20th January, 2017

[AnthonyM]

No Bart. that will be the salvation when true commerce is in place.

Not for the sick who cannot pay the price.

[Craig Lamson]

Not for the sick who cannot pay the price.

Many are currently covered in most states by Medicaid. 

[Rob C]

Regarding doctors and making a profit.

Doctors in Spain get paid to work for the health service, as they do in the UK and anywhere else I know of that has a national health service funded by taxation. Of course they get paid, but that's not commerce: that's having a job.

In Spain, for sure, some docs also have a private practice of their own, but they also work a given amount of time for the state provision. I remember seeing one doctor who dealt with my wife in a private hospìtal also working in the emergency section of the public service when she was taken there in an emergency. There's a cross-over that seems to work.

The problems arise when private companies become embroiled in the provision of state services. Medicines, as in drugs, are another thing altogether, and the cost of those is negotiated most of the time, with the R&D costs etc. proportioned out in various ways via those prices. Problems arise when some new drug comes along and the companies want too high a price for the pubic services' pockets. As result, medication touted as cure for cancer or some other highly emotive ailment is refuses listing as prescribed drug by the public service, and then all hell breaks loose as to why. At which point the wonderful press leaps in and cries foul! and sells even more rubbish on the back of promised exposés, when most of the time all they can expose is the total non-news that drug companies make a bleedin' fortune. Just look at their listings on the stock market if in any doubt: they are money in the bank, pre-collapse bank.

Separation is key, in my opinion, and I can never accept that access to medical assistance should depend on wealth of patient, which any form of private health insurance cannot avoid representing. Of course, if sufficient exclusions and restrictions are built in, then a low-cost insurance becomes of less value than none.

Bit of a mess, really.

Rob

[BradSmith]

The underlying problem in the US regarding the cost of health care is, imho, fairly simple.  It isn't the cost of insurance or drugs or who pays for it.  It is the total amount of money that flows to the industry.   Too many people involved, earning too much money.  Money only flows to, or benefits people.  A relatively small amount goes to shareholders of public corporations involved in the industry.  But it mostly goes to salary/benefits for people involved directly and indirectly in this industry.  These include: medical professionals and all other employees of health care companies and; to all the employees of pharmaceutical and med equipment companies; to researchers; to construction workers who build immense hospitals and clinics; and to the people who research, design, manufacture, install and maintain all of the equipment in those facilities. 

I have a friend who spent 20 years of his career in executive management of a couple high tech, stock exchange listed computer based firms at the Chief Financial Officer type level.  He was recruited away into the bio-med research/pharma world in a similar position for another exchange listed company.  All of these firm's HQ's were in the same area.  He was stunned at the salaries in his new industry being paid to people, top to bottom, at ALL levels, not just the top people.  As just one example, he said that low level accounting staff in the Finance Department earned, on average, about 60% more per year in his new med related company than the same type people in the high tech computer company. 

Unless and until something is done to either reduce the number of people in and/or supporting the industry or to reduce their salaries, we're just proverbially rearranging the deck chairs on the Titanic.
Brad   

   

[Alan Goldhammer]

I think you really have to remove the private insurance element from the public sphere. The twain cannot function in harmony because the private will always seek all ways by which to drive up costs and exploit the situation to profit. It's its raison d'être.

Both the Netherlands and Switzerland provide healthcare to all citizens though a highly regulated private insurance network.  There have been some very good proposals here in the US to do the same thing.  Of course it doesn't provide Cadillac care but one could purchase after market insurance for that.  Medicare right not doesn't provide everything and one needs to have an add on policy.  If you want to read more see:  http://www.hamiltonproject.org/assets/legacy/files/downloads_and_links/A_Comprehensive_Cure-_Universal_Health_Care_Vouchers_Brief.pdf  My friend Zeke Emanuel is one of the authors of the voucher proposal

Alan

[Alan Goldhammer]

Many are currently covered in most states by Medicaid.

But not if they move to block grants to the states.  Even Dr. Price who is the nominee for Secretary of Health and Human Services said so at his confirmation hearing.

[Craig Lamson]

But not if they move to block grants to the states.  Even Dr. Price who is the nominee for Secretary of Health and Human Services said so at his confirmation hearing.

