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+--- Thread: Health Care Passed (/showthread.php?tid=2209)
- dmano - 03-21-2010
Now we are all really screwed. Upside down and sideways by the great Obama. Boy I thought I would only get F'd in the arse if I went to prison, how come it feels funny when I walk, after tonight........
- cjbcpa - 03-22-2010
Well, all the vulgarity aside (not sure that's an intelligent way to make a point) this really has me troubled.
We already have a government and entitlement programs that we can't afford and now we've gone ahead and put 16% of the nations economy under government oversight. We also nationalized the student loan system at the same time in case you missed that in the midst of all the noise (their oversight of the home mortgage industry has been a real comfort these last years).
We're expanding the medicare/medicaid rolls while partially paying for it by reducing the amount we pay the very same providers we will count on to deliver it. Oh, and we're going to reduce waste to help pay for it too. There's a winning combination that only the central government could conjure up. And I haven't even mentioned higher taxes yet. Doesn't anyone find it a perverse notion that Medicare/Medicaid are so large that this plan uses reductions in reimbursements to fund nearly half a trillion dollars of this?
Health care for all is a great aspiration, but why stop there. Now that we've made it, and a college education an entitlement, how about food, clothing and shelter. There must be something left we haven't taxed yet to pay for it.
I fall squarely in the Libertarian camp so I'm disgusted with both our political parties. Their both equal opportunity offenders in my view. Time for a constitutional convention.
- emayer - 03-22-2010
Well said Chris.
As some one directly impacted by the legislation on several levels, I have some deep concerns for all of us. What bothers me more in the end though is how this whole process was handled. It should be clear to all that government is an entity serving itself and notable special interests in a symbiotic arrangement. The will of the people is flatly ignored and our individual freedoms (and responsibilities) continue to erode before us. It's starting to look like the Weimer Republic around here and we know where this will lead once everyone realizes that the current system cannot sustain itself.
I'm curious as to what extent individual states will challenge the constitutionality of the legislation. From the legal minds here, are there any grounds?
- AMoore - 03-22-2010
cjbcpa wrote:
Quote:Health care for all is a great aspiration, but why stop there. Now that we've made it, and a college education an entitlement, how about food, clothing and shelter. There must be something left we haven't taxed yet to pay for it.
No doubt these same words were stated by many in the 60's when the goverment passed civil rights and medicaid legislation, in the thirties, when Social Security was passed, when public education became a right, and in the 1860s when the government regulated property ownership.
Lets face it folks, we are all proponents of socialism, the difference between us is how much.
Also, to those of you who have formed an opinion based on uninformed rhetoric and generalizaitons and do not know what the bill includes, I submit as follows: Please review and then I will respect your opinion no matter which side you come down on.
People with "preexisting" health problems: Six months after the bills are enacted, health plans would be prohibited from excluding children who have preexisting conditions. In 2014, this prohibition would be extended to adults. That year, insurers would no longer be allowed to set annual limits, rescind coverage, or impose excessive waiting periods before coverage starts.
Young adults living on their own: Parents would be able to add nondependent children up to age 26 to existing insurance plans starting six months after the legislation is enacted.
Medicare beneficiaries: Currently, seniors with Medicare prescription coverage must pay out of their pocket for drug spending that falls between $2,830 and $6,440 because of the "doughnut hole" in the Medicare law.
Seniors who hit this "idiosyncratic feature" this year would get a $250 rebate. In 2011, the gap would be reduced through a discount on brand-name drugs. By 2020, it should be eliminated, although seniors would still have to pay 25 percent of their prescription-drug costs.
The uninsured: Almost everyone without insurance would have to get it by 2014 or pay a fine.
To make insurance more affordable, states would create purchasing pools, or "exchanges," in which private insurers would offer plans that small businesses and people without employer coverage can buy.
The federal government would subsidize insurance premiums for families earning up to four times the poverty level ($88,200 for a family of four). Tax credits would also be available to make premiums more affordable as a percentage of income.
For the poorest of the uninsured, Medicaid, the federal-state insurance program, would be expanded to cover people with incomes up to 133 percent of the poverty level ($29,327 for a family of four). Childless adults would also be eligible for Medicaid for the first time starting in 2014.
The federal government would pick up 100 percent of the cost of services to newly eligible individuals through 2016, and pay most of the costs thereafter.
People who choose to remain uninsured: Penalties would be phased in, reaching $695 for an individual or 2.5 percent of household income in 2016, whichever is greater.
Enforcement of the new system is expected to fall to the IRS, which would require taxpayers to file a certificate of insurance with their tax return - or pay the fine.
People already insured through employers: The overhaul aims to preserve the employer-based insurance system, so in the short term, covered employees should not be affected. "If you work for a large company, there's no reason they would drop or change the coverage," Field said.
