Is Obamacare going to make things worse?

[Quantum Windbag]

I could have sworn this was one of the big selling points for this abomination.

That might come as a surprise to those who thought getting 32 million more people covered by health insurance would ease ER crowding. It would seem these patients would be able to get routine health care by visiting a doctor's office, as most of the insured do.
But it's not that simple. Consider:
_There's already a shortage of front-line family physicians in some places and experts think that will get worse.
_People without insurance aren't the ones filling up the nation's emergency rooms. Far from it. The uninsured are no more likely to use ERs than people with private insurance, perhaps because they're wary of huge bills.
_The biggest users of emergency rooms by far are Medicaid recipients. And the new health insurance law will increase their ranks by about 16 million. Medicaid is the state and federal program for low-income families and the disabled. And many family doctors limit the number of Medicaid patients they take because of low government reimbursements.
_ERs are already crowded and hospitals are just now finding solutions.

Health overhaul may mean longer ER waits, crowding - Yahoo! News

 

[SFC Ollie]

Doctors are already warning Medicare patients.

 

[syrenn]

ER's need to learn and use the word:

Triage

and just start telling people who come in for visits, they are NOT emergency's and go to their regular doctors.

 

[Jeremy]

Is Obamacare going to make things worse?

Does a one legged duck swim in circles?

 

[Greenbeard]

I'm curious about something. I frequently find that conservatives will say something like "no one opposes health care reform, I just want to do it differently." And then they usually clarify that their goals are roughly the same as people in the center or on the left: improving cost, quality, and access.

But then a story like this comes out and a common reaction among conservatives I've interacted with has been an attitude something like "see, the goal of expanding access is misguided because we don't have the capacity for it." The implication there being that our system's strengths arise in part because a fair number of people are excluded from it and bringing more people into it is a fundamentally bad idea.

I'm not yet sure how to reconcile this. Is that an admission that health care reform suggestions coming from conservatives are (or ought to be), by their very nature, not designed to allow more people to access care? One would think that would extend to affordability, too (i.e. making care more affordable would also put strains on provider capacity). So I'm let wondering what, philosophically, a conservative reform would be designed to do? What's the aim there?

 

[Quantum Windbag]

I'm curious about something. I frequently find that conservatives will say something like "no one opposes health care reform, I just want to do it differently." And then they usually clarify that their goals are roughly the same as people in the center or on the left: improving cost, quality, and access.

But then a story like this comes out and a common reaction among conservatives I've interacted with has been an attitude something like "see, the goal of expanding access is misguided because we don't have the capacity for it." The implication there being that our system's strengths arise in part because a fair number of people are excluded from it and bringing more people into it is a fundamentally bad idea.

I'm not yet sure how to reconcile this. Is that an admission that health care reform suggestions coming from conservatives are (or ought to be), by their very nature, not designed to allow more people to access care? One would think that would extend to affordability, too (i.e. making care more affordable would also put strains on provider capacity). So I'm let wondering what, philosophically, a conservative reform would be designed to do? What's the aim there?

The law that passed was not about reforming health care, it was about controlling it. Health care cannot be reformed through regulations that perpetuate the problems, and claiming that it is a right only makes things worse. The only rights we have are things other people do not have to subsidize, if they are subsidized they are entitlements.

There were a lot of bills over the years that tried to address the real problems in health care, and all of them were ignored in order for that Obama could claim he got something done. This law does not address the rising cost of malpractice insurance, does nothing to give the consumer real options, and forces people to buy into a systems that is doomed to failure.

 

[Greenbeard]

The law that passed was not about reforming health care, it was about controlling it. Health care cannot be reformed through regulations that perpetuate the problems, and claiming that it is a right only makes things worse. The only rights we have are things other people do not have to subsidize, if they are subsidized they are entitlements.

