patrick.net

Vicente says

And if you are mistaken about this? Are you going to be back here apologizing and saying “ZOMG MY HMO DIDN’T COLLAPSE!” or will you just switch to some new tack? You seem convinced that it’s a zero sum game and there’s only so many units of health care to go around like a mineral, and are terrorized that someone is about to hornswoggle you out of your rightful share.

We will be forced to ration care somehow. That process is not one that I have heard addressed by either side, besides some moronic pundits throwing around "death panel" and "grandma killer" type phrases. Seriously though, how will rationing be decided? This is kind of important.

I would love to have an I-told-you-so follow up on this bill in two years time. How do we decide who wins? More importantly, what are we betting? Honor? Bragging rights?

Maybe HMO will do to doctors what most in America live with now. "Work more for less!" Whattya gonna do about it, we'll just SWAT the AMA really hard and modify visa rules so we can bring in cheaper doctors from somewhere else in the world! We have rationing right now. I remember like 5 years ago when my brother had a hernia and struggled mightily to get it treated in a timely fashion. Was there a hue & cry about rationing then? It's always existed! Even as a child watching MASH and other medical shows I learned the word "triage" which is a French word popularized after WWI for the prioritization of those needing medical treatment.

Soon enough, we'll find out!

Here is an interesting article about the AMA, regarding your comment.

http://www.forbes.com/2009/08/25/american-medical-association-opinions-columnists-shikha-dalmia.html

"One way to relieve the shortage of providers that the medical industry has created would be for the AMA to abandon its aggressive game of turf-protection and allow nurses, midwives, physician assistants and practitioners of alternative therapies such as chiropractors, to offer standard treatments for routine illnesses without physician supervision. For instance, midwifery, once a robust industry in this country, has been virtually destroyed, thanks to the intense lobbying against it by the medical industry. In 1995, 36 states restricted or outright banned midwifery, even though studies have found that it delivers equally safe care at far lower prices than standard hospital births. "

In the short-term there’ll probably be increased involvement of nurse and other “non-MD” professionals. The system will cope.
I agree Vicente; my doctor's group (which I have access to under a HMO plan -- which is more about being a gatekeeper) employs an NP (nurse practitioner). Hell, at times I prefer the NP and can get seen right away if the need is urgent. With more NPs, doctors get relegated to a managerial role.
Honest Abe said: its FREE
Cadillac health care plans (you know, the ones where you don't even think about the cost of seeing the doctor because its FREE) will be heavily taxed under ObamaCare.

Vicente, If I'm wrong I'll be happy to apologize. What I think will happen with an overloaded system, unfortunately, will be rationed care.

Honest Abe says

You’re joking, right? “The system will cope” - haha, the system will be flooded - and why not, its FREE. Every scratch, every cut, everything that most people would take care of themselves will now get “proper” medical attention, after all, its free !! Comrade, common sense says that a dramatic increase in the load will simply overload the system and as a result the system will provide an equally lower quality of care for all.

Because that's exactly how it is in other countries, right?

Oh, sorry, I forgot you've never been to one.

Kevin, why would you assume I've never been to another country? My point was that you cannot overload any system and expect the same level of service. Schools try to limit the number of students per classroom to provide a higher level of instruction. High quality cruise lines have a smaller number of passengers to staff ratio in order to provide a higher level of service. The worlds best cars are produced in lower numbers to insure a higher quality end product. Shall I continue?

And by the way, you're right - I haven't been to one foreign country, I've been to 11 (actually 12, but why count Canada?).

Honest Abe says

Kevin, why would you assume I’ve never been to another country? My point was that you cannot overload any system and expect the same level of service. Schools try to limit the number of students per classroom to provide a higher level of instruction. High quality cruise lines have a smaller number of passengers to staff ratio in order to provide a higher level of service. The worlds best cars are produced in lower numbers to insure a higher quality end product. Shall I continue?

So, your idea is to not let some people have access to health care? Is that how we handle schooling? We just tell the kids--sorry, this school is full. Too bad.

tatupu70 says

So, your idea is to not let some people have access to health care? Is that how we handle schooling? We just tell the kids–sorry, this school is full. Too bad.

Not sure how the government will handle rationing of care. If we eliminate the ability to pay as the rationing method, what do we have left?

CBOEtrader says

Not sure how the government will handle rationing of care. If we eliminate the ability to pay as the rationing method, what do we have left?

