That healthcare thing ... again...

[Zakharra]

Maybe an escalation but the distribution of discretionary Federal funds is their authority to do, naturally its unlikely to be done. But they could target key funding such as medical and science research funding, Federal contracts and reduce funding for transportation projects and select enough programs to make not mandating care (under a state model)  a prefered option.

You tied all federal spending to that one  issue. Which boiled it down to one thing, 'Do it OUR way, or you don't get a damned thing. Period.' It is a very big escalation and I cannot see how constitutionalist could see this as being constitutional at all.

My guess is the High Court ,at most, will toss out the mandate since there are other options to compel participation and uphold the rest of the law, one judge already said that is possible. And the lifetime penalty is likely the vehicle they would use.

Yeah...  Compel participation and a lifetime penalty?  That's really constitutional there, Ruby. Real constitutional..

[RubySlippers]

That is the one benefit they must take the presidency and the Senate with enough seats to prevent procedural blocks to hold off a repeal. Sadly the president has one weapon he could order the adminstration agency to give blanket waivers from Obamacare to all states that ask which is in the law, thereby nullifying it. Of course that person could refuse but what is the odds of that happening.

I think this will come down to politics the health care industry will keep the law in place there is to much money at stake not to by pressuring the GOP, they will have a president that will try to repeal the law and blame the Senate for the Democratic block doing that (if they can hold at least 40 seats). Everyone saves face and the law kicks in in 2014 in full force. I have a feeling that once its in place and states work with it they will find its a good law they can build on. If Obama gets back in then its over nothing will stop it unless they could override a veto.

It will in the end come down though to the Supreme Court if they declare the law constitutional then the issue would fall in favor of the president and put pressure on the GOP since that ammunition would be gone they are using - that the law itself is unconstitutional. Lets say they tie it in with Medicare and Social Security as the same sort of mandate which I feel is what they will end up saying. And that the market is so unique as to make the need for the law pressing and necessary.

[Trieste]

Okay, so I did my best to introduce a fairly narrow topic in the OP, and I'd really appreciate sticking to it. Zakharra and Ruby, maybe you guys can start a dialogue thread if you'd like to continue your discussion? Or you're always welcome to open your own thread? Either way, please take it elsewhere, thank you.

You ain't just whistling dixie, sister. I think that the Affordable Care Act was a step in the right direction. If you look at the health outcomes of the states, those that have ripe social and health care systems have the lowest instances of infant mortality, highest life expectancy, and best overall health. If <insert delinquent state name> won't provide for it's citizens, it's up to us to do it.

The strongest proponents of "repeal and replace" have been, as far as I have seen, people who would not be affected at all by the Affordable Care Act. At least, I think so. Sometimes it's hard to tell what Michelle Bachmann is saying, since she has a habit of starting one sentence and finishing another.

[Oniya]

So, I was walking up to the store yesterday, and there was a group of protestors outside our post office (no clue why) who were upset because apparently the healthcare bill covers certain female-only procedures.  I'm sure you can all guess, but I don't want to derail the thread into that debate.  I can't help thinking that it's far more appalling that something like 50 million people are without health insurance at all.

If I ever see them when I don't have a little Oni in tow, I'm going to ask them about that.

[HockeyGod]

The strongest proponents of "repeal and replace" have been, as far as I have seen, people who would not be affected at all by the Affordable Care Act. At least, I think so. Sometimes it's hard to tell what Michelle Bachmann is saying, since she has a habit of starting one sentence and finishing another.

Yes, I would agree. I would add that they have false perceptions that they won't be affected by the ACA. This is a game changer and we'll all be affected - for the most part positively. Will there be losers? Of course, I don't think there has ever been a policy or law that didn't have some winners and some losers. *sigh* This gets back to my point (was it in this thread, I've already forgotten?! lol) that if you repeat a lie enough it miraculously becomes truth. Sad.

Interestingly on my recent trip to the UK I went to the People's Museum in Edinburgh. Basically it is a museum of various movements and history of the people - nothing to do with royalty or well known historical figures. I happened across this poster...