That's easy to say because discussion on this particular forum (and in many other places) focuses almost entirely on the 300 pages of the law relating to insurance market reform. The rest of the law--the bits pertaining to actual health care--go unnoticed. The primary care workforce capacity-building provisions of the law are a throwaway line in the OP's article. The investment in community health centers doesn't seem to get any mention at all.

Is there ever much discussion of interoperable EHR adoption, care coordination through models like the medical home or accountable care organization, payment reform to transition to a system that prices health as an output good of our health care system, or the long-term shifts toward emphasizing quality and effectiveness?

You mention subsidization but this doesn't jibe with your other posts. I take it that you don't like the the tax exemption for employer-based plans. And yet in the other thread you advocated tax privileged creations like HSAs, which allow consumers to pay for health-related expenses with pre-tax dollars, privileging consumption on health care goods over other types of consumption. The current tax code subsidizes employer-provided health insurance, and it subsidizes direct spending on health care from things like HSAs. Should we end all of those entitlements or just keep the ones you like?

There were a lot of bills over the years that tried to address the real problems in health care, and all of them were ignored in order for that Obama could claim he got something done. This law does not address the rising cost of malpractice insurance, does nothing to give the consumer real options, and forces people to buy into a systems that is doomed to failure.

What bills did you like? Paul Ryan and Tom Coburn's bill (which created structures suspiciously similar to the health insurance exchanges)?

More to the point, you didn't answer my question. What is the point of any reform in your view? I assume it's not increasing access (or its relative, lowering costs) because that would strain capacity and I gather from this thread that this is to be avoided at all costs. So what goal should reform try to achieve? Or should there be no reform at all?

 

[Quantum Windbag]

That's easy to say because discussion on this particular forum (and in many other places) focuses almost entirely on the 300 pages of the law relating to insurance market reform. The rest of the law--the bits pertaining to actual health care--go unnoticed. The primary care workforce capacity-building provisions of the law are a throwaway line in the OP's article. The investment in community health centers doesn't seem to get any mention at all.

I am not responsible for other peoples posts, so don't tell me what other people do not talk about. Community health centers are a joke. They exist to service people who do not have other medical coverage, and this law is supposed to extend coverage for everyone. Funding for two of them in Vermont was buy in to buy the vote of Bernie Sanders of Vermont, and they were extended to other states when the hoopla about special deals started to cover it up. Yet Vermont is still getting two of them. Interesting, isn't it?

Is there ever much discussion of interoperable EHR adoption, care coordination through models like the medical home or accountable care organization, payment reform to transition to a system that prices health as an output good of our health care system, or the long-term shifts toward emphasizing quality and effectiveness?

I don't talk about those because I haven't figured out all the catches yet. But if you want to talk about the new menu requirements for restaurants that will keep smaller from expanding due to the prohibitive costs and all the other bad things I do know about in the law then we can certainly do that.

You mention subsidization but this doesn't jibe with your other posts. I take it that you don't like the the tax exemption for employer-based plans. And yet in the other thread you advocated tax privileged creations like HSAs, which allow consumers to pay for health-related expenses with pre-tax dollars, privileging consumption on health care goods over other types of consumption. The current tax code subsidizes employer-provided health insurance, and it subsidizes direct spending on health care from things like HSAs. Should we end all of those entitlements or just keep the ones you like?

Where have I ever supported subsidization of anything? I think you are confusing me with someone else. As a rule of thumb, eliminating all tax breaks for anyone is a good idea. If someone sits me down I might admit to exceptions, but there is no reason make a practice of it.

What bills did you like? Paul Ryan and Tom Coburn's bill (which created structures suspiciously similar to the health insurance exchanges)?

More to the point, you didn't answer my question. What is the point of any reform in your view? I assume it's not increasing access (or its relative, lowering costs) because that would strain capacity and I gather from this thread that this is to be avoided at all costs. So what goal should reform try to achieve? Or should there be no reform at all?

I didn't like any of them really, but I like parts of some of them. I even like parts of the law that actually passed, but the mistake was trying to do everything at once, and not even addressing the things that have actually driven down health care costs.

