told him exactly the same thing and sent him home again. After that I rotated off the service, so I didn't see him again.

Good thing no one waits for their health care here. 'Cause that might cause problems which would then have a higher M&M rate, and be even more expensive...

Great system, huh?


And on the topic of Michael Moore's movie -- I admit to being a raving liberal, but parts of SICKO were excessive, even for me. I think it's fun for liberals to see, but I'm not sure it would change the mind of an educated conservative, because the flaws in it pissed even me off a little.

 

[KHE]

Hi Chorizo Bandito! Nice to have another liberal on this thread with us.

Great system, huh?


And on the topic of Michael Moore's movie -- I admit to being a raving liberal, but parts of SICKO were excessive, even for me. I think it's fun for liberals to see, but I'm not sure it would change the mind of an educated conservative, because the flaws in it pissed even me off a little.

I consider myself a conservative on most issues. However, I still advocate for some kind of single payor system. Perhaps that is incompatible with conservatism but I don't think it is.

I have never fully understood why people who are against single payor systems use the argument that they don't want the "gubmint" making medical decisions for them. On some level, it's understandable yet these same people are willing to let a high school graduate at Aetna or Cigna make those some decisions. Is that some how more acceptable?

Also, Mr. Moore's movie is simply ridiculous. How anyone can see a movie like that and give it even an ounce of credibility is beyond me, considering the fellow who made the movie. I saw it, but I really didn't need to. I knew exactly what he was going to say. It's the same reason why I never listen to or watch Rush Limbaugh or Sean Hannity. I KNOW what they are going to say about EVERYTHING. There isn't a chance that they are going to say something insightful or interesting. It's just the same ol' telegraphed blather.

 

[baya]

I consider myself a conservative on most issues. However, I still advocate for some kind of single payor system. Perhaps that is incompatible with conservatism but I don't think it is.

Nice to have you on the thread too. Better to have individual opinions on individual topics than adhere to a strict party line, IMHO. I don't think single payor is incompatible with conservatism either. In fact, the influence of people who believe in small, efficient government would be an excellent influence to have in the creation of a single-payor system.

I have never fully understood why people who are against single payor systems use the argument that they don't want the "gubmint" making medical decisions for them. On some level, it's understandable yet these same people are willing to let a high school graduate at Aetna or Cigna make those some decisions. Is that some how more acceptable?

Nope, it's not any more okay. And what does it mean to have the "gubmint" making choices? It's not actually a sentient entity. People make the choices, and it's up to us "the people" to decide which people make them.

I think these choices should be debated and codified by a national panel of expert physicians, with periodic updating as medicine and technology evolves.

Presumably all the major specialties should be included. Which sub-specialties should be included? Should they be voted in? Should they be appointed? By whom? Should some MPHs be included? How about some people with experience as patient advocates? Anyone else I've forgotten who should have a direct voice in this?

What system would end up as a relative "win" for patients, physicians, and tax-payers? Let's try to ignore the insurance companies coffers, shall we?

Also, Mr. Moore's movie is simply ridiculous. How anyone can see a movie like that and give it even an ounce of credibility is beyond me, considering the fellow who made the movie. I saw it, but I really didn't need to. I knew exactly what he was going to say. It's the same reason why I never listen to or watch Rush Limbaugh or Sean Hannity. I KNOW what they are going to say about EVERYTHING. There isn't a chance that they are going to say something insightful or interesting. It's just the same ol' telegraphed blather.

Yeah, I really can't support Mr. Moore's movie as anything more than entertaining. Some of his points were valid, in my opinion, but they were lost amongst those that weren't. Too bad.

 

[Mirror Form]

No profits.

Okay, so I'm sure a lot of efficiently run and smart organizations will be rushing to provide something that you're not allowed to profit off of. Remember that in the end, capitalism typically does better than socialism, ESPECIALLY in efficiency.

Not allowed to reject applicants for pre-existing conditions.

Uhm, do you know what the definition of insurance is? If you could get coverage for pre-existing conditions, then it's no longer insurance!!!!!!!!!

