20th January, 2017

[Craig Lamson]

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

The difference is everyone pays the state. Regardless.   Again I'm more than happy to retain our system.

[Craig Lamson]

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

So paying your own way is now unfair and exchanging the fruits of your labor with others for the fruits of theirs is unfair?  Who is John Galt?

[N80]

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.

Big ones bailed in big markets. don't blame the liberal media for reporting that. Virtually all others were losing money and weighing getting out.

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 is not a network or managed care issue. This is a problem with the ACA exchange plans. They are private but contracted differently. The problem is they pay providers and hospitals poorly so practices and hospital systems do not contract with them. Simple as that. Has nothing to do with a restrictive network

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.

You don't seem to understand. Its the same problem. Medicare pays about 30 cents on the dollar. Thats why most of us don't take new Medicare patients. Obamacare exchanges are exactly the same. Government over management and lowballing.

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.

I get the statistics from my own practice and the hospital system I was employed by. It gets extremely complicated because physician contracts are in flux right now transitioning to an RVU system. I'll be glad to explain but it will take a long time. The bottom line is that these policies are not desirable to providers. We are accepting them now but it is for political reasons. Trust me, they suck for providers unless the provider is on an RVU contract.

[N80]

A Bronze Obamacare Policy does just what you want.

Few of my most needy patients can afford it.

[Craig Lamson]

A Bronze Obamacare Policy does just what you want.

Have you actually looked closely at the specifics of a bronze policy?  The networks, or lack of them more like it?  And I'm still paying for a lot of things I  don't need or want and my choices of providers still suck.

The problem...again...is the government is DEMANDING I purchase certain coverage items.  I HAVE NO CHOICE. 

Heck, if your friend Zeke gets his way I will someday be denied life extending care after I reach 75. According to your friend life is over after 75.  No value in saving those worthless seniors.   

I'll think of that while I attend the 87th birthday of my Father in Law.  He is one of the most vital, and productive people I know.  I'm sure if your friend Zeke had his way, my FIL's Carpel Tunnel surgery scheduled for Monday would be cancelled.  No use wasting all that money.
 

[N80]

You know, you have a point. There was a lot of rhetoric about death panels and all that. Obvious hyperbole, but there was a reality to it that no one paid attention to. Part of the funding for the ACA came from cuts to Medicare. Funny how the libs didn't scream about that. So to pay for insurance for all you cut healthcare for the elderly. So that slides by. Doesn't get a lot of attention in the media (imagine that). But look a little closer at what was cut. What got cut was payments to oncologists and cardiologists. So decrease the funding for two things that kill most old people. No, not a death panel, but the effect is the same and so is the intent.

The other interesting thing is that AARP, which is extremely liberal, openly supported the ACA even though the law contained cuts to Medicare. As soon as the ACA was passed the AARP starts running ads about how Medicare doesn't cover enough expenses for old people so you need to buy secondary insurance from them. Follow the dollar.

[James Clark]

You know, you have a point. There was a lot of rhetoric about death panels and all that. Obvious hyperbole, but there was a reality to it that no one paid attention to. Part of the funding for the ACA came from cuts to Medicare. Funny how the libs didn't scream about that. So to pay for insurance for all you cut healthcare for the elderly. So that slides by. Doesn't get a lot of attention in the media (imagine that). But look a little closer at what was cut. What got cut was payments to oncologists and cardiologists. So decrease the funding for two things that kill most old people. No, not a death panel, but the effect is the same and so is the intent.

Generally you make well-reasoned arguments, and I enjoy reading your POV even though I disagree more often than not.  This is a bridge too far though - you do yourself a disservice.  Besides, as a class, the over 65 crowd holds the lion's share of the wealth in this country. 

[BradSmith]

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.