The goals of reform should be simple. Provide the opportunity for everyone to get health care when they need it, allow people to choose what they want to cover if they choose to purchase insurance, and allow them to negotiate directly with doctors over costs. Why is it that things like plastic surgery, lasik, and optometry, which are not generally covered by insurance, has gone down in cost over the years, while other medical treatment has gone up faster than inflation? Could it be because market forces actually work the way people who believe in the free market believe?

I don't know how to reach all the goals we need to, but trying to do it all at once, using a model that hasn't worked anywhere else, is not the answer.

 

[Greenbeard]

Community health centers are a joke. They exist to service people who do not have other medical coverage, and this law is supposed to extend coverage for everyone.

Wow, I had to actually check and make sure I was in the thread I thought I was in--namely, the one about the possibility that strained ERs will require alternate places to get urgent care and, more broadly, about the need for primary care capacity development. And yet the value of CHCs seems to go unnoticed in such a thread. Odd.

And no, they're not simply for the uninsured, over a third of those who rely on CHCs are covered by Medicaid (and, of course, many more people will be eligible for Medicaid in just over three years). Since one of the key points in your article--quoted in your OP no less--is that many of those who strain ER capacity are Medicaid patients who simply need to find a regular place for primary care, one would think you'd make the connection to expanded CHC capacity. But I can wait.

I don't talk about those because I haven't figured out all the catches yet.

I really don't understand this conspiracy theory mindset. The world isn't out to get you. And improving health policy isn't necessarily a red-blue issue. Even red states are experimenting with things like care coordination models to try and improve quality while reducing costs. Oklahoma converted its SoonerCare choice program to a patient-centered medical home model almost two years ago.

The "catch" is that our current delivery system is massively inefficient in almost every aspect.

But if you want to talk about the new menu requirements for restaurants that will keep smaller from expanding due to the prohibitive costs and all the other bad things I do know about in the law then we can certainly do that.

Yes, that's exactly what I want to talk about. All the scary bad things you've read about the law and your aversion to menu labeling. Maybe you'll pick up some rep points from conservative members of the board--you can use the discussion as a spring board for running for USMB president.

I mean, really did you honestly just say let's ignore the delivery system reforms so I can trash menu-labeling? Please, get serious. We're not on TV here, man.

Where have I ever supported subsidization of anything? I think you are confusing me with someone else.

Weren't you the one promoting "How American Health Care Killed My Father"? If not, my apologies.

The goals of reform should be simple. Provide the opportunity for everyone to get health care when they need it

Even if it leads to ER overcrowding?

allow people to choose what they want to cover if they choose to purchase insurance, and allow them to negotiate directly with doctors over costs.

I'm not quite sure how to put these two together.

Why is it that things like plastic surgery, lasik, and optometry, which are not generally covered by insurance, has gone down in cost over the years, while other medical treatment has gone up faster than inflation?

Medical spending has risen faster than inflation, medical costs overall are rising. If elective, non-urgent procedures like these were included in insurance coverage, I'm sure that total spending on them would be higher but that doesn't necessarily indicate that the procedures themselves would be more expensive or that their costs wouldn't have fallen. In fact, the argument behind tort reform as a cost control is that it will reduce unnecessary procedures--that is, the problem is pegged as being primarily one of volume, not necessarily of procedure-by-procedure cost. For example a quick search suggests the following about heart valve surgery:

Between 1992 and 1997, length of hospital stay decreased from 13.4 to 8.0 days and cost decreased from $37,047 to $21,856. Similarly, between 1992 and 1997 for mitral valve repair, length of stay decreased from 15.6 to 8.1 days and cost decreased from $45,072 to $21,747. The net result over the time period from 1988 to 1997 was an average decline in the cost of operation of $785 a year, adjusted for other factors.​

Granted, since the examples you're using are elective the potential additional demand should be taken into account, but at the same time the structure of the market for that particular procedure (relatively simple with providers easily able to enter the market for it, which is why the number of providers offering the procedure has grown so much) mitigates some of that.