Why should I pay money for health insurance every month, if i could just wait until I got sick and then sign up?

Not allowed to cancel someone's insurance as soon as they're diagnosed with cancer.

Well yeah, but that's why when you sign up for health insurance you read the contract. Can't say I've heard of too many policies that can cancel you as soon as you get sick.

 

[Mirror Form]

2) What's wrong with rationed health care? Is it really that big of a calamity to wait a few weeks to have your cataract removed? Last time I checked, nuclear sclerosing cataracts didn't develop overnight... Heck, I'd wait 6 weeks for elective knee surgery if it was free!

Oh really? How'd you like to lie in bed for 3 months until you could get your hip replacement surgery?

3) Sure we may make less, but it's not just about our paycheck. How much is it worth to not have to worry about your granddparents, parents, brothers, sisters and kids getting health care? Alot of Americans pay more for their health insurance than they do for their mortgage...and that's before they get sick. I think for alot of docs, the benefit to those they care about would more than make up for the pay cut.

And how many pay cuts are you willing to take? Our salaries have already been slashes repeatedly. BTW, I'd be more worried about my loved ones geting good healthcare if the system was socialized.

On a related note, has anyone seen Michael Moore's "Sicko"? It may just soften your opinion on single payer systems.

Yeah, that's a good way to develop an unbiased opinion. There was almost certianly no attempt by MM to present things so that our healthcare system looked bad and socialized systems looked great. BTW, I have no doubt that cubans all receive excellent healthcare. No doubt that the peolple MM brought there were treated just the same as everyone else.

 

[baya]

Okay, so I'm sure a lot of efficiently run and smart organizations will be rushing to provide something that you're not allowed to proft off of. Remember when we found out that in the end, capitalism typically does better than socialism.

Good point. But it ain't working, so we gotta fix it somehow. The current capitalist system is not providing good medical care for huge numbers of patients.

Why not? What do you suggest to fix it?

Personally I think we have given the insurance companies a chance, and they've screwed it up royally, so we should try something else.

Or, if sticking with capitalism is the key to success, maybe we should reconsider how health care is purchased. Can you suggest a capitalist model that might work better?

Uhm, do you know what the definition of insurance is? If you could get coverage for pre-existing conditions, then it's no longer insurance!!!!!!!!!

yup, that's right. I think insurance is a bad paradigm for paying for health care. Do you think it's a good one? Why don't we consider a non-insurance paradigm?

WTF would I pay money for health insurance every month, if i could just wait until I got sick and then sign up?

You wouldn't, of course. But that's not the scenario I'm referring to.

What I'm referring to as a problem is when people need to switch insurance companies (for example when they lose their job or move geographically) and then can't get re-insured.

Well yeah, but that's why when you sign up for health insurance you read the contract. Can't say I've heard of too many policies that can cancel you as soon as you get sick.

I have. I'll try to dig up some references for you, but for now here's what I've heard of:

The patient purchases health insurance and fills out a myriad of forms, including PMH. They do their best to fill them out properly. They are accepted into the plan and go along paying their premiums, deductibles, and co-payments for years. They have minor illnesses and routine checkups and everything is fine. The insurance company is profiting because the patient is fairly healthy. In return the patient has peace of mind. Everything is hunky dory.

Then the patient develops a serious, expensive illness. The insurance company senses that it's profit margin is about to be compromised, and takes action. Its employees scour the patient's records to find ANY previous illness that was not mentioned on the PMH, and use it as a reason to deny coverage to the patient now. One patient said she was denied coverage (after having been in enrolled in the plan for a period of time) because she once had a yeast infection, which resolved with OTC topical meds, and she had failed to reveal this in her insurance application.

The patient tries to fight back legally, but this is difficult to do while seriously ill. The patient's quality of care suffers. Often the patient dies. They might have died even with the best of care, but then again they might not have.

One variant of this was a plan that actually excluded coverage for cancer treatment of all types. Furthermore, this was buried in fine print and the patient didn't realize the restriction when she signed up. She was a friend of my family, and died of cancer last year. I didn't know her personally, but I do think her case was another tragic example of how the current system fails Americans all over this country on a routine basis.