It would then  be up to the states to fund them, if they wish, if that were to happen. I have no problems with that at all. I

[Craig Lamson]

Both the Netherlands and Switzerland provide healthcare to all citizens though a highly regulated private insurance network.  There have been some very good proposals here in the US to do the same thing.  Of course it doesn't provide Cadillac care but one could purchase after market insurance for that.  Medicare right not doesn't provide everything and one needs to have an add on policy.  If you want to read more see:  http://www.hamiltonproject.org/assets/legacy/files/downloads_and_links/A_Comprehensive_Cure-_Universal_Health_Care_Vouchers_Brief.pdf  My friend Zeke Emanuel is one of the authors of the voucher proposal

Alan

Yea, Emanuel did such a fine job on the ACA. [/sarcasm]  I think I'll pass.

[N80]

Get back to us when the forgotten folk that Trump appealed to are still forgotten in 4 years time, and no longer have health care, and are joined by a whole lot more folk who lost their jobs when protectionism fails.

The positive impacts of the ACA have been inflated. This idea that it provided 20 million people with insurance is grossly misleading. Several million of these were just children under 26 who stayed on parent's plans. Many if not most of these would have had some other health insurance without the ACA. The largest portion of these 20 million (12-14 million) were covered by state Medicaid plans that were extended by the ACA, not ACA exchanges as most people are lead to believe. The problem with extended Medicaid is that it is funded by the ACA for a few years and then reverts back to the states to pay for. None of the states that accepted this could afford their own Medicaid budget before and certainly will be plunged into fiscal crisis when they will have to pay for more than they could afford before.

So in fact, no more than about 8 million or so have gone on ACA exchanges. Of these a certain percentage would have afforded existing commercial plans before the ACA gutted them.

And the fact is that even this smaller number could not be supported by the companies who ran the exchanges. They were losing millions on these plans and most of the major providers bailed late last year and this year.

Also, many if not most physicians and hospital systems did not accept ACA exchanges. In my previous practice (part of one of the largest healthcare systems in the nation, did not). So I lost patients who signed up, confirming Obama's calculated lie that you could keep your doctor. Then, they could find no one to see them. The had insurance but couldn't access care. I now accept ACA exchanges but they are next to useless for people who are really sick. The cost is high and the deductibles are astronomical. My truly ill ACA patients are no better off than before. Many of my currently uninsured patients cannot afford any ACA exchange and are now 'tax' criminals for remaining uninsured.

Too many people are still drinking the ACA kool-aid. No matter what you think about how the system was before, the ACA has been an unmitigated disaster and this is not to mention how many physicians are leaving medicine because of the oppressive bureaucratic burdens it has required. We are 20 percent less efficient than before the ACA. That means 20% fewer patients seen. That means decreased access for EVERYONE.

My prediction is that Trump and the Republicans are going to make a staggering mess of all this. But I also predict that their mess will not be any worse than the mess Obama has caused. From the inside, as a physician, and insurance customer and a patient, US healthcare is at its worst level in 30 years.

[N80]

The underlying problem in the US regarding the cost of health care is, imho, fairly simple.  It isn't the cost of insurance or drugs or who pays for it.  It is the total amount of money that flows to the industry.   Too many people involved, earning too much money.  Money only flows to, or benefits people.  A relatively small amount goes to shareholders of public corporations involved in the industry.  But it mostly goes to salary/benefits for people involved directly and indirectly in this industry.  These include: medical professionals and all other employees of health care companies and; to all the employees of pharmaceutical and med equipment companies; to researchers; to construction workers who build immense hospitals and clinics; and to the people who research, design, manufacture, install and maintain all of the equipment in those facilities. 

I have a friend who spent 20 years of his career in executive management of a couple high tech, stock exchange listed computer based firms at the Chief Financial Officer type level.  He was recruited away into the bio-med research/pharma world in a similar position for another exchange listed company.  All of these firm's HQ's were in the same area.  He was stunned at the salaries in his new industry being paid to people, top to bottom, at ALL levels, not just the top people.  As just one example, he said that low level accounting staff in the Finance Department earned, on average, about 60% more per year in his new med related company than the same type people in the high tech computer company. 

Unless and until something is done to either reduce the number of people in and/or supporting the industry or to reduce their salaries, we're just proverbially rearranging the deck chairs on the Titanic.
Brad   

 

Yes, great idea. Pay your cardio-thoracic surgeon less. Let's see, four years of college, four years of med school, residency programs for this level are often 7 years and the pay is pathetic and the workload is far more than any other field will even allow. Debt for them at this point often hundreds of thousands of dollars. So sure, cut their pay. Then see what you get.