I did ask to take photos and the docent allowed. You could take photos in the museum for a suggested donation.

Anyway, what I find interesting is that the poster could be used today, just substitute "Privatization" with "ACA" and substitute "NHS" for "market" or "individual" or "freedom" or whatever other word is being used to decry health care reform.

[RubySlippers]

Simple answer heartless and clueless politicians that don't get basic facts. If poor people don't get care they end up in the ER/Hospitals, they can't or won't pay their bills and can't go to jail for non-payment of debts therefore the costs get passed on to those that can pay. And the Federal, state and local government have to add in money for indigent care to hospitals or they will not stay open so its an added hit in that besides your own costs get higher the taxes also pay for the poor.

The extended costs are poor people become disabled and can't work and then qualify for social security, Medicaid, food stamps and other assistance making them even more of a burden.

The basic economics is not hard to understand for me I can't pay then someone else has to, is that so complicated?

[Sure]

Out of all my experiences with insurance or lack thereof, being under Masshealth was only slightly better than being uninsured and practically equivalent in most cases. But then again, I had people trying to sabotage my ability to access it for various reasons.

Anyway, my issues:
1.) It still presumes to insure children through their parents, which is incredibly disadvantageous to those without a conventional nuclear family, such as the over two million orphans in the US.
2.) There's still a lack of coverage for men's health in various areas (andrology, male breast cancer, etc). In other places, it continues issues such as female birth control being more widely available than male.
3.) The regulation of the insurance markets is still balkanized, only one of the results is that insurance tends to be state based and doesn't apply throughout the whole of the US.
4.) The second part of that last statement actually deserves its own talking point: Travel a lot? Don't stay in one place a lot? It's hard to find health insurance which easily covers you.
5.) The current system of administering healthcare is far too complex and wasteful. The bill preserves this, and though the solution did not necessarily have to be a single payer system but after the Democrats gave that up they apparently just decided to give up on this front.

That's what I can think of off the top of my head. Any bill which implemented the third and fifth point, possibly the fourth as well, would be so different as to be remarkable, and overwrite various portions of the current bill.

[js207]

I am UK based lady and what really gets my goat is when people complain about the NHS (our national healthcare service). They complain the wait time in hospitals is too long and that the food sucks or whatever :P

But I know when I am ill I do not have to worry about anything other than getting better, I know that there will be someone there to take care of me and I know (like you) that I can ask for help if I need it.
(quote snipped slightly)
People argue about what should be free and what shouldn't and it is hard to tell where the line should be drawn.
Currently you can get plastic surgery on the Nhs for things like boob jobs if your body negative feelings are upsetting your life, obese people and smokers get healthcare for 'self inflicted' problems (which is a massive debate among some circles) and so on.

It really gets my goat when I see comments like this ... yes, wait times can indeed be too long, or you can simply be denied treatment entirely. Yes, you can get the taxpayer to fund your boob job - but you may well be denied funding for treatment to prevent you losing your eyesight, or to treat expensive forms of cancer, because someone else's rack adjustment came higher up the budget priorities. My mother had to pay hundreds of pounds last year to see an orthopaedic surgeon and get the foot surgery she needed - her GP had tried an NHS referral, but that was blocked (diverted to an orthotic technician to try giving her an insole - something the GP had already tried anyway, without success) so she had to get a private referral to see the same surgeon without getting blocked by NHS interference. Back in the late 90's, I needed a CT scan ... for which the wait was well over a year, unless I paid.

Is healthcare here free? Far from it; not only do those of us with jobs pay a substantial amount for it, far too many of us needing treatment then have to pay for it a second time in order to receive the treatment anyway. It is generally cheap (cheaper than most of Europe) and generally adequate, though far too many people get denied treatment or end up having to pay privately for the care they need anyway. I do find their priorities quite disgusting in places, that completely non-essential procedures can be funded easily while genuinely necessary treatment is delayed or denied.

The $400/yr "saving" thanks to the taxpayer picking up the tab for that poster's contraception is depressing as well as short-sighted. Apart from anything else, you do know premiums are up about 9% in the last year, thanks largely to the first batch of ACA changes? Where did you think the $400/yr was going to come from?