Well, I think public school is a good analogy. How do we make sure that everyone is able to go to elementary school?

tatupu70 says

Well, I think public school is a good analogy. How do we make sure that everyone is able to go to elementary school?

Our public school system is in shambles. We crowd them in like sardines, and don't seem to care about the quality of the education. Our politically-correct brainwashing keeps us from acknowledging there is a difference in educational aptitude, and we thus fail to teach the non-college types any employable skills. Then we proclaim "no child left behind" and let all of them pass with "diplomas" anyways. There is an obvious class-based tier system, where rich kids get pretty good educations and poor kids get far, far less.

Perhaps this is a good analogy of the health care system.

I figured out how Lord Barry is going to pull this off ... all of the illegals are going to be sent to medical school to become State Doctors .... problem solved.

CBOEtrader says

tatupu70 says

So, your idea is to not let some people have access to health care? Is that how we handle schooling? We just tell the kids–sorry, this school is full. Too bad.

Not sure how the government will handle rationing of care. If we eliminate the ability to pay as the rationing method, what do we have left?

We have Queen Palin's Death Panels. I mean, don't you believe her? That's what this legislation has set up. Don't worry, you'll get your rationing if Queen Palin has anything to say about it.

CBOEtrader says

Here is an interesting article about the AMA, regarding your comment.
http://www.forbes.com/2009/08/25/american-medical-association-opinions-columnists-shikha-dalmia.html
“One way to relieve the shortage of providers that the medical industry has created would be for the AMA to abandon its aggressive game of turf-protection and allow nurses, midwives, physician assistants and practitioners of alternative therapies such as chiropractors, to offer standard treatments for routine illnesses without physician supervision. For instance, midwifery, once a robust industry in this country, has been virtually destroyed, thanks to the intense lobbying against it by the medical industry. In 1995, 36 states restricted or outright banned midwifery, even though studies have found that it delivers equally safe care at far lower prices than standard hospital births. “

I'm not defending the ama but the forbes article is pure crapburger. From the article "No new medical schools have been allowed to open since the 1980s." simply garbage. Almost 2 dozen new medical schools have opened in the last 10 years (a few are in the final stages of accredidation). That isn't too hard to check even of the semi literates that seem to be the majority of the staff writers at Forbes. Forbes is very close to being all opinion all the time on the best of days but this article couldn't be called journalism by even the most liberal definition of the word. It's always amazing to me that Forbes manages to say in business.

Nurse midwifes are legal, common, and used extensively in all states. What you are referring to is lay midwifes who are not certified or formally trained (although they can be). There are only 9 states that outright ban lay midwifes, 21 states allow them, 5 require licensing but don't have a mechanism in place for it, and the other 15 states lay midwifes practice in the absence of any state law on the issue. So 36 states allow lay midwifes, not ban them. All states allow and encourage nurse midwifes. Did you get this (mis)information from Forbes also?

bob2356 says

I’m not defending the ama but the forbes article is pure crapburger.

MMMMMMmmmm....crapburger. Interesting. After you pointed this out, it does appear that your description of the medical school issue, and midwifery is more accurate than the author's. Though she is not technically wrong, it is very misleading. I definitely read it in a way that was not reality. Her statement about medical schools is wrong, as you stated.

I have been bamboozled by slick misinformation. This is my embarrassed face.

As much information as we process in this media bombardment era, it is impossible to check every fact that you hear. It is impossible to rationally think through all of your decisions, affiliations, or beliefs despite how much anyone would like to think that they do. To do so would be too cumbersome for anyone to get anything done. I am reminded of Burridan's ass...

Anyways, this woman is now on my shitlist. Her name is Shikha Dalmia. She is a frequent (bi weekly?) contributer to Forbes. I would suggest that you write an editorial letter to forbes. If it written well enough it might get published (wishful thinking?). She frequently writes about Obamacare as of late, so you should find plenty of material.

http://search.forbes.com/search/colArchiveSearch?author=shikha+and+dalmia&aname=Shikha+Dalmia

Nomograph says

Take a look at all the other first-world industrialized nations and see how they handle it.

