Nobody likes "Obamacare", so what should we replace it with? - page 3

by MunoRN

4,625 Views | 28 Comments

A few years ago I asked a Doctor I worked with how he would reform healthcare, his response was "don't ask a Doctor, if I want to know what's based for patients I ask a Nurse". Liberals don't like our current Health Care... Read More


  1. 4
    Quote from jmqphd
    Ironically, the single payer option probably would have been more constitutionally sound. The main issue before the court last week was one involving the Commerce Clause. The question was (simply put) can the government force people to engage in commerce so that the government can then regulate that commerce.

    Looked at from that angle... it's quite clear that this would be a radical departure from the way we've understood the (admittedly elastic) commerce clause.
    That has been my take on this all along -- there is no question that Congress could legally, constitutionally decide to tax the citizenry to pay for a publicly-funded healthcare system that would cover everyone (as they have already similarly done with Social Security and Medicare); whether or not it is legal/constitutional for Congress to require everyone to enter into business with a private company to buy a product that they may or may not want to buy is an entirely different matter.

    Ironically, that was also one of the points made by the conservative member of the panel on the Chris Hayes show Saturday AM, while the more liberal members of the panel twisted themselves (and the commerce clause) into pretzels trying to explain how the mandate could pass constitutional muster.
    tewdles, herring_RN, lindarn, and 1 other like this.
  2. 2
    Quote from jmqphd
    Ironically, the single payer option probably would have been more constitutionally sound. The main issue before the court last week was one involving the Commerce Clause. The question was (simply put) can the government force people to engage in commerce so that the government can then regulate that commerce.

    Looked at from that angle... it's quite clear that this would be a radical departure from the way we've understood the (admittedly elastic) commerce clause.

    Now, here are two interesting side lights to the drama.

    First: It is true that the Supremes are not elected and have life time appointments. But they do notice what happens during elections. That the congress responsible for the ACA is now just a memory and that the electorate spoke rather forcefully cannot have gone unnoticed.

    Secondly: I do not understand the President. He does some strange things. Calling out the Supremes so publicly during the SOTU speech, in a setting in which no one could (per protocol) object, was not wise. (One might even say he "acted stupidly".) The majority opinion in Citizen's United (the case he was denigrating) was written by Justice Kennedy. It was a direct affront to him. Kennedy is the swing vote that will give the ACA thumbs up or down.

    Again today, the President was setting up an anti-court campaign narrative to the effect that it would be unprecedented for the court to overturn a law enacted by a duly elected legislative branch. Hello??? Mr. Obama... you went to Harvard Law. Didn't they tell you about Marbury v. Madison? You know... 1803? I know it was a way long time ago and all. But, sir... you see... um... that is what the Court does. It decides if legislation is congruent with the Constitution. A foolish, foolish system... but it's the one we have. Alas.

    Oh, well... none of this matters. All of that arguing and aggressive questioning by the justices could be a total head fake. They may have laughed over a few drinks and then all voted to uphold the ACA. We'll just have to wait until June to find out.
    As I've said before the government shouldn't require people to buy commercial products, they can only mandate taxes for public services, which we can't do mandates without a public option, something Republicans have strongly opposed all along. On it's premise at least, Republicans agree with a mandate of some sort, so If they've come around allowing a public option for the purpose of having a "legal" mandate I don't think you'll find many democrats who would be opposed to introducing a public option.

    While the court probably does notice what happens during elections, their role, as Obama correctly pointed out, is rule only on the legality of legislation, not rule based on politics.