Had I been in charge, the approach would have been very different. For one thing, I'd have addressed Sure's points 3 and 4 fully, by legislating for inter-state sale of health insurance, pre-empting state coverage mandates to keep costs down. No more denying people insurance against heart attacks because they can't afford to pay for IVF as well!

[Trieste]

The $400/yr "saving" thanks to the taxpayer picking up the tab for that poster's contraception is depressing as well as short-sighted. Apart from anything else, you do know premiums are up about 9% in the last year, thanks largely to the first batch of ACA changes? Where did you think the $400/yr was going to come from?

Given that I have state names peppered all through my post, I thought it would be obvious that I am in the US rather than the UK. It's not the taxpayer that picks up my tab; my insurance is not subsidized whatsoever. So for me, not having to pay a co-pay for hormonal birth control is a savings. Please read a little more carefully before dismissing my viewpoint as short-sighted, thank you.

P.S. On a whim, I did the math, and if the insurance company raises my premium by the 9% due to this change, it will only be $189 more. So I'm still saving money. Interesting.

[RubySlippers]

About the NHS okay it may have issues but if you are poor and sick will the person get generally accepted medical preventative and life saving care or not? Seems to me if you were in the US your shafted since if your poor your not going to get preventative care for common medical conditions like diabetes and when you get sick a hospital may not have to treat you unless your life is in danger then smack you with a huge bill.

Just two weeks ago I was peeing up blood badly, went to the ER scared, they did tests finding out it was a bladder infection and treated me (iv with water, a antibiotic and a prescription) lasting an hour. The bills are almost $5k! I have a low income, make only cash for income, have no bank account, no car, no house and my credit rating is 390 so I figure there is not much they can do to me. Tried negotiating the bill nothing is offered I can afford they want their money in at most 6 months. So have no choice but to tell each billing party I can't pay ,save the labs that was $39, and let them go to collections if they care to take it that far. Guess where they will end up getting the money. I'm why they passed Obamacare if it was income based I would have access to Medicaid then.

$5000 to me is my annual income for the most part off the books and add $2000 reportable income, $5000 in six months is just not doeable.

So who would repeal this anyone without mercy and without common sense we cost the system money when poor and uninsured and have pre-existing conditions. And worse there is a mandate in place if my condition was urgent and life threatening the hospital and others would have to treat me in the US so why is that good and Obamacare bad? Then I would be a charity law case ,if I was admitted that day, and the hospital couldn't bill me for the bed, drugs etc. but they would pass that on to everyone else. But ER release I have no such safeguards. Plus they fix it so the ER doctor, labs, all tests are done by different parties so the hospital is technically not doing them. Then I get six bills from different parties most of which if I was admitted I'd still be on the hook with.

Do I like this no. If they took payments in amounts I could afford I would pay, but none are talking about that. So in short yes I wish I was in the NHS it would better than what I have now - nothing pretty much.

But arguing about the repeal is threatening lives most of us are law-abiding citizens doing the right thing in the main and scraping by, if i commited a crime and go to jail I would get health care the Sheriff has this nice faciility all new that is a mini-hospital. Your a decent citizen your not. That just doesn't make sense to me.

[LustfulLord2011]

The healthcare system is somewhat of a shambles right now. Health insurance isn't available to everyone, and a lot of people in need of serious medical treatment have been turned away because they cannot afford to pay. In addition, the health insurance companies consider it a loss any time that they have to pay on a claim at all, so they actively try to make sure that you get the lowest possible level of service for your money. Health care is one thing that I think SHOULD be socialized; it's the only way I see to ensure that everyone gets the care they need, and that the health care providers actually get paid. Make federal insurance available to ALL citizens, and allocate a portion of the income tax around the country to subsidize it. Of course, for such a plan to work, they would have to remove the caps on the income tax... otherwise, there wouldn't be NEAR enough money to handle it.