 

[baya]

Oh really? How'd you like to lie in bed for 3 months until you could get your hip replacement surgery?

That would suck. But most people seek medical attention at an much earlier stage of the disease, so it would probably be 3 months of limping rather than 3 months of lying in bed.

The reality is that health care is rationed in this country and everywhere else, because it's impossible to treat every medical issue instantly and perfectly.

So the question is, on what basis do we decide to ration care?

Currently in the US, we do it based on socio-economic status. I personally don't think that's terribly ethical.

Our current system has poor people getting to the bed-bound stage while rich people get their hip replacement when they want it.

I would prefer that we ration based on medical necessity. So if you need a hip replacement so badly that you're bed bound, you should get it sooner than someone with a hip that twinges a little when they run 10 miles.

Of course it's not quite that simple, and there are ethical questions around issues such as geriatric patients with multiple morbidities, etc. But we deal with ethical quandaries all the time, and rationing based on socioeconomic status is not an optimal solution.

 

[PDT4CNV]

The democratic party ought to change their name to the Socialist party. Equal everything for everybody.


Do you all want a politician with 3 years of law school under his belt with a nurse practicioner as his/her advisor telling your physician how to practice medicine? I dont, although seems like thats what is happening.

The government is interested in what is "cost effective." This actually means that they want to provide what is least expensive without being considered sub-standard. Go to a VA hospital or County hospital and you will see what this means and what kind of care you would get under a government health care system.

Regarding re-imbursements, they are the pits already. I feel bad for the general surgeons. Can you imagine cutting into an abdomen for a hernia repair and getting a measly $300. My plumber makes more that for his time and doesnt assume $10 million in liability if something goes wrong. The government is ruining the medical profession. While top notch health care for everyone sounds grand and nice in some kind of utopian la la land, in the United States of America, a governement run health care system would be a disaster. How many political scandals and government screw-ups are in the news each day? Each hour?

 

[Chorizo Bandito]

The democratic party ought to change their name to the Socialist party. Equal everything for everybody.

Equal healthcare for everybody? Dude, that sounds terrible!

Do you all want a politician with 3 years of law school under his belt with a nurse practicioner as his/her advisor telling your physician how to practice medicine? I dont, although seems like thats what is happening.

That's already happening, and the insurance company then loosely bases their reimbursements on the medicare number. Why would a single payer system represent such a big change?

The government is interested in what is "cost effective." This actually means that they want to provide what is least expensive without being considered sub-standard. Go to a VA hospital or County hospital and you will see what this means and what kind of care you would get under a government health care system.

The VA hospitals may not be as pretty, but people do get good care! Providing cost effective standard of care is a good thing, last time I checked.

How many political scandals and government screw-ups are in the news each day? Each hour?

Here's an idea: let's get the Enron guys to manage our health system. Or maybe sub-prime mortgage brokers. Last time I checked some of the worst financial fiascos didn't originate with the government (unless, of course, you count our trillion dollar war, started by the former CEO of a Texas oil firm).

Fact is, there's corruption everywhere but at least the government is expected to look out for the little guy. You can't say that about a for-profit company, and healthcare is a bit different than selling widgets.

ps, I expected the Michael Moore endosement to draw some fire and I'll gladly accept it- the movie does have alot of fallacies, but he does make one good point: we have alot of socialized services in America already (police, fire, roads, natural parks, air traffic, border patrol, etc). Why not add healthcare to the list?

pps, thank you Baya for making a good point about wait times for elective procedures. If your initial evaluation is earlier, it would indeed seem like you were waiting longer even if you were treated at the same stage of disease. It'd be interesting to see if anyone has hard data comparing the American vs Canadian systems.

pps, a pleasant weekend to you all. I will disappear now as my program stil does q4 overnight call

 

[PDT4CNV]

Equal healthcare for everybody? Dude, that sounds terrible!



That's already happening, and the insurance company then loosely bases their reimbursements on the medicare number. Why would a single payer system represent such a big change?