People who have high-cost "Cadillac" insurance plans: Beginning in 2018, an excise tax would be imposed on high-cost group plans, including those of labor unions. The tax would apply to individual plans that cost $10,200 or more and family plans that cost $25,500. Dental and vision plans would not be included.
House Democrats dramatically scaled back this moneymaking provision of the Senate bill. To make up for the lost revenue, the Medicare payroll tax would be increased for individuals making more than $200,000 and couples making more than $250,000. Starting in 2013, people in these brackets would also pay a 3.8 percent tax on investment income, such as dividends, interest, and capital gains.
Primary-care physicians: When treating Medicaid patients - that is, poor people - these doctors would be paid up to 100 percent of Medicare rates beginning in 2013. Currently, their reimbursement is about 70 percent.
- emayer - 03-22-2010
Good summation.
As mentioned, plenty are more upset about the negotiations and tactics used in passing the legislation than the plan itself, although there is plenty here to question. Most of us agree that some element of reform is necesary, perhaps I'm out of line in thinking that the average citizen would have preferred some basic changes rather than another sweeping social program. After all, Medicare, Medicaid, and Social Security are failures in their own right. Should we expect this will be different?
A few thoughts on the reform plan:
1. Very few if any docs take Medicaid patients in the office. Aside from the lousy reimbursement, unfortunately the clientele tends to be poorly compliant and more litigious. Even matching Medicare rates will convert few (see #2).
2. There is an increasing trend for docs to drop Medicare as the reimbursements have not matched private insurers in many areas and the system is so onerous to deal with that it drives office overhead up. On a yearly basis, an approximate 22% doctor "fix" is passed in the eleventh hour. This is not factored into the CBO calculations for the reform. While there is fraud and waste in the system, there is no $500 BILLION to be found.
3. Lack of docs. An example: As a specialist, I am currently operating at 97% of the national average in volume. It isn't possible to absorb a greater load without sacrificing quality of care or relying on secondary extenders. I'm not certain that's what patients want or expect. There is a massive shortfall in MDs already absent this legislation. Who wants to study medicine now?
4. Tort reform? The costs of this are difficult to quantify but there is no question we are practicing defensive medicine. I would argue there is more cost savings here than looking for massive fraud within Medicare.
5. Private insurers. I for one, feel that the market should be completely opened to allow patients to purchase/transport plans from other states. While I agree with the legislative changes requiring continued coverage for preexisting conditions etc, there will be costs associated with this. Over time, my guess is that it will ultimately price insurers out of the marketplace creating a de facto universal health-care plan.
6. Is fining an individual for not purchasing a service constitutional?
- AMoore - 03-22-2010
emayer wrote:
Quote:A few thoughts on the reform plan:
1. Very few if any docs take Medicaid patients in the office. Aside from the lousy reimbursement, unfortunately the clientele tends to be poorly compliant and more litigious. Even matching Medicare rates will convert few (see #2).
Quote:A bit of an overstatement I think. I taught the poor for 12 years before becoming a lawyer. My students had access to Dr. Offices; although I agree that given a choice, a doctor would prefer alternative coverage. Offering loan forgiveness (yes another govt. program) would provide incentive for doctors to work in clinics in poor urban or rural areas. Moreover, not all doctors went to med school in order to become rich.
2. There is an increasing trend for docs to drop Medicare as the reimbursements have not matched private insurers in many areas and the system is so onerous to deal with that it drives office overhead up. On a yearly basis, an approximate 22% doctor "fix" is passed in the eleventh hour. This is not factored into the CBO calculations for the reform. While there is fraud and waste in the system, there is no $500 BILLION to be found.
Quote:Agreed that the system is onerous. Changes are needed, but we have to be carful that an easier system does not result in fraud. I'm not qualified to opine on the details.
Quote:3. Lack of docs. An example: As a specialist, I am currently operating at 97% of the national average in volume. It isn't possible to absorb a greater load without sacrificing quality of care or relying on secondary extenders. I'm not certain that's what patients want or expect. There is a massive shortfall in MDs already absent this legislation. Who wants to study medicine now?
Quote:See response to #1.
Quote:
4. Tort reform? The costs of this are difficult to quantify but there is no question we are practicing defensive medicine. I would argue there is more cost savings here than looking for massive fraud within Medicare.
Quote:Runaway jury verdicts have decreassed substantially in the last 15 years. Have your premiums? I doubt it. The big variables in determining malpractice insurance rates is competition and whether the investment return on the premiums is high enough. Pennsylvania now requires that Certificates of Merit be filed by Plaintiffs, certifying that a doctor/specialist in the relevant field, believes that a case is viable based on the facts alleged in a complaint. Also, venue shopping is no longer permitted in Pennsylvania. Caps are not the answer. Cut my arm off by mistake and my economic damages will be minimal. My loss of life's pleasures, however, would be devistating. A few million dolars would certainly ease that pain, and hopefully ensure that that doctor is more careful in the future.