It is already happening in primary care, the lowest paid physicians. The best and brightest either reject medicine altogether or they elect not to do primary care. You suggest fewer providers when there is a national shortage and access to care is getting worse every day?

It is amazing that people who think like this still expect and demand the highest levels of technology and care when their lives and health are on the line. And all of this in a culture that does not bat and eye at a basketball player or movie star making 20 million dollars a year.

[kers]

I do not know anything about ACA or Obamacare...
I live in the Netherlands and here everybody needs to have a standard basic heath insurance. If you earn too little the state pays for it.
You can have a basic heath insurance for 100$ a month for an employee and some part for the employer.
Adds on can be bought separately.
The insurance has a yearly own risk of 350$
It used to be a state insurance now it is privatized ; we have about 4-5 insurance companies. You can change your insurance company every year.
It works reasonably well. The insurance companies have reduced medicine costs and made hospitals work more together.

[Craig Lamson]

The positive impacts of the ACA have been inflated. This idea that it provided 20 million people with insurance is grossly misleading. Several million of these were just children under 26 who stayed on parent's plans. Many if not most of these would have had some other health insurance without the ACA. The largest portion of these 20 million (12-14 million) were covered by state Medicaid plans that were extended by the ACA, not ACA exchanges as most people are lead to believe. The problem with extended Medicaid is that it is funded by the ACA for a few years and then reverts back to the states to pay for. None of the states that accepted this could afford their own Medicaid budget before and certainly will be plunged into fiscal crisis when they will have to pay for more than they could afford before.

So in fact, no more than about 8 million or so have gone on ACA exchanges. Of these a certain percentage would have afforded existing commercial plans before the ACA gutted them.

And the fact is that even this smaller number could not be supported by the companies who ran the exchanges. They were losing millions on these plans and most of the major providers bailed late last year and this year.

Also, many if not most physicians and hospital systems did not accept ACA exchanges. In my previous practice (part of one of the largest healthcare systems in the nation, did not). So I lost patients who signed up, confirming Obama's calculated lie that you could keep your doctor. Then, they could find no one to see them. The had insurance but couldn't access care. I now accept ACA exchanges but they are next to useless for people who are really sick. The cost is high and the deductibles are astronomical. My truly ill ACA patients are no better off than before. Many of my currently uninsured patients cannot afford any ACA exchange and are now 'tax' criminals for remaining uninsured.

Too many people are still drinking the ACA kool-aid. No matter what you think about how the system was before, the ACA has been an unmitigated disaster and this is not to mention how many physicians are leaving medicine because of the oppressive bureaucratic burdens it has required. We are 20 percent less efficient than before the ACA. That means 20% fewer patients seen. That means decreased access for EVERYONE.

My prediction is that Trump and the Republicans are going to make a staggering mess of all this. But I also predict that their mess will not be any worse than the mess Obama has caused. From the inside, as a physician, and insurance customer and a patient, US healthcare is at its worst level in 30 years.

True story about how even the simple things have gotten worse since Obamacare.  When my Dr used to order blood work she checked off boxes on a single page.  Now I get, anywhere from four to 6 pages from the printer for the same tests.  So much more efficient and cost effective.  The reality for me now is that I end up paying for everything out of pocket now because I don't reach my deductible. In practice I don't really have a problem with that, but I can't just buy a catastrophic policy to cover the big stuff.  I'm forced by the government to buy an"ACA" compliant policy that covers many things I don't need.

[Craig Lamson]

Yes, great idea. Pay your cardio-thoracic surgeon less. Let's see, four years of college, four years of med school, residency programs for this level are often 7 years and the pay is pathetic and the workload is far more than any other field will even allow. Debt for them at this point often hundreds of thousands of dollars. So sure, cut their pay. Then see what you get.

It is already happening in primary care, the lowest paid physicians. The best and brightest either reject medicine altogether or they elect not to do primary care. You suggest fewer providers when there is a national shortage and access to care is getting worse every day?

It is amazing that people who think like this still expect and demand the highest levels of technology and care when their lives and health are on the line. And all of this in a culture that does not bat and eye at a basketball player or movie star making 20 million dollars a year.

I loved that line too.   Let's rephrase it.