[js207]

Trieste: I am well aware you're in the US - apart from anything else, prescription co-pays are much lower than that in England, and zero in Scotland. Yes, your extra 9% doesn't make up for their lost $400 - so either you or their other customers will be making up that shortfall somewhere else - higher copays on other things, higher premiums again next year, service cuts. Economically speaking, there are good reasons for copayments existing, and eliminating them really is a short-sighted "saving" measure overall.

RubySlippers: Turn up at an NHS hospital as an emergency case (i.e. ER), you will get necessary life-saving treatment to stabilise your condition for discharge - much as you would in the US; for anything else, you need to go through your GP to see if you can get funding approval for it, just as you would with an HMO plan in the US only with longer waits and less recourse if denied treatment. (The test they apply here is not 'generally accepted' care, but a cost figure set and assessed by a government committee named NICE: essentially, treatment must cost less than X thousand per quality-adjusted year of life expectancy, which is why certain treatments to save eyesight got denied funding.) The $5k bill for an IV and antibiotic does sound stupid - but as you said, you know part of that is to pay for that unfunded mandate to provide treatment to people who can't pay.

Lustful: Yes, they try to avoid spending money where possible - hardly a shock, the NHS does too. Your complaint sounds more like an argument for reforming and expanding Medicaid - in particular, improving the unfunded mandate which causes the problems RubySlippers noted and inflates costs for other people - but "ObamaCare" actually does precisely the opposite, as Illinois discovered to their cost when they wanted to check people's Medicaid entitlement and were blocked by the federal government. What "cap" on income tax are you thinking should be removed?

[Trieste]

If you'd like, you're perfectly welcome to throw out those economic reasons - in another thread. As it stands, the stats you were tossing around are irrelevant, and also off-topic to the original discussion of "repeal and replace". :)

[js207]

If you'd like, you're perfectly welcome to throw out those economic reasons - in another thread. As it stands, the stats you were tossing around are irrelevant, and also off-topic to the original discussion of "repeal and replace". :)

You have a point, yes: the $400 figure isn't really relevant to this (though it wasn't me who raised it!) - and I had missed that you were referring to Massachussetts at that point, but the 9% I quoted was US-wide and specifically regarding PPACA not MA, so the extra $189 you'll be paying (assuming your policy is average) is unrelated to the extra costs your policy is now incurring in MA, but very much relevant to the question of repealing/replacing PPACA or not.

Back to PPACA then: what are you getting for your extra $189, now we know that isn't replacing the $400? 'Sure' posted a list of 5 problems, all of which PPACA either overlooks or makes worse rather than better. Yes, the MA law moves the cost of your contraception around, but what does PPACA do for or to you?

(As an aside, I also note that you are paying less for your health insurance than I pay for the NHS right now - and doesn't provide me with any contraception, either.)

[Callie Del Noire]

Robert Reich - 7 Lies
His later points on Medicare/Medicaid are very interesting.

[Torch]

(As an aside, I also note that you are paying less for your health insurance than I pay for the NHS right now - and doesn't provide me with any contraception, either.)

I would presume that's because you are male. I don't know of any health insurance provider in the US that provides contraception for men, other than the permanent kind.

[Caela]

Callie, the video is interesting. My biggest issue with what he said was when he mentioned trying to change the way we pay docs/hospitals to being from fee for services, to fee for healthy outcomes. I promise you if they do that you will get a lot of docs and hospital that will simply STOP performing many of their services! You can't always fix someone that's sick and get a healthy outcome.

When I worked in a Main OR I did mostly vascular surgery and a LOT of what we did wasn't going to make the patient any better. It was extending their lives, maybe making them more comfortable, maybe giving them a little longer to try and move up a transplant list but it did very little to make them healthier. You saw these patients and KNEW they were pretty much the walking dead and just hadn't given in to that final outcome yet. Or their families hadn't. The number of patients we were working on simply because the family wouldn't let go was staggering! There would be no "healthy outcome" for them and if that's the criteria for paying a doc you'll find a lot of them just saying, "No."