You ignored my underlying point and took the easy way out in your response.  I specifically avoided MD salaries because they are a relatively small part of the overall expenditures on medical costs.  My point was that given that per capita medical spending in the US dwarfs the per capita spending in the rest of the "advanced" nations in the world, and that our medical outcomes are somewhere below average for these nations, we are either paying far more in salaries or we are paying far more people. Probably both. And our outcomes compared to other "wealthy or advanced" countries is at best, average.   

And regarding your example about the income of the cardio-thoracic surgeon, others can judge if their average salary in the US in 2011 (per Medical Group Management Assoc) of approx $475,000 is "too high".  If I correctly follow your logic, our society should double the pay of all of the people I was referring too, and then our medical care problems would all go away.  Oh, except that the cost will have doubled.   

Because this thread has wandered so far afield, I'm done with it at this point.

[N80]

You ignored my underlying point and took the easy way out in your response.  I specifically avoided MD salaries because they are a relatively small part of the overall expenditures on medical costs.

You said "medical professionals". That includes doctors and nurses, mostly. So if I interpreted your response wrong, I'm sorry.....that I'm not a mind reader.

My point was that given that per capita medical spending in the US dwarfs the per capita spending in the rest of the "advanced" nations in the world, and that our medical outcomes are somewhere below average for these nations

That is a far more complicated problem. The biggest problem is not that we're big spenders. The problem is primarily four-fold. Number one, we are, as a nation, fat, rich and sedentary. Lifestyle is the biggest killer. It takes a lot of money to fix people who are, as a nation, trying to kill themselves. That has absolutely nothing to do with the capability of the healthcare system. Second, we expect the best, the quickest and no limits. An American with a tummy ache expects a full body MRI and now. We have an insatiable appetite for healthcare. Again, this has nothing to do with the delivery of good care. Third, the US pretty much foots the bill for medical research and innovation. The rest of the world follows. That costs. Big. Fourth, medical malpractice. It is a lottery that costs this nation billions. It shapes the way physicians treat their patients and if you think we practice CYA medicine all day every day, then you are right. We order way too many tests and procedures but you only get sued for the test you didn't order. So yes, we're a fat, lazy, spoiled rotten and litigious nation that pretty much pays for the bulk of cutting edge medical innovation. But NONE of that impugns our ability to deliver good care.

The other issue is that our healthcare system is constantly compared to those of tiny socialist western European nations who have the money to fund universal healthcare primarily because the US spend billions keeping them from killing each other or at the very least keeping the Russians out of their backyards. Let Sweden build a military capable of keeping the Russians (or the Germans) at bay and see what their healthcare system looks like. And the truth is, the majority of European nations are crumbling fiscally under their socialized systems the most costly of which is likely healthcare. So at least compare apples to apples.

And regarding your example about the income of the cardio-thoracic surgeon, others can judge if their average salary in the US in 2011 (per Medical Group Management Assoc) of approx $475,000 is "too high".

I'm a primary care physician. I don't make anywhere near that much. But I know how a CT surgeon gets where he is and I know how he lives when he gets there. They work like dogs. They work hours that most people can't even dream of. Even in my residency program we routinely worked 120 hours a week, sometimes straight through for 36 hours. Surgery programs are worse, or used to be, there are limits now. But it does't stop when they get done with residency. It keeps going. And further, they are the top of the pyramid when it comes to skill and brains. Almost no one else can do what they do. And you seem to insinuate that $500k is too much. It is not. In my opinion it is not enough. Especially when your local beer and wine distributor or any big city ambulance chaser lawyer makes more than that. Or consider a professional football player, non starter: base salary about 5 years ago was about $400,000.

But this line of reasoning is dangerous. You have a computer. I bet you have a nice camera. Already most of the world's population could claim you have too much money. Its easy to spend other people's money.

If I correctly follow your logic, our society should double the pay of all of the people I was referring too, and then our medical care problems would all go away.  Oh, except that the cost will have doubled.

You neither followed my logic or used any yourself in that statement. 

Because this thread has wandered so far afield, I'm done with it at this point.

The dramatic exit!