High end fashion photographers get paid too much.   Their compensation should be lowered so the are paid the same as the average baby photographer.   After all they are both just taking photos of people....

[Rob C]

I loved that line too.   Let's rephrase it.

High end fashion photographers get paid too much.   Their compensation should be lowered so the are paid the same as the average baby photographer.   After all they are both just taking photos of people....

If those high-fliers work shooting fashion for the state (highly unlikely!) then you may have hit on something... Thing is, neither I nor my wife ever had to hire a photographer, which would have been a discretionary action; having cancer is not. Neither is a heart attack nor a broken leg.

Nobody was suggesting, AFAIK, that docs not be rewarded for their efforts, and if they are working in the private sector, sky-high payment might be fair too: as long as there's a choice for the citizenry of a good public system, taxation funded, at reasonable cost. That will never be offered via a business model. Business means business, which means as much as you can pull out of the deal. I already suggested an earnings point at which you jump from state medicine to private insurance. I wouldn't expect Mr Trump or his fellow politicos to expect to go public health. Nor Mr Gates, of course.

As I suggested posts ago, there has to be a totally independent national system, where all docs owe the country that educated them so many years of their trade. For example: you want to study medicine in the UK, fine: then accept that you give back ten, fifteen years after which you can also do private work, as long as the state still gets a slice of your time as well. If you are a foreign student studying in the UK, then great, too: you pay whatever the courses cost, and can then waltz back to where you came from and syphon the blood of your own people, but the UK will have incurred no debt for you to reimburse: you paid up front.

Seems fair to me.

Rob C

[Craig Lamson]

If those high-fliers work shooting fashion for the state (highly unlikely!) then you may have hit on something... Thing is, neither I nor my wife ever had to hire a photographer, which would have been a discretionary action; having cancer is not. Neither is a heart attack nor a broken leg.

Nobody was suggesting, AFAIK, that docs not be rewarded for their efforts, and if they are working in the private sector, sky-high payment might be fair too: as long as there's a choice for the citizenry of a good public system, taxation funded, at reasonable cost. That will never be offered via a business model. Business means business, which means as much as you can pull out of the deal. I already suggested an earnings point at which you jump from state medicine to private insurance. I wouldn't expect Mr Trump or his fellow politicos to expect to go public health. Nor Mr Gates, of course.

As I suggested posts ago, there has to be a totally independent national system, where all docs owe the country that educated them so many years of their trade. For example: you want to study medicine in the UK, fine: then accept that you give back ten, fifteen years after which you can also do private work, as long as the state still gets a slice of your time as well. If you are a foreign student studying in the UK, then great, too: you pay whatever the courses cost, and can then waltz back to where you came from and syphon the blood of your own people, but the UK will have incurred no debt for you to reimburse: you paid up front.

Seems fair to me.

Rob C

The original posters example was talking about accounting people, not DRs.  You seem fine with having the government in charge, and that's fine.  Others are not, and in the US that's a lot of people.  Different strokes.  And here, you pay your own costs for education.  The "state" does not train you.

Let's just say we agree to disagree.

[Alan Goldhammer]

True story about how even the simple things have gotten worse since Obamacare.  When my Dr used to order blood work she checked off boxes on a single page.  Now I get, anywhere from four to 6 pages from the printer for the same tests.  So much more efficient and cost effective.  The reality for me now is that I end up paying for everything out of pocket now because I don't reach my deductible. In practice I don't really have a problem with that, but I can't just buy a catastrophic policy to cover the big stuff.  I'm forced by the government to buy an"ACA" compliant policy that covers many things I don't need.

A Bronze Obamacare Policy does just what you want.

[Alan Goldhammer]

And the fact is that even this smaller number could not be supported by the companies who ran the exchanges. They were losing millions on these plans and most of the major providers bailed late last year and this year.

Not true, only a few bailed and of course were highly profiled in the press.  The one real failure has been in the more rural areas where providers have a difficult time making a go of it.  That was true before Obamacare as well.

Also, many if not most physicians and hospital systems did not accept ACA exchanges. In my previous practice (part of one of the largest healthcare systems in the nation, did not). So I lost patients who signed up, confirming Obama's calculated lie that you could keep your doctor. Then, they could find no one to see them. The had insurance but couldn't access care. I now accept ACA exchanges but they are next to useless for people who are really sick. The cost is high and the deductibles are astronomical. My truly ill ACA patients are no better off than before. Many of my currently uninsured patients cannot afford any ACA exchange and are now 'tax' criminals for remaining uninsured.