Speaking from a surgical standpoint as well, there are a lot of unhealthy outcomes that have nothing to do with the doctor and the service they provided, but with the patient themselves. The number of folks that are non-compliant with their doc's orders and prescriptions is amazing. Will there be some sort of penalty for these people because if there's not you'll again just see a bunch of healthcare people going.."No."

Doctors, nurses, techs of all kinds, work hard and deserve to be compensated for the time and effort they put in, not just for the outcome of that work.

I'm all for finding ways to cut the cost of healthcare, but to tie being paid to an outcome that can be effected by things entirely outside the control of the treating physician (or if the patient has more than one, who do you blame if the outcome is bad???) and entirely invalidating the work they did simply because the family, spouse, patient, isn't happy with the result. 

[RubySlippers]

I would like to point out its not always the patiants fault I often get treatment orders up front I have no hope to follow up with. Case in point I had a leg infection and was in the hospital almost a week ,yes I paid the bills the charity care law eliminated all hospital charges, but the doctor ordered a $1500 antibiotic (10 pills) and I was clear I did not have that kind of money. I insisted he find something I can afford or I would not sign any release papers and when he did not take that seriously I did just that. A visiting Indian doctor suggested a drug available at Walmart that cost $4 for a ten day course of treatment (40 pills for $6) and it worked fine. My follow up was not an issue. But the prefered drug was for me astronomical in cost.

So what is a patiant to do if you say this to most doctors its like talking to a brick wall that money is an issue in care. I would argue most of the time its this case we are not bad patiants just have to be realistic on what we can and cannot do.

[Callie Del Noire]

Callie, the video is interesting. My biggest issue with what he said was when he mentioned trying to change the way we pay docs/hospitals to being from fee for services, to fee for healthy outcomes. I promise you if they do that you will get a lot of docs and hospital that will simply STOP performing many of their services! You can't always fix someone that's sick and get a healthy outcome.

I agree with the concern. it's one of the things I wasn't too sure of in the video. HOWEVER, I think that a lot of the drug companies are more interested in treating than curing. And that is something that needs to change. Medical issues are, and always will be, sticky and tricky.

[Oniya]

I'll admit that I don't always agree with everything Reich says, but he's got a good head on his shoulders more often than not.  The 'cure-based pay' for doctors sounds just as 'fair' as that deal they have where teachers get paid based on how well their classes do.

Which is to say, not very.

There are some diseases that just can't be cured, such as most cases of pancreatic cancer (it metastasizes quickly and without many symptoms until it hits end-stage).  Merit-based pay for doctors would mean nobody would want to go into oncology or geriatrics.

[Caela]

I would like to point out its not always the patiants fault I often get treatment orders up front I have no hope to follow up with. Case in point I had a leg infection and was in the hospital almost a week ,yes I paid the bills the charity care law eliminated all hospital charges, but the doctor ordered a $1500 antibiotic (10 pills) and I was clear I did not have that kind of money. I insisted he find something I can afford or I would not sign any release papers and when he did not take that seriously I did just that. A visiting Indian doctor suggested a drug available at Walmart that cost $4 for a ten day course of treatment (40 pills for $6) and it worked fine. My follow up was not an issue. But the prefered drug was for me astronomical in cost.

So what is a patiant to do if you say this to most doctors its like talking to a brick wall that money is an issue in care. I would argue most of the time its this case we are not bad patiants just have to be realistic on what we can and cannot do.

Ruby, I wasn't talking about patients that can't afford to do something, I was talking about patients that DON'T.

Easiest example from my own experiences: We would have diabetics coming in that had insurance that covered their insulin, so having their drugs wasn't a problem. These people get extensive training on how to deal with their disease and knew what they should/shouldn't be eating and how they needed to modify their lives to best handle condition. They CHOOSE to disregard the proper use of their meds and CHOOSE to live their lives in a manner that aggrevates their disease instead of helping it. They choose to eat things they know they shouldn't and simply jack up the amount of insulin the give themselves instead of actually managing their sugars properly.