It is undeniable that Canada and the UK ration care. The rationing in these purely socialized healthcare systems is a scary prospect.

http://www.npr.org/templates/story/story.php?storyId=92916560

http://online.wsj.com/article/SB124451570546396929.html

In France and Germany, they have been able to kick the rationing can down the road by keeping costs lower than we do here. However it is becoming a topic of debate. From what I can tell, rationing will happen in Germany and France but no one seems to agree on how.

http://www.dw-world.de/dw/article/0,,5139759,00.html

http://online.wsj.com/article/SB124958049241511735.html

Given that we spend 16% of our GDP on healthcare, with France coming in a distant 2nd place with 11%, we will have an immediate need to ration care.

Nomograph says

Not sure how the government will handle rationing of care. If we eliminate the ability to pay as the rationing method, what do we have left?

Are you implying that insurance companies don't already "ration" care? They routinely deny to pay for treatments as it is.

tatupu70 says

Are you implying that insurance companies don’t already “ration” care?

No.

tatupu70 says

They routinely deny to pay for treatments as it is.

The hodgepodge of government mandates, regulatory burdens, and local insurance monopoly pricing has resulted in many issues. The above is one way that the insurance companies attempt to control costs.

Given that the government is mandating coverage by insurance companies to those with pre-existing conditions, our society will have a decision to make. Do we allow health care expenditures to go significantly higher, or do we ration care in some other way? I suspect in reality, it will be a combination.

Not only does no one seem to be able to answer the rationing question, but most supporters of this bill deny the necessity of discussing the issue.

CBOEtrader says

Not only does no one seem to be able to answer the rationing question, but most supporters of this bill deny the necessity of discussing the issue.

I'm not sure what you mean. Given that we already ration care in that sense--if it continues, nothing will have changed. What sorts of questions do you have?

Rationing based on ability to pay? Who is arguing against that? And if you are against rationing based on ability to pay, then what other things do you also think we need government to provide for people?

Is it governments job to educate us?

Is it governments job to clothe us?

Is it governments job to house us?

Is it governments job to feed us?

Is it governments job to entertain us?

Is it governments job to find us a job?

Is it governments job to make sure we make/have enough money?

Is it governments job to give us meaning in life?

What is our job, to provide for the government?

Just asking questions.

AdHominem:

Is it governments job to provide police protection?

Is it governments job to ensure waterways are not polluted?

Is it governments job to provide for proper sewer systems and waste disposal?

Is it governments job to provide inspection for building standards and food safety?

Is it governments job to provide a system of roadways?

Is it governments job to provide a national defense?

Is it governments job to provide regulation for smog emissions from tailpipes?

Is it governments job to provide regulation for banks so they don't claim "profits" and run off with your money?

Is it governments job to provide regulation for life/fire/health insurance companies so they don't claim "profits" and run off with your money?

I'm assuming your answer to all these is *NO*. Though I'd love to hear why you'd answer yes to any.

Mark,

Is it governments job to take from those who have and give to those who do not? I would assume your answer is a whole hearted YES! Since I asked the questions first perhaps you could also answer first? What is governments job? Education, Clothing, Housing, Nutrition, Entertainment, Employment, Finance, Meaning?

What is our job?

And if you are against rationing based on ability to pay, then what other things do you also think we need government to provide for people?

we need a government to guarantee access to everything that is needed to become, and remain, a productive member of society, without regard to ability to pay.

Your minarchist world would be no utopia, even if you could find an economy on the planet run like one. No taxes just means sky-high rents and land values, a Monopoly®-game economy of a few big winners and many people shut out of the wealth game.

AdHominem says

Mark,
Is it governments job to take from those who have and give to those who do not? I would assume your answer is a whole hearted YES! Since I asked the questions first perhaps you could also answer first? What is governments job? Education, Clothing, Housing, Nutrition, Entertainment, Employment, Finance, Meaning?
What is our job?

In answer to your questions, mostly NO. Basic survival, yes it does. That's the whole point of police protection or national defense. It would be a little absurd to provide police protection to someone you're willing to let starve to death. So yes, government is responsible for feeding people, at least at a basic level. And I'd add it's responsible for providing many other basics too, as I implied in my questions, along with some education.

Troy says

a productive member of society

That is an interesting and ambiguous concept. Especially in a country founded on the pursuit of happiness principle. If my pursuit of happiness does not meet your definition of "productive member of society" then what? Do you round me up and put me in the ghetto, prison or the work camp? It is dangerous to think in your vague idealistic terms. Furthermore the most important criticism of your line of thinking is that it places the collective and society above the individual. As if a woman or man has to bow to the will of the society, or sacrifice himself for the collective. That is not liberty. That is not what Patrick Henry stood for, and I dare say it is not what the blood of the Revolution was spilled for.