I don't understand what you are saying here.  Participants get an insurance policy and not an exchange.  Now some of these policies may have a very restrictive network but hey, that's nothing new.  This was started by the insurance industry back in the 1990s and it was called "managed care"  Stay in network and things are cheap go out of network and thing cost.  It's not different from non-Obmacare corporate policies.  Physicians are even refusing to take Medicare patients these days (I can point to two internal medicine practices I contacted recently)  Don't blame all the faults of the health care system on Obamacare.

Too many people are still drinking the ACA kool-aid. No matter what you think about how the system was before, the ACA has been an unmitigated disaster and this is not to mention how many physicians are leaving medicine because of the oppressive bureaucratic burdens it has required. We are 20 percent less efficient than before the ACA. That means 20% fewer patients seen. That means decreased access for EVERYONE.

  Where do you get this statistic from?  How is it any different from other insurance?  I've had two daughters on Obamacare policies (no subsidies, the paid the full freight) and their experience has not been what you describe.

My prediction is that Trump and the Republicans are going to make a staggering mess of all this. But I also predict that their mess will not be any worse than the mess Obama has caused. From the inside, as a physician, and insurance customer and a patient, US healthcare is at its worst level in 30 years.

This is an evolutionary fault.  I spent my whole working career in the pharmaceutical industry and followed healthcare reform throughout that time.  The only people who have found that express satisfaction are those who belong to well run HMOs (Kaiser, Geisinger, Harvard Pilgrim, Intermountain and some others).  those of us who have had coroporate plans and/or Medicare can tell you lots of stories about what is wrong.

[Alan Goldhammer]

As I suggested posts ago, there has to be a totally independent national system, where all docs owe the country that educated them so many years of their trade. For example: you want to study medicine in the UK, fine: then accept that you give back ten, fifteen years after which you can also do private work, as long as the state still gets a slice of your time as well. If you are a foreign student studying in the UK, then great, too: you pay whatever the courses cost, and can then waltz back to where you came from and syphon the blood of your own people, but the UK will have incurred no debt for you to reimburse: you paid up front.

Seems fair to me.

Rob C

In the US, the military, which runs its own medical school, will provide free medical education in return for some number of years of service.  My two skin cancer surgeons are both ex-Army field surgeons.  Some small rural communities are doing something similar if the doctor promises to come to their community for a set number of years.

[Rob C]

The original posters example was talking about accounting people, not DRs.  You seem fine with having the government in charge, and that's fine.  Others are not, and in the US that's a lot of people.  Different strokes.  And here, you pay your own costs for education.  The "state" does not train you.

Let's just say we agree to disagree.

In Britain there are choices: some elect to pay for expensive - therefore by definition - exclusive private schools (called public schools, I know not why) and the education is better for many reasons, not least the support some of those kids - not all - receive back home; for the rest, state-provided schooling is there, good, bad and indifferent, depending on your luck in where you find yourself living/studying. There's a premium on houses within the catchment area of a good school...

University is heavily subsidised, but still unavoidably expensive, but in Scotland (different, non-independent country with own laws) pretty much affordable, which is why it attracts a lot of students from more expensive areas of Britain. In many university towns rented accommodation for students is incredibly expensive.

Social engineering constantly tries to force top universities to accept people from underprivileged backgounds, regardless of whether they are actually bright enough or not. A huge problem that this "forced equality" causes is for the student there under those circumstances: university is a helluva lot more than education and attending lectures, and it's remarkable how much money has to be found to pay for all sorts of social and spin-off ventures in which the students are expected to take part, and not having the parental money is a very obvious problem that must make many students (and parents) feel terrible, quite apart from the instant social differences (and stigmas) that they encounter from accent to peer ability.

Social mobility is very low in Britain, but then it probably is everywhere else, too. Some mountains are too steep to climb, and when havng money is often not enough, impossible.

Rob

[Rob C]

In the US, the military, which runs its own medical school, will provide free medical education in return for some number of years of service.  My two skin cancer surgeons are both ex-Army field surgeons.  Some small rural communities are doing something similar if the doctor promises to come to their community for a set number of years.

You see? There really are ways to be fair if people are willing to give it a try and not live by the motto of screwing everybody else. I hope those ventures become widely popular and create change.

Rob