[Rob C]

"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"

..........................................

So paying your own way is now unfair and exchanging the fruits of your labor with others for the fruits of theirs is unfair?  Who is John Galt?

And you reached this conclusion from the lines you quoted by...¿?

Why invoke Atlas? He's not gonna foot the bill, however you make him twitch. And I bet he doesn't pay for any wall, either.

;-)

Rob C

[tom b]

Getting back to the original post, Milania is not wearing an American designed dress on her most important day, she won't be living in the White House, it seems that she has no interest in her new duties including charities, she will make a lousy first lady. She did look good, Trump continues to look freakishly bad, any chance of a new hairdresser.

Cheers,

[Alan Goldhammer]

Getting back to the original post, Milania is not wearing an American designed dress on her most important day, she won't be living in the White House, it seems that she has no interest in her new duties including charities, she will make a lousy first lady. She did look good, Trump continues to look freakishly bad, any chance of a new hairdresser.

Cheers,

She did say during the campaign that her principal issue if she became first lady would be to address bullying.  This is an admirable cause and I would like to see her make some progress on this (seriously).  Regarding the design of her dress, a key issue here is whether her jewelry line and Ivanka's comprehensive clothing lines will shift manufacturing to the US in keeping with the President's desire.

[Alan Goldhammer]

The difference is everyone pays the state. Regardless.   Again I'm more than happy to retain our system.

Insurance of me but not for thee!  I imagine that you do not regard affordable healthcare as a right.

[Alan Goldhammer]

Big ones bailed in big markets. don't blame the liberal media for reporting that. Virtually all others were losing money and weighing getting out.

I don't think that is correct, there are a fair number of them that are still staying in and they adequately priced their products so they are not losing money.

You don't seem to understand. Its the same problem. Medicare pays about 30 cents on the dollar. Thats why most of us don't take new Medicare patients. Obamacare exchanges are exactly the same. Government over management and lowballing.

I'm well aware of Medicare since I'm on it and also worked on health policy issues at various times during my career.  Medicare only works because the patient pool is so large.  Imagine if doctors in Florida started to refuse Medicare assignment in large numbers. 

Obamacare specified things that were to be covered, it didn't say how this was to be accomplished.  It was up to the plans to make those decisions.  Now maybe they did this wisely and maybe not, we likely won't ever know.  I'm sympathetic to all the critics out there, I personally felt that Obamacare was a complicated kludge and it was the only way that healthcare could have been done at the time.  I well remember Senator Baucus trying in vain to get some of his Republican counterparts engaged and was willing to accept some of their ideas but of course this failed when Senator McConnell established 'massive resistance' to anything President Obama might propose as the party mantra.

I get the statistics from my own practice and the hospital system I was employed by. It gets extremely complicated because physician contracts are in flux right now transitioning to an RVU system. I'll be glad to explain but it will take a long time. The bottom line is that these policies are not desirable to providers. We are accepting them now but it is for political reasons. Trust me, they suck for providers unless the provider is on an RVU contract.

Thanks for clarifying this.  I'm also aware of the flux right now as I have a number of close friends who are in the medical profession.  A lot of them are fed up with the current situation and want some form of national health care that would simply things and improve access.  the American Medical Association is not the monolith it once was.  I'm still interested in hearing what solutions there are to the current issue of healthcare access.  I've looked at all the proposals over the years and only find a couple of them that are workable.  the key difficulty that I find in the "educated consumer" model of choice and "skin in the game" is that pricing and quality are not transparent at all.  One can not really shop around for the best bargain and quality.  Secondly, health savings accounts that have been touted by many only work if one is reasonably healthy and has enough income that he/she can seed the HSA and build up principal.  Anyone who is on a lot of meds or has a complicated medical condition can't do this and will have full out of pocket expenses every year.

It's a hugely complicated matter and I always felt that there would be a major push towards nationalized system at some point.