Quote:5. Private insurers. I for one, feel that the market should be completely opened to allow patients to purchase/transport plans from other states. While I agree with the legislative changes requiring continued coverage for preexisting conditions etc, there will be costs associated with this. Over time, my guess is that it will ultimately price insurers out of the marketplace creating a de facto universal health-care plan.
Quote:Agreed that insurance companies should be able to cross state lines, and this could happen since insurers will no longer be permitted to offer garbage plans that cap and limit coverage. I do fear redlining of certain regions and states.
Quote:6. Is fining an individual for not purchasing a service constitutional?
Good question since there is no opt out provission. I can be fined for not having car insurance, but I am not required to drive a car. Cars, however, are necessary for our economy to work so, in a sense, there isn't much difference. While an individual is not legally required to own a car, the vast majority of us are nonetheless required to own a car in sense.
- emayer - 03-22-2010
AMoore wrote:
Quote:emayer wrote:Not to overtake the thread, I'll pick one item for now:Quote:A few thoughts on the reform plan:
1. Very few if any docs take Medicaid patients in the office. Aside from the lousy reimbursement, unfortunately the clientele tends to be poorly compliant and more litigious. Even matching Medicare rates will convert few (see #2).Quote:A bit of an overstatement I think. I taught the poor for 12 years before becoming a lawyer. My students had access to Dr. Offices; although I agree that given a choice, a doctor would prefer alternative coverage. Offering loan forgiveness (yes another govt. program) would provide incentive for doctors to work in clinics in poor urban or rural areas. Moreover, not all doctors went to med school in order to become rich.
It's a vast overstatement, preachy, and frankly naive to think that docs are in this profession for wealth alone. I'm sure you don't favor such comments being made about lawyers either. I for one, enjoy my profession foremost and actually provide indigent care on a monthly basis. There are far easier ways to make a dollar than medicine.
The truth is that it boils down to economics within the practice environment. Aside from the extra costs of medical school plus an additional 6 years of residency at sub-minimum wage levels, on a daily basis we have to contend with increasing overhead in the setting of declining reimbursement. Medicaid does not cover basic costs let alone turn a profit. In many areas of the country the same can be said of Medicare. My point about being so overloaded with patients is that given a choice of payors to fill a given office visit, who do you think a practitioner is going to choose? How would you feel if your gross revenue averaged about 40% of billed charges? Think you would be in business long?
- AMoore - 03-22-2010
emayer wrote:
Quote:AMoore wrote:Quote:emayer wrote:Not to overtake the thread, I'll pick one item for now:Quote:A few thoughts on the reform plan:
1. Very few if any docs take Medicaid patients in the office. Aside from the lousy reimbursement, unfortunately the clientele tends to be poorly compliant and more litigious. Even matching Medicare rates will convert few (see #2).Quote:A bit of an overstatement I think. I taught the poor for 12 years before becoming a lawyer. My students had access to Dr. Offices; although I agree that given a choice, a doctor would prefer alternative coverage. Offering loan forgiveness (yes another govt. program) would provide incentive for doctors to work in clinics in poor urban or rural areas. Moreover, not all doctors went to med school in order to become rich.
It's a vast overstatement, preachy, and frankly naive to think that docs are in this profession for wealth alone. I'm sure you don't favor such comments being made about lawyers either. I for one, enjoy my profession foremost and actually provide indigent care on a monthly basis. There are far easier ways to make a dollar than medicine.
The truth is that it boils down to economics within the practice environment. Aside from the extra costs of medical school plus an additional 6 years of residency at sub-minimum wage levels, on a daily basis we have to contend with increasing overhead in the setting of declining reimbursement. Medicaid does not cover basic costs let alone turn a profit. In many areas of the country the same can be said of Medicare. My point about being so overloaded with patients is that given a choice of payors to fill a given office visit, who do you think a practitioner is going to choose? How would you feel if your gross revenue averaged about 40% of billed charges? Think you would be in business long?
Eric, I meant you nor your profession any disrespect. You may have misread my comment. I stated as follows, "Moreover, not all doctors went to med school in order to become rich." I was ponting out that if economically viable, many would be willing to work in the poor rural and urban areas, and suggested loan forgiveness to that end.
- emayer - 03-22-2010
Aaron,
My apologies for the misinterpretation of your comment. Given the context in which it was written, I hope you can understand my mistake. This is an extremely difficult topic to fully comprehend especially since the more salient aspects have not been fully discussed and I am not convinced that our politicians at the center of this get it either. That said, while some of the legislation looks good on paper, I hope you can see that there are some legitimate worries amongst those of us on the front lines rendering care that go well beyond our own financial well-being.
- dmano - 03-22-2010
So does that also mean that not all lawyers are in it for the money? Why then are they all sue happy and are getting richer than a Dr. that saves lives? Back in the day our parents wanted us to become Dr's now they want us to be lawyers all for the almighty dollar... funny huh