But what happens when you consider non-elective or time-sensitive procedures? Or complex procedures offered through institutions (e.g. a hospital) for which your personal bargaining power is exceptionally low and the costs of the procedure are simply too high for you to pay unassisted? That's why insurance pools to pay for health costs were formed in the first place. You could easily make an argument that those pools are overused now but your solution only works well in a specific subset of circumstances.

 

[Quantum Windbag]

Wow, I had to actually check and make sure I was in the thread I thought I was in--namely, the one about the possibility that strained ERs will require alternate places to get urgent care and, more broadly, about the need for primary care capacity development. And yet the value of CHCs seems to go unnoticed in such a thread. Odd.

And no, they're not simply for the uninsured, over a third of those who rely on CHCs are covered by Medicaid (and, of course, many more people will be eligible for Medicaid in just over three years). Since one of the key points in your article--quoted in your OP no less--is that many of those who strain ER capacity are Medicaid patients who simply need to find a regular place for primary care, one would think you'd make the connection to expanded CHC capacity. But I can wait.

The strain is coming because we are not going to have enough doctors, not because we don't have enough ERs. Did you miss that part in the article I posted? Does building CHCs somehow magically create doctors? Like I have said, this law does nothing to address the problems.

I really don't understand this conspiracy theory mindset. The world isn't out to get you. And improving health policy isn't necessarily a red-blue issue. Even red states are experimenting with things like care coordination models to try and improve quality while reducing costs. Oklahoma converted its SoonerCare choice program to a patient-centered medical home model almost two years ago.

The "catch" is that our current delivery system is massively inefficient in almost every aspect.

Adding in government regulations and control is going to make it more efficient? What universe do you live in?

This is not a conspiracy, even if the world is out to get me. You cannot replace incompetency and inefficiency through the government, you can only replace it through free market competition that forces an industry to adapt to its customer base.

Yes, that's exactly what I want to talk about. All the scary bad things you've read about the law and your aversion to menu labeling. Maybe you'll pick up some rep points from conservative members of the board--you can use the discussion as a spring board for running for USMB president.

I mean, really did you honestly just say let's ignore the delivery system reforms so I can trash menu-labeling? Please, get serious. We're not on TV here, man.

The government cannot "fix" health care, it is the problem with health care. This has nothing to do with what I have heard, as any honest person who is reading my posts would know. I am an informed consumer, and I resent the fact that the government thinks I cannot make my own decisions. Until the government gets out of the delivery system entirely there will be no reform, so don't go trying to tout what is not going to happen.

Weren't you the one promoting "How American Health Care Killed My Father"? If not, my apologies.

I recommended it because it tells, form the perspective of a consumer, what the problems are. That does not mean I think he has all the right answers, something I am sure that he will admit himself. Before you go assuming you know my position on a subject you should ask.

Even if it leads to ER overcrowding?

ERs are not for health care, they are for emergency treatment.

I'm not quite sure how to put these two together.

Why not? My company has a health insurance plan that covers drug and alcohol treatment, something I absolutely do not need. It is covered because the state requires health insurers to offer it, so everyone who has health insurance pays for something no one who is working for my company needs. If I was able to buy health insurance like I buy home insurance I could choose what I want to pay for, and what I do not, and determine my own deductible. Because my home insurance does not cover painting the house I shop around and determine the best price I can get for the work I want done.

Why don't we do this with health insurance? Because we cannot, all we can do is watch helplessly as heath care spirals out of control, all because a bunch of lobbyists and politicians know more about what we need than we do.