So what happens to them? The diabetes ravages their bodies and they come in for surgery after surgery and we slowly chop parts off their bodies as their neuropathy's (I know I spelled that wrong) get worse and they develop gangrene in their extremities.  There is no healthy outcome for these patients because they choose to be totally non-compliant in their own care.

If payment is based on healthy outcomes and not on the work being done then what are doctors supposed to do with these people? Just let them die because they make bad decisions?

[Callie Del Noire]

I'll admit that I don't always agree with everything Reich says, but he's got a good head on his shoulders more often than not.  The 'cure-based pay' for doctors sounds just as 'fair' as that deal they have where teachers get paid based on how well their classes do.

Which is to say, not very.

There are some diseases that just can't be cured, such as most cases of pancreatic cancer (it metastasizes quickly and without many symptoms until it hits end-stage).  Merit-based pay for doctors would mean nobody would want to go into oncology or geriatrics.

True.. but when you have a disease being TREATED with no intent for curing by industry, they need to be persuaded to change their outlook. The medical community on the other hand, has jumped the shark on how they are run. HMOs have really boned a lot of folks. As a disabled Vet, if it wasn't for Tricare being accessable to me I'd really be screwed. And that is just for my bipolar issues.

[Caela]

I'll admit that I don't always agree with everything Reich says, but he's got a good head on his shoulders more often than not.  The 'cure-based pay' for doctors sounds just as 'fair' as that deal they have where teachers get paid based on how well their classes do.

Which is to say, not very.

There are some diseases that just can't be cured, such as most cases of pancreatic cancer (it metastasizes quickly and without many symptoms until it hits end-stage).  Merit-based pay for doctors would mean nobody would want to go into oncology or geriatrics.

Nobody would want to go into a lot of doctoral fields. You'd lose a lot of surgeons too, particularly vascular surgeons where a lot of the surgeries are palliative or just to extend things a little longer (such as dialysis fistulas) so a patient might make it long enough for a transplant.

Oh and paying teachers based on how kids do on standardized tests if F*****! They end up having to teach for the test instead of just teaching so the kids end up learning LESS then if you just left the teachers alone to teach their lessons. I get that there needs to be some gauge to how well students in a system are doing but there has to be a better way. No idea what it is, but there has to be something better.

[Torch]

  Merit-based pay for doctors would mean nobody would want to go into oncology or geriatrics.

This is already happening, at least on some level, with obstetrics. OB's know that anything less than a perfect outcome, i.e. perfect baby, is going to result in a lawsuit by the patient. Many OB/GYN's are simply fed up with outrageous malpractice insurance premiums along with sue-happy patients. They are either retiring, or dropping the obstetrics part of their practice to concentrate solely on gynecological patients.

[Caela]

This is already happening, at least on some level, with obstetrics. OB's know that anything less than a perfect outcome, i.e. perfect baby, is going to result in a lawsuit by the patient. Many OB/GYN's are simply fed up with outrageous malpractice insurance premiums along with sue-happy patients. They are either retiring, or dropping the obstetrics part of their practice to concentrate solely on gynecological patients.

This isn't the case where I'm at. At least not at the moment. We have a raging OB service going! lol We have two large groups and like four smaller ones and then our residents clinic as well and everyone is doing just fine. I do know a few OB's that dropped the OB part of their practice as they got older and chose to concentrate strictly on GYN but haven't noticed a drop in OB's overall. I think most of the docs are tired of the ridiculous malpractice insurance and all the CYA they already have to do...which doesn't help with the cost of healthcare in the least.

Talking to one of the old GYN's I used to work with (he had his own practice, not part of a hospital and no partners so everything fell on him) and he told me that to get all the bills paid for the year, staff, equipment, malpractice insurance etc. he had to clear a million dollars...before he started actually getting to pay himself. Nearly 1/3 - 1/2 of that was malpractice insurance ALONE. The man had reached the point in his career where he did strictly elective procedures, NO OB, no high risk surgeries, no oncology etc. and still nearly a 1/4 of his yearly income went to malpractice insurance. It is insane what they will let people sue a doctor for.

People need to understand...a bad outcome does NOT necessarily mean any malpractice was committed!