[Craig Lamson]

Insurance of me but not for thee!  I imagine that you do not regard affordable healthcare as a right.

No, health insurance is not a right, no more that affordable food, or affordable heat etc. 

[Craig Lamson]

And you reached this conclusion from the lines you quoted by...¿?

Why invoke Atlas? He's not gonna foot the bill, however you make him twitch. And I bet he doesn't pay for any wall, either.

;-)

Rob C

You miss the point entirely. 

[Rob C]

She did say during the campaign that her principal issue if she became first lady would be to address bullying.  This is an admirable cause and I would like to see her make some progress on this (seriously).  Regarding the design of her dress, a key issue here is whether her jewelry line and Ivanka's comprehensive clothing lines will shift manufacturing to the US in keeping with the President's desire.

I thought she was wearing Hervé Pierre? He's originally from France, but moved to America a long time ago, and has worked in the States ever since. Doesn't that count as 'American made' in the brave, embracing sense of the words? I'm sure the seamstresses etc. beavering away would be shocked to have been thought, for even a fleeting second, as being anything less - even if they may have been illegals! (This is not an allegation, just a joke! ForAIK, the thing might have been run up over the weekend in some little shop in Hong Kong! They are quick, talented and nimble out there.)

If anything, as a former model, she was able to, and exercised a lot of professional savvy in selecting something that looked the part so well. I mean, the opportunities for coming out clad like a diamond dog were immense! The lady should be given her due! Which forces the question; a BMW made in America, is that really a BMW, then? I'm sure any buyer would certainly like to pride himself that it is! I wonder is folks buying Chevrolet in Asia believe they really are, or whether it's still little old, bankrupt old Daewoo under the paint? The mysteries of international commerce and the frailties of the human ego!

Regarding any private companies she or Trump offspring may have, they are not in office as President; why would they be held to the same rules and be obliged to surrender something that may have been grown on the back of their own expertise?

Naturally, the arguments against my position just stated above are obvious enough; but the problem that brings them about is something else even more obvious: I believe that politics should be left to career politicians and that businessmen or busnesswomen should never have access to similar state positions. Try as they will to change their status quo, nobody but a hick from the deepest sticks (with the straw still attached) will ever believe that the reality of real ownership has been given away. If it has, one has voted into power the most unsuitable person ever! Someone who can't protect his own position effectively is never going to be able to do it on behalf of an even larger firm: a country.

As for throwing out entire administrations-worth of civil servants just to replace them with chosen true believers, what an unimaginable waste of broader experiences gained under varying party colours, mistakes and successes. I'd have expected that people who have spent their lives working under the leash of a variety of different parties would not need to reinvent any wheels each time.

But then that's the olde worlde.

;-)

Rob

[Rob C]

You miss the point entirely.

I'm hardly surprised! It's totally hidden.

;-)

Rob

[JNB_Rare]

She did say during the campaign that her principal issue if she became first lady would be to address bullying.  This is an admirable cause and I would like to see her make some progress on this (seriously). 

And Mexicans everywhere slapped themselves in the forehead and said ¡Ay, caramba!

I'm sure the First Lady was speaking primarily about young people, cyberbullying and such. Bullying is one of the many social issues that will require a concerted and sustained effort in education (and law) to bring about social change. And it is a global issue. For example, there is a man currently on trial in the Netherlands whose cyberbullying (allegedly) caused one young girl here in Canada to take her own life. He is on trial for dozens of charges of similar cyber activity.

Unfortunately, we seem to inundated with examples of bullying tactics (and other despicable behaviours) both in the news, and in media (reality shows, fictional dramas, video games, and Internet sites that that glorify aggressive and violent behaviour, as well as xenophobia, homophobia, and bigotry in general). It takes leadership to set the tone, set the example, and push to see effective change. I wish the First Lady well on her endeavours.

[Craig Lamson]

I'm hardly surprised! It's totally hidden.

;-)

Rob

No, it was right in front of your face if you had chosen to see it.