    Obama did criticize the Citizens United decision 2 years ago, just Presidents before him have done; Reagan openly criticized the court for their decision on school prayer as well as Roe v Wade. GW Bush popularized the term "activist Judge" with his criticism of the court's ruling on marriage:
    "Activist judges, however, have begun redefining marriage by court order, without regard for the will of the people and their elected representatives. On an issue of such great consequence, the people's voice must be heard. If judges insist on forcing their arbitrary will upon the people, the only alternative left to the people would be the constitutional process. Our Nation must defend the sanctity of marriage."
    herring_RN and lindarn like this.
  3. 5
    Quote from jmqphd
    No,no...of course no one wants the indigent STEMI patient to die on the street. This is the exact accusation that Alan Grayson made in the well of the House... you know, the Alan Grayson who is now a private citizen...
    I would have thought it true that no one wants that indigent or un-insured patient to die on the street...until I watched the debate during which the audience actually applauded that idea and shouted from the seats that we should let them die. I felt badly for Dr. Paul as he tried to answer in a thoughtful way. This heartless attitude of my neighbors alarms me and makes me worry for the future of the country that has prided itself on issues of human rights and security. What is it that is inscribed on the statue of Liberty?
    herring_RN, lindarn, BCgradnurse, and 2 others like this.
  4. 7
    How about replacing it with actual health care (rather than what appears to be an unconstitutional mandate for the purchase of health "insurance")?

    I seriously doubt this will happen as there are too many who have swallowed the politicians' (and the media's) efforts to divide people. As a result, some here have resorted to derogatory and otherwise useless comments... not surprising by any means.

    Why do so many believe that either (politicians or media) has our best interests at heart? Because they say they do.
  5. 2
    I think there could be a way to provide care for the indigent and for people who are in the process of pulling themselves out of an unfortunate hole.

    I don't think there is a way to do a one size fits all. But I believe that MD's and DDS's and APN's would be willing to donate their time and do charitable work if the malpractice issue was resolved. That's #1 and is a mandatory minimum. You will get no primary care practitioner extending themselves for the good of the less fortunate if they are more subject to the litigation lottery. I don't know what form this would take... probably some form of cap on pain and suffering.

    If you really wanted more donations of PCP time and attention, give them a tax incentive to help the indigent. Some deduction for the free time they give away.

    With that as a framework, let each community and each care-giver make decisions as free people serving other free people. It would be a start, especially for health maintenance and disease prevention. More complex care... well, let the creativity of each community figure out what their resources are and how to use them effectively. Public-private enterprises, non-profits, it could take lots of shapes.

    Just a thought.
    tewdles and VivaLasViejas like this.
  6. 1
    Malpractice tort reform is worth pursuing, although it's not going make that big of an impact, tort reform has been estimated to save between 0.4 and 0.5% of our health care costs. I think the estimates under value the effects on decreasing defensive medicine, although even if you double those numbers we're still looking at saving 1%, far short of the 25-30% we need to save to remain viable.

    Charitable work on the part of clinics and hospitals is already tax deductible. Additional deductions for caregivers as well is not a bad idea, although it's really just shifting costs around - whether we pay the Doc $50 for somebody's office visit or credit their tax payments by $50 it makes no difference, we're out $50 either way.

    Letting communities come up with ideas to care for the indigent as well as using public-private enterprises, non-profits, etc is our current system. I find it hard to believe that making no changes to the system that is heading in a bad direction will magically cause the downward spiral to suddenly reverse itself. What changes would you make to already existing community/non-profit/etc. systems of healthcare?
    elkpark likes this.
  7. 3
    I'm married to a doc so take what I say with that in mind...

    If doctors could deduct some % of no-pays (or can't pays) from their taxes, they would be willing to see more of them. When my husband has ER duty, he will see anyone. If the person is admitted, he will follow them. If the person is indigent, or a veteran (I'm not making this up) or on medicaid, he will not be paid a thin red dime. The hospital has a relationship with the county and they are reimbursed, but the physician is not. But, in spite of all this, when these people are discharged, they want to continue following up with my husband in his office. He tells them no. He doesn't like doing this. He has no animus toward them. But we cannot afford to give away that time when his overhead is obscene. It literally costs him money to see these people after hospitalization.

    It costs him a great deal of money.

    And he cannot deduct any of it. If there was any slack, any small % of break for him on his taxes (yes, we owe the IRS 13K this year because I work and earned too much) then there would be some patients he could follow.

    I think if you do this for every PCP and specialist in the country... you BET it could make a difference. Cost shifting? Perhaps. When tax $$ go to DC, the amount that returns to the people for things like medical care has been so shriveled by the government's take, their inefficiency and graft, the returns are a pitiful shadow of what we paid.