Medical spending has risen faster than inflation, medical costs overall are rising. If elective, non-urgent procedures like these were included in insurance coverage, I'm sure that total spending on them would be higher but that doesn't necessarily indicate that the procedures themselves would be more expensive or that their costs wouldn't have fallen. In fact, the argument behind tort reform as a cost control is that it will reduce unnecessary procedures--that is, the problem is pegged as being primarily one of volume, not necessarily of procedure-by-procedure cost. For example a quick search suggests the following about heart valve surgery:

Between 1992 and 1997, length of hospital stay decreased from 13.4 to 8.0 days and cost decreased from $37,047 to $21,856. Similarly, between 1992 and 1997 for mitral valve repair, length of stay decreased from 15.6 to 8.1 days and cost decreased from $45,072 to $21,747. The net result over the time period from 1988 to 1997 was an average decline in the cost of operation of $785 a year, adjusted for other factors.​

Granted, since the examples you're using are elective the potential additional demand should be taken into account, but at the same time the structure of the market for that particular procedure (relatively simple with providers easily able to enter the market for it, which is why the number of providers offering the procedure has grown so much) mitigates some of that.

But what happens when you consider non-elective or time-sensitive procedures? Or complex procedures offered through institutions (e.g. a hospital) for which your personal bargaining power is exceptionally low and the costs of the procedure are simply too high for you to pay unassisted? That's why insurance pools to pay for health costs were formed in the first place. You could easily make an argument that those pools are overused now but your solution only works well in a specific subset of circumstances.

See, you think we can't make decisions, and that we need someone looking out for us. The market will adjust if we let it, that is easily demonstrated by the fact that it works in every other instance where it exists. Will it work out that some people will not be able to afford everything they want? Yes, but that is going to happen anyway. There will be no way that the resources will be available for everyone to get anything they need, which is the best argument I can think of to keep the government out of health care as much as possible. People might resent insurance companies who deny them services they think they need, but they will absolutely revolt once the government starts doing the same thing. You can deny that all you want, but that outcome is inevitable if the government stays involved in health care.

 

[boedicca]

After 18 months, it's quite fair and rational to conclude that anything Obama does is likely to make things worse.

Just sayin'.

 

[Greenbeard]

The strain is coming because we are not going to have enough doctors, not because we don't have enough ERs. Did you miss that part in the article I posted? Does building CHCs somehow magically create doctors? Like I have said, this law does nothing to address the problems.

I suppose "nothing" is a relative term. For example, some of the primary care workforce development provisions of the law (from the excellent Kaiser summary):

• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013)
• Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)
• Improve workforce training and development:
  • Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)
  • Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011); increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community-based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for payments for the expenses associated with operating primary care residency programs. (Funds appropriated for five years beginning fiscal year 2011)
  • Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)
  • Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010) Provide grants for up to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011)
  • Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

That's a flavor of it. I would encourage you to spend some time on the 262 pages in the law on workforce development (that would "Title V -- Health Care Workforce") if you want a bit more.

Adding in government regulations and control is going to make it more efficient? What universe do you live in?

Creating statewide health information exchange (as is happening right now) through the use of interoperable EHRs will. Coordinating care in a patient-centered environment will. Restructuring payment to reward quality instead of just quantity will. Pricing health as an output good will. Does government have a role to play in encouraging that? I think you'll find that it's difficult to argue that the answer is no if you still expect to get those outcomes.

This is not a conspiracy, even if the world is out to get me. You cannot replace incompetency and inefficiency through the government, you can only replace it through free market competition that forces an industry to adapt to its customer base.

Competition among who? Insurers or providers?

I recommended it because it tells, form the perspective of a consumer, what the problems are. That does not mean I think he has all the right answers, something I am sure that he will admit himself. Before you go assuming you know my position on a subject you should ask.

Apologies. I assumed since you were posting an article promoting consumer-driven health care (i.e. greater reliance on HSAs), you supported it. My bad.

ERs are not for health care, they are for emergency treatment.

The point of your article is that many people use them in lieu of primary care physicians. So, yes, they're supposed to be only for emergency treatment but the question is how they actually are (and will be) used. The reform law increases access, which at first could have results like those mentioned in the OP. But that's identical to your goal of: "Provide the opportunity for everyone to get health care when they need it." Both require long term primary care workforce development initiatives if they're to work.