If it truly is governments job to provide all these things, it becomes just another tool of the corporations to make money in the "service" of providing these things. Never mind the fact that EVERYTHING the government has it must TAKE from someone else.

CBOEtrader says

Not only does no one seem to be able to answer the rationing question, but most supporters of this bill deny the necessity of discussing the issue.

Nonsense. It hasn't been discussed much in the public sphere in the US, but the limits of public funded heath care has been debated for decades in other countries.

We have public eduction in the US, but we don't guarantee a free PhD for everybody who wants it. This is not rocket science.

AdHominem says

That is an interesting and ambiguous concept.

So where is your line? I assume from all your posts you think the government should provide nothing, and citizens should have no legally enforceable financial obligations to one another. Still waiting to hear otherwise.

MarkInSF says

AdHominem says

Mark,

Is it governments job to take from those who have and give to those who do not? I would assume your answer is a whole hearted YES! Since I asked the questions first perhaps you could also answer first? What is governments job? Education, Clothing, Housing, Nutrition, Entertainment, Employment, Finance, Meaning?

What is our job?

In answer to your questions, mostly NO. Basic survival, yes it does. That’s the whole point of police protection or national defense. It would be a little absurd to provide police protection to someone you’re willing to let starve to death. So yes, government is responsible for feeding people, at least at a basic level. And I’d add it’s responsible for providing many other basics too, as I implied in my questions, along with some education.

Fair enough. We are mostly on the same page then. And as far as basic survival, that is not the job of the government either. It is your responsibility. It is my responsibility. The universal truth is that we are responsible for ourselves and our neighbors regardless of what government we have.

The problem is that these problems are local problems. They need to be handled on the local level. Now some communities may choose to have government handle them formally (I don't prefer this because it is a pass the buck type of attitude but it may work on a small scale where people are more accountable to one another), and other communities will have other solutions based on charity and personal responsibility.

We also have to make allowance for deliberate poverty. Some people actually choose to live like bums and do not want to work for a living. In a truly free society they need to be allowed (not encouraged) to do so. They also need to be allowed to suffer the consequences. I agree that it is a bit strange for a city to provide police protection to someone who its citizens are willing to let suffer and die (I am not condoning or suggesting that) and yet our life and laws are full of such contradictions. We will fight tooth and nail to save a whale or and injured bird and yet we slaughter pigs, chickens and cattle by the thousands every day. We will spend hundreds of thousands of dollars to fight to save the life of a premature baby but that same aged baby is chopped to bits and sucked through a tube as a matter of routine by the abortionist.

Rather it is our responsibility as individuals to deal with each problem and person individually. There is no substitute for personal responsibility. Take care of yourself and those around you. If we do this, then we don't need a big government that becomes a parasite and tool of the corporations.

Given that we spend 16% of our GDP on healthcare, with France coming in a distant 2nd place with 11%, we will have an immediate need to ration care.
Admittedly, this is from the ABA (but so be it -- it's a nice summary). Cost containment doesn't have to be a dirty word: Over time, there have been innovations in cost containment among health insurers in a multi-payer system. Out-patient surgery, which is less expensive than in-patient surgery, is now common. Pre-certification has reduced hospital admissions and concurrent review has reduced length-of-stay in hospitals.

AdHominem says

As if a woman or man has to bow to the will of the society, or sacrifice himself for the collective. That is not liberty. That is not what Patrick Henry stood for, and I dare say it is not what the blood of the Revolution was spilled for.

ZZzzzzz. The 19th century came after the 18th century, and a lot was learned about "liberty", and how the rich can seize it from others.

A grand total of 13,000 people voted for President in 1792. That time of villages and towns is long, long gone.

FWIW, I'd like to think a straight land value tax would be enough, or nearly enough, to support the modern-day US of A. Kneecap rentierism, and it'd be a lot easier for everyone to make ends meet in this country.

This site is rife with people proud of the rental property empires they are assembling. Makes me sick.

MarkInSF says

Nonsense. It hasn’t been discussed much in the public sphere in the US, but the limits of public funded heath care has been debated for decades in other countries.