The VA hospitals may not be as pretty, but people do get good care! Providing cost effective standard of care is a good thing, last time I checked.



Here's an idea: let's get the Enron guys to manage our health system. Or maybe sub-prime mortgage brokers. Last time I checked some of the worst financial fiascos didn't originate with the government (unless, of course, you count our trillion dollar war, started by the former CEO of a Texas oil firm).

Fact is, there's corruption everywhere but at least the government is expected to look out for the little guy. You can't say that about a for-profit company, and healthcare is a bit different than selling widgets.

ps, I expected the Michael Moore endosement to draw some fire and I'll gladly accept it- the movie does have alot of fallacies, but he does make one good point: we have alot of socialized services in America already (police, fire, roads, natural parks, air traffic, border patrol, etc). Why not add healthcare to the list?

pps, thank you Baya for making a good point about wait times for elective procedures. If your initial evaluation is earlier, it would indeed seem like you were waiting longer even if you were treated at the same stage of disease. It'd be interesting to see if anyone has hard data comparing the American vs Canadian systems.

pps, a pleasant weekend to you all. I will disappear now as my program stil does q4 overnight call

I think I'll just watch tv, claim a disability, go to clubs at night, shop-lift and drink alcohol during the day while you work hard and pay for my food, housing, health care, and illegitimate child care. The number of americans on the government pay-roll for all of their living expenses including health care is increasing year by year. This is not a good thing. Guess who is baring the brunt of that cost? Whatever happened to personal responsibility for one's well-being.

Regarding government health care, I wouldnt be caught dead in our county hospital (or I probably would be dead actually). And the VA is not what you say it is, it remains about 5-10 years behind what would be provided in private community or University hospitals. I know because I periodically see patients at both our VA and county hospital.

When you start collecting your own pay-check, you will realize that there remains quite a big difference between what medicare/medicaid reimburses and private insurance (like BCBS).

And if you are curious about Canada, don't forget about Belinda Stronach, of the Canadian parliament who last year sought her breast cancer reconstruction in 'ol USA (while denying it had anything to do with the sub-standard government run canadian health care system).

 

[KHE]

And if you are curious about Canada, don't forget about Belinda Stronach, of the Canadian parliament who last year sought her breast cancer reconstruction in 'ol USA (while denying it had anything to do with the sub-standard government run canadian health care system).

To be fair, Ms. Stronach did have the cancer diagnosis and mastectomy performed in Canada.

However, it is always dangerous to frame this debate with a series of anecdotes. We all know someone, or can find someone on the internet with a good or bad experience with both the Canadian and American systems. It's also fair to say that there may be some reasons why an American would go to Canada, and some why a Canadian would go to the United States.

My sister is a pharmacist in Niagara Falls Canada and she's got tons of American patients filling their prescriptions from their American doctors in Canada.

As I said before, the Canadian system is NOT utopia by any stretch of the imagination. However, I believe that there is enough money floating around in the current system that we could provide health care coverage to all and STILL have the system we currently have.

A single payor does not automatically translate into "government run." We should disavow ourselves of that notion.

 

[baya]

The democratic party ought to change their name to the Socialist party.

No thanks.

Do you all want a politician with 3 years of law school under his belt with a nurse practicioner as his/her advisor telling your physician how to practice medicine? I dont, although seems like thats what is happening.

No. Nor do I want the insurance company lackies telling me how to practice medicine. Why should we settle for either scenario?

The government is interested in what is "cost effective." This actually means that they want to provide what is least expensive without being considered sub-standard. Go to a VA hospital or County hospital and you will see what this means and what kind of care you would get under a government health care system.

The situation at VAs and County hospitals is not surprising. When you let the private insurers cherry-pick the healthy and the wealthy, and make the government care for the sick and the poor with inadequate funding, it's no surprise that the care is sub-optimal.

I don't really see how this is an argument against a properly funded health-care for all plan.

Regarding re-imbursements, they are the pits already. I feel bad for the general surgeons. Can you imagine cutting into an abdomen for a hernia repair and getting a measly $300. My plumber makes more that for his time and doesnt assume $10 million in liability if something goes wrong.

yup. This is a problem. I agree.