    Just a small degree of freedom to see indigent patients and defer some of the expense... it's a direct benefit to the patient and the community.
    VivaLasViejas, tewdles, and tntrn like this.
  8. 1
    I agree that tort reform is not the answer.

    There is something about minimizing the damages that a person can receive when they have suffered malpractice that does not sit right with me. Perhaps because I feel that it is impossible to put a one size fits all price on an injury.

    How can we say that the woman with breast cancer who has the wrong breast removed is entitled to X amount of compensation because that is what some panel decided her breast was worth? In that case she ends up with NO breasts and some court appointed fixed amount to compensate her for the recklessness of the staff/surgeon responsible. How is that improving anything? Too many people are injured by the careless or incompetent actions of health care workers, and they deserve something for their suffering. I am not sure that the "something" they get should be standard rather than specific to each case...no two are the same, so why should the compensation be the same?

    OTOH, too many frivolous cases actually make it into the courtroom to suit any of us. In some part, lawyers are to blame for this. So much of our lives would be simpler, IMHO, if we removed legaleeze from our daily lives and just spoke and wrote like people rather than some dusty law book.

    There is no question that MDs pay a pretty penny for malpractice insurance. And, in typical insurance fashion, the malpractice insurance companies push all of the risk to the purchasers of the product rather than assume it themselves as part of their business model. Additionally, if MDs were more open to the idea of self-policing and speaking out about the "bad actors" who practice amongst them, they might not have to pay such high prices for the insurance that covers those incompetents and their errors.

    Just rambling thoughts from an aging nurse who has seen too many bad things happen to good people.
    Last edit by tewdles on Apr 6, '12 : Reason: content
    elkpark likes this.
  9. 3
    Quote from jmqphd
    I'm married to a doc so take what I say with that in mind...

    If doctors could deduct some % of no-pays (or can't pays) from their taxes, they would be willing to see more of them. When my husband has ER duty, he will see anyone. If the person is admitted, he will follow them. If the person is indigent, or a veteran (I'm not making this up) or on medicaid, he will not be paid a thin red dime. The hospital has a relationship with the county and they are reimbursed, but the physician is not. But, in spite of all this, when these people are discharged, they want to continue following up with my husband in his office. He tells them no. He doesn't like doing this. He has no animus toward them. But we cannot afford to give away that time when his overhead is obscene. It literally costs him money to see these people after hospitalization.

    It costs him a great deal of money.
    Just to clarify, your husband loses a great deal of money due to the number of ER patients that don't have any way of paying their bills, and yet you oppose a reform plan that would drastically increase the number of patients who have the coverage to pay for his services?

    (As an aside, ER Physicians in Nevada are reimbursed by medicaid as well as the VA, the billing codes ER Physician medicaid reimbursements are 99234-99238).

    Quote from jmqphd
    And he cannot deduct any of it. If there was any slack, any small % of break for him on his taxes (yes, we owe the IRS 13K this year because I work and earned too much) then there would be some patients he could follow.
    Tax breaks, already given to hospitals and clinics, are a very inefficient way of fixing a larger problem. To cover the costs of indigent patients, medicare and medicaid offer varying reimbursement schedules depending on the volume of indigent patients, add in the tax breaks, inflated private insurer charges to cover losses, and you have a poorly planned stop gap system that ends up just shifting costs around and adding to the total cost in the process by using a fragmented, unconsolidated way of filling the gaps - some gaps get overfilled, others still have leaks.

    Quote from jmqphd

    I think if you do this for every PCP and specialist in the country... you BET it could make a difference. Cost shifting? Perhaps. When tax $$ go to DC, the amount that returns to the people for things like medical care has been so shriveled by the government's take, their inefficiency and graft, the returns are a pitiful shadow of what we paid.

    Just a small degree of freedom to see indigent patients and defer some of the expense... it's a direct benefit to the patient and the community.
    Actually of all the payers of healthcare, the government is by far the most efficient, in fact it's not even close. Medicare runs an overhead cost of 1.5-2%, private payers on the other hand keep 14% and more for themselves.
    everwonder_y, tewdles, and elkpark like this.


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