Nobody likes "Obamacare", so what should we replace it with? - page 2

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... Read More

  1. Visit  jmqphd profile page
    5
    No one knows what the Supremes will do and I am not going to speculate. (Pray, perhaps, but not speculate.) Just want to make a few observations. First, as the OP mentioned, the affordable care act is pretty roundly disliked, and the polls indicate this disaffection has increased as the details of the plan and its implementation by HHS have evolved. Second, the conservative arguments against the act were (are still) denigrated and derided by progressives. Ms. Pelosi when asked if the bill was constitutional... "Are you kidding? Are you KIDDING?" (Enlightened discourse if I've ever heard it.)

    But now the case has been argued before the Supreme Court. The "swing" Justice, Anthony Kennedy raised the arguments that have been widely discussed by conservatives at some length. And in spite of the fact that the objections have been bounced around for over two years, the Solicitor General seemed unable to articulate any rational response. Even the progressive and mainstream press (a distinction without a difference) has said he "blew it."

    It's possible, of course, that Kennedy and/or some other strict constructionist will side with the affordable care act. But the point is that arguments against the act are not fringe. They get to the heart of how we understand the relationship between the a free people and their government.
    Last edit by jmqphd on Mar 31, '12 : Reason: semantics
    Blue Jam, tewdles, lindarn, and 2 others like this.
  2. Visit  MunoRN profile page
    1
    You won't find many liberals who will defend the mandate, particularly since it's been a core Republican principle for health care reform for some time. If the argument for keeping health care insurance for-profit is that it a free-market environment will produce the best insurance, then making the purchase of the product (insurance) mandatory removes the free-market influence on the product and therefore removes any benefit of a for-profit environment.

    Even so, it's hard to argue against the idea of a mandate of some sort. Regardless of whether or not a mandate exists, people will continue to essentially be covered to some degree; a person who has chosen not to buy any sort of health insurance who goes into an ER with a STEMI will get a heart cath, even possibly emergent open heart surgery, so it makes sense to argue that everyone who is capable of paying their fare share needs to contribute to at least the level of coverage guaranteed to them by our "social contract" (not to mention EMTALA). If we truly view this type of care as optional then we need to be willing to actually follow through and not send the ER STEMI patient to the cath lab and let them die if they chose not to buy insurance, which is actually what Scalia suggested we do.
    lindarn likes this.
  3. Visit  d'cm profile page
    7
    our current system is incredibly inefficient. how else could we be spending so much more than any country in the world and have such poor results? the inefficiencies persist because healthcare is not "free market" friendly. market forces do not work toward improved outcomes and lower cost when the supply is locally limited and when there is almost no "cost" to the consumer. quite the opposite. under our current system there is no economic force pushing towards improved outcomes and lower cost. that includes hmos, who in competition with each other have little room to affect e[font="calibri"]fficiencies by providers and certainly add many themselves. the ada does very little to address these problems. there is also the issue of how the employer based insurance drags on our economy. as employees we pay for every cent of the insurance through lost wage increases and poorer employers which decreases their stock price, which affects our savings and iras and the snowball keeps rolling.

    here's my solution as a nurse: single payer with case managers in charge.

    i am a fiscal conservative. i am a democrat.
    everwonder_y, Altra, BCgradnurse, and 4 others like this.
  4. Visit  jmqphd profile page
    1
    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.

    We must have redundant safety nets and it would shock many here to find out that most conservatives give this a lot of thought and the ideas being developed and discussed are rich and fully nuanced and have nothing to do with animus toward the poor. There are a range of ideas being proposed, many at the think-tank level, all with advocates and detractors. And, in State Houses across the country there are people trying to anticipate what will become of the health care act, and how they will manage if it lives, dies, or falls into some zombie netherzone of political influence.

    The health care economy is such a complex thing that no one completely understands it. Rather like the Amazon Rain forest. Touch the ecology with regard to one little species and you change predator/prey relationships in ways that reverberate across the entire region. Spare one type of grass, and trees die down river... it's a mess.

    I'm sorry, but I look at DC at the 500 plus individuals that make the sausage and I am not encouraged that they know what they are doing. I don't know what will take the place of the health care act, but I am certain that one-size-fits-all is NOT the answer.
    VivaLasViejas likes this.
  5. Visit  MunoRN profile page
    3
    The mandate issue is not about the indigent, it's about whether or not the people who are able to pay should pay for services they will receive whether or not they choose to contribute. Holding these folks to their choice not to receive treatment of their STEMI is not a theoretical accusation of Grayson, it's what Justice Scalia suggested just the other day that we do to avoid our mandate problem.

    Our current issues with healthcare delivery and cost is about more than just how provide care to the poor, it's our overall costs and quality that is a problem. There are conservative principles of healthcare reform out there, although "rich and nuanced" is hardly the term I'd use. These principles include: an individual mandate, protection of the for-profit insurance sector, block grants for medicaid, and ability to buy insurance across state lines. PPACA includes the individual mandate, not only protects the for-profit insurance industry but sends more business their way, and the ability to buy insurance across state lines. In a nod to conservatives' preference for the right's of individual states to determine what's best for them, the ability to buy insurance across state lines exists in the form of compacts, where persons from states can only buy insurance from other states with similar insurance regulations. Currently, states have leeway in how they administer medicaid funds, and they receive funds based on their needs. Block grants would give extra money to states that need it less and not enough to states that need it more, which would by definition be more wasteful and inefficient than our current "take what you need but not more than that" system.

    Our healthcare system is complicated, and making it less complicated is a big part of reform. Is the conservative view that we should just let it continue to be so complicated that it threatens to suffocate itself? There are some differences in healthcare delivery between urban and rural areas, but the basic pathophysiology of diseases don't vary between rural nevada a rural New York, heart failure is still heart failure. I think that there are some things that are better dealt with at a local level, but not everything. It makes sense that we have a Federally run armed forces, rather than 50 individual air forces, marine corps, etc. Just as with business (which conservatives argue government should be more like) consolidation of similar services makes them more effective and efficient.

    So is your suggestion that we reform but at the state level? What would reform at the state level include? Mandates? Public options? Still looking for some "rich and nuanced" ideas.
    lindarn, herring_RN, and elkpark like this.
  6. Visit  elkpark profile page
    2
    There was a v. interesting discussion of all of this on the "Up with Chris Hayes" show this morning (the entire two hours of the show). I think it's probably available on the website.

    Personally, I'm another single-payer advocate.
    BCgradnurse and lindarn like this.
  7. Visit  jmqphd profile page
    5
    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.
    Blue Jam, Altra, tewdles, and 2 others like this.
  8. Visit  elkpark profile page
    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.
  9. Visit  MunoRN profile page
    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.
  10. Visit  tewdles profile page
    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.
  11. Visit  Overland1 profile page
    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.
  12. Visit  jmqphd profile page
    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.
  13. Visit  MunoRN profile page
    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.


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