The government is ruining the medical profession.

How is the current problem the sole fault of the government?

While top notch health care for everyone sounds grand and nice in some kind of utopian la la land, in the United States of America, a governement run health care system would be a disaster. How many political scandals and government screw-ups are in the news each day? Each hour?

plenty. And how many corporate scandals are in the news on a regular basis? plenty. Who's more likely to screw over the public on purpose? Those who wanted to be "public servants" for whatever reason, or those who want to profit? Really, there's plenty of good guys and bad guys in each sector, and the trick is that we need proper oversight for any solution.

 

[alleyesonme]

There are close to 50 million uninsured in the US, which means almost 250 million DO pay for health insurance regularly, and are more or less satisfied. What happens for the majority of people when you change to universal health care, and now their coverage is not what it was before or they now have to wait for services they were able to get in a timely manner previously.
If we take a look at the county and VA system, do you not anticipate that different tiers of health care will continue to develop, as those that can afford "private" care go to physicians where they can pay out-of-pocket.
Finally, when you talk about universal health care and health care spending, somehow, you must try to pass legislation through a House and Senate, which is heavily influenced by lobbyists for both big business insurance companies and doctors. Good luck!

Finally, we can discuss and argue the pros and cons of the system in the US, Canada, UK, etc. all the way to the next presidential election. However, it would be much more useful to propose solutions to the problems, which has yet to be addressed.

 

[KHE]

Finally, we can discuss and argue the pros and cons of the system in the US, Canada, UK, etc. all the way to the next presidential election. However, it would be much more useful to propose solutions to the problems, which has yet to be addressed.

I posted this on another forum: This is my proposed solution to the problem:

Here is my solution to this whole mess…..obviously anyone who reads this is going to be able to say “YEAH! WELL WHAT ABOUT THIS SITUATION OR THAT SITUATION?” Obviously, I’m not smart enough to plan for every possible contingency but here is my proposal in a nutshell.

The solution that I propose is basically this: Medicare for all. The various state Medicaid programs will be scrapped. We will just have medicare for everyone. And that medicare will occur in basically the same form it does now. It will cover 90% of inpatient expenses and 80% of out patient expenses. People have to be willing to pay at least a small portion of the costs over and above what they pay for in “premiums” so that we don’t have a situation where people run to the ER with every scraped knee.

There will be NO DRUG coverage. There will be no coverage for contact lenses or for any “cosmetic” procedure or equipment. It will cover one dental cleaning per year. If you want 2, then you pay for one of them. Patents for drugs would be reduced to 12 years and to obtain a patent, it would have to be shown that the new drug is significantly different than the old one. NO more of this crap where pharmacies add a methyl group to a huge complex molecule and call it a new wonder drug.

Nursing home care would be covered at a defined and reasonable rate. If someone wants to pay more, or purchase insurance to defer the cost of a fancy nursing home, then that is their choice. For those that do not pursue this option, they will still be required to pay 10% of their in patient care at the home. If someone dies, then the medicare program will be able to pursue the estate for the remaining 10% if left unpaid. No more mansions in “trusts” so that a wealthy grandma can impoverish themselves and go on Medicaid because there won’t be any Medicaid.

If patients want to buy private health insurance through any of the current plans to cover medications, extra benefits for glasses or contact lenses, or dental benefits, then they are free to do so.

Doctors will be allowed to participate or not. If they choose not to participate, that is fine. They are on their own to convince patients to pay them privately.

This system will be funded the way it currently is: Through payroll taxes. There would be a 1% increase in payroll taxes to the employee and the employer. Ultimately, this should work out more favorably for both parties because employees won’t have to spend thousands of dollars for health insurance, and employers won’t have to spend thousands of dollars on health insurance.