Every country does this in a different way. There is no default method. Canada uses a very different method than Germany. It would be prudent to know how our glorious leaders and their hired army of bureaucrats plan to ration care here.

MarkInSF says

We have public eduction in the US, but we don’t guarantee a free PhD for everybody who wants it. This is not rocket science.

Now we're getting somewhere. So, what is the healthcare equivalent to a high school diploma? Fixing broken bones, flu shots, etc? Then what is the college and PhD healthcare equivalent? Cancer treatment, heart transplant? Obviously hi tech and expensive cutting edge treatments will still be there. Since everyone can't have access to the most expensive treatments, who does? No one? Only the rich? Only government employees? How is it decided that you are one of the important people who has access to top tier care, whereas someone else should only get high school diploma level care? You claim this is not rocket science, but no one has any good answers. Many supporters of this bill even seem to believe that by some magical efficiency fairy, the government will have enough money to buy presidential level care for everyone.

Troy says

ZZzzzzz. The 19th century came after the 18th century, and a lot was learned about “liberty”, and how the rich can seize it from others.

Troy, are you really saying that the constitutional ideals are out of date?...

Troy says

FWIW, I’d like to think a straight land value tax would be enough,

...while at the same time advocating the Georgist philosophy that has barely been discussed since 1890?
Just pointing our the silliness of that logic.

Though, to be honest I think there is a lot of value in the Georgist philosophy. It would be interesting to see a microcosm of this tax system.

@CBOEtrader, End of life care is the low hanging fruit; everyone knows it. Maybe there will be a serious discussion after the next election cycle. Research suggests that this wouldn't fall under the category of rationing (bring on the death panels)...
The reality is that patients want to have a say in what happens to them when they're sick and, more often than not, they don't want heroic and often hugely costly measures to save them. In the new study, researchers found that more than 90 percent of the adults who had living wills requested either limited care or "comfort care" at the end of life. Only 1.9 percent (a total of 10 patients out of 3,746) asked for "all care possible." Doctors must acknowledge this and have honest and informative conversations with their patients. In another study, published in 2008, researchers found that end-of-life discussions resulted in less aggressive care—including ventilation and resuscitation—and earlier hospice enrollment, which equaled better quality of life for patients.
I'll give you this, though, the first study may be biased as, by its nature, it selected the population willing to think about end of life issues (by virtue of them having living wills).

I fail to understand why we go to the expense and red tape of Death Panels?

Why can't their family members leave their elders out in the woods to be eaten by wolves?

I suppose we need them for people with no directly identifiably living relatives though.

Soylent Green

End of Life Care is a huge money-making endeavor. Hospices are paid $140/day (minimum) to provide care for patients, which translates into a weekly nursing visit, aide visits 3x/wk, chaplain visit monthly and social work visits every month, plus medications & supplies - even if the patient is in a nursing home receiving 24 hour care. Hospices are springing up everywhere, and their marketing practices are unbelievable. They'll tell you that you don't have to be dying to receive hospice care.

Hospice does have its place, but as long as they're allowed to sign anyone one and figure it out later, hire non-medical marketers to evaluate a patient, and are paid the same amount whether the person is already receiving 24 hour care in a board & care or nursing home, this care is expensive and often redundant. Physicians should feel comfortable to prescribe end of life meds without the added expense to the system of placing the patient on hospice.

People do want to be comfortable at the end of their lives - but they should have options beyond someone shoving hospice down their throat. Especially if they're in a hospital that owns a hospice or home health company they're pushing on the patient, or if the doctor is the medical director of the hospice. There's a lot of reform needed.

Might I add that the biggest changes to hospice occured during the republican administration? There's huge home health/hospice lobby...

elliemae says

Might I add that the biggest changes to hospice occured during the republican administration?

and therefore are bad

AdHominem says

elliemae says

Might I add that the biggest changes to hospice occured during the republican administration?

and therefore are bad

No, they're bad period. But since some people around here consistently assign blame I thought I'd head that one off at the pass.

Hey, you are the one who brought up the Republican association. Anyways hospice is only bad because it is another program where the recipients get benefits that they don't pay for, while the government pays for "services" that likely would not be paid for by anyone if they had a choice. In other words it is NOT a free market, just another wealth transfer scheme dressed up in a bleeding heart social program.