Reimbursement for office visits and other “visits” would be the same as they are now and the law would be written such that reimbursement for office visits could never go down and the fees for office visits would go up biannually based on inflation. However, reimbursements for procedures and diagnostic testing would be reviewed every 5 years and adjusted up or down accordingly. For example….if someone invents an MRI machine that costs $1000, then the Medicare plan should not have to continue to provide reimbursement based on a machine that once cost $50000. If a new and cheaper process to test blood is developed, then it stands to reason that medicare shouldn’t continue to pay based on the costs of running the old technology.

No discrimination of providers…., podiatrists, chiropractors, physicians, dentists, optometrists, psychologists would all be eligible to participate in the system. There would be fee parity.

Malpractice awards across the land would be capped at $250000 for punitive damages and this amount would go up with inflation. Economic damages would be unlimited.

I have more…but that’s a start. Now, I know that a bunch of people out there are going to moan that it will never happen because of the insurance lobby, or the trial lawyer lobby, or whatever lobby you want. That may well be true. But I still have faith that the public will rise up in support of this. But it is also why this plan requires a strong leader who is not beholden to special interest groups to put it into action.

 

[rubensan]

Doctors will be allowed to participate or not. If they choose not to participate, that is fine. They are on their own to convince patients to pay them privately.

.

I think that your assessment is the direction that we will probably move in. As a health care provider in Los Angeles where "universal health care" (MediCAL) is given to every pregnant woman, child under the age of 18, and people who's income falls below a certain level, it is interesting to see how the dynamics of health care and hospitals have changed since this was implemented. In poorer, urban areas there are providers who opt to take MediCAL but there are virtually no hospital beds to take of these patients when they get sick b/c hospitals will go broke if they have to rely solely on MediCAL reimbursement. All of the hospital beds are in wealthier ares of this city and are staffed by MDs who refuse to take MediCAL. Not so universal.

It is interesting that the county hospital where I work at and Kaiser Permanente's "flagship" hospital in Hollywood where I did my internship are cutting there inpatient services by 25-30% as they open their new hospitals....at a time where they already have a 99-100% census on a given day. On the other hand Cedars, Huntington and USC's University hospital where you sole MediCAL is not accepted are doubling their inpatient capacity. It is one thing to get providers on board, however, if universal health care is going to work we need to have some intelligent policy as far as inpatient services are concerned.

 

[leagueelbow]

Doctors will be allowed to participate or not. If they choose not to participate, that is fine. They are on their own to convince patients to pay them privately.

I feel this is something that could work quite well in some areas of medicine and not so well in others.

For instance, this is already happening in dermatology. My home dermatologist hates dealing with insurances companies so much that he charges each patient privately and generates the paperwork for the patient to file with the insurance company independently. He can do this because he's the only dermatologist serving my rural hometown (and quite a few adjoining areas too)

I'm not so certain this is possible for other fields say family medicine or even opthalmologists. In that same rural hometown, an ophthalmologist who decides to charge private fees instead of accepting insurance would be run out of business by the others who continue to accept insurance.

 

[orbitsurgMD]

I feel this is something that could work quite well in some areas of medicine and not so well in others.

For instance, this is already happening in dermatology. My home dermatologist hates dealing with insurances companies so much that he charges each patient privately and generates the paperwork for the patient to file with the insurance company independently. He can do this because he's the only dermatologist serving my rural hometown (and quite a few adjoining areas too)

I'm not so certain this is possible for other fields say family medicine or even opthalmologists. In that same rural hometown, an ophthalmologist who decides to charge private fees instead of accepting insurance would be run out of business by the others who continue to accept insurance.

What we need to be able to do is be allowed to accept or decline Medicare by procedure. For instance, I might be willing to do office comprehensive exams for the Medicare allowable rate, but not a bilateral ptosis repair or a cataract extraction with IOL. Patients ought to be able to use their benefits either way and decide for themselves whether paying the doctor the extra amount for that procedure is worthwhile or not.

 

[Elden]

If you've never heard John Kitzhaber's thoughts on the matter it is well worth your time (yes, this link is to a loooong video but I promise it's a great discussion!):

http://wecandobetter.org/node/1793

He's a doctor and former governor. And don't let his tie or mustache scare you off, he's perhaps the most sensible speaker on our health care system that I've come across.

Enjoy!