Why not?

Because if you're relying on an insurer (even if only for selected items of your choosing), you're not negotiating with doctors over costs; reimbursements by your insurer will be negotiated between the insurer and the provider. So I can't tell if you're advocating removing insurance from the picture entirely or not.

Why don't we do this with health insurance?

It sounds like you're reasoning "if I won't need it, why should I pay insurance premiums for it?" To which I would respond: most of the things you pay premiums for are things you won't need, particularly if you're very lucky. That's part of the point of insurance. If you do eventually need them, the pool will assist in your payment. If you don't, well, you're part of the pool assisting someone else. And when it comes to something you do need, the pool will assist.

See, you think we can't make decisions, and that we need someone looking out for us. The market will adjust if we let it, that is easily demonstrated by the fact that it works in every other instance where it exists.

Again, I can't really respond to platitudes over policy ideas (you've already accused me of misrepresenting your position once). Are you talking about abolishing insurance as a payment mechanism?

 

[boedicca]

None of those programs aimed at "increasing the workforce" will mean anything if we don't have the money to pay for it. What are they going to do? Institute a nurse draft?

 

[Quantum Windbag]

The strain is coming because we are not going to have enough doctors, not because we don't have enough ERs. Did you miss that part in the article I posted? Does building CHCs somehow magically create doctors? Like I have said, this law does nothing to address the problems.

I suppose "nothing" is a relative term. For example, some of the primary care workforce development provisions of the law (from the excellent Kaiser summary):

• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013)
• Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)
• Improve workforce training and development:
  • Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)
  • Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011); increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community-based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for payments for the expenses associated with operating primary care residency programs. (Funds appropriated for five years beginning fiscal year 2011)
  • Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)
  • Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010) Provide grants for up to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011)
  • Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

That's a flavor of it. I would encourage you to spend some time on the 262 pages in the law on workforce development (that would "Title V -- Health Care Workforce") if you want a bit more.

Adding in government regulations and control is going to make it more efficient? What universe do you live in?

Creating statewide health information exchange (as is happening right now) through the use of interoperable EHRs will. Coordinating care in a patient-centered environment will. Restructuring payment to reward quality instead of just quantity will. Pricing health as an output good will. Does government have a role to play in encouraging that? I think you'll find that it's difficult to argue that the answer is no if you still expect to get those outcomes.



Competition among who? Insurers or providers?




Apologies. I assumed since you were posting an article promoting consumer-driven health care (i.e. greater reliance on HSAs), you supported it. My bad.



The point of your article is that many people use them in lieu of primary care physicians. So, yes, they're supposed to be only for emergency treatment but the question is how they actually are (and will be) used. The reform law increases access, which at first could have results like those mentioned in the OP. But that's identical to your goal of: "Provide the opportunity for everyone to get health care when they need it." Both require long term primary care workforce development initiatives if they're to work.



Because if you're relying on an insurer (even if only for selected items of your choosing), you're not negotiating with doctors over costs; reimbursements by your insurer will be negotiated between the insurer and the provider. So I can't tell if you're advocating removing insurance from the picture entirely or not.

Why don't we do this with health insurance?

It sounds like you're reasoning "if I won't need it, why should I pay insurance premiums for it?" To which I would respond: most of the things you pay premiums for are things you won't need, particularly if you're very lucky. That's part of the point of insurance. If you do eventually need them, the pool will assist in your payment. If you don't, well, you're part of the pool assisting someone else. And when it comes to something you do need, the pool will assist.

See, you think we can't make decisions, and that we need someone looking out for us. The market will adjust if we let it, that is easily demonstrated by the fact that it works in every other instance where it exists.

Again, I can't really respond to platitudes over policy ideas (you've already accused me of misrepresenting your position once). Are you talking about abolishing insurance as a payment mechanism?

How many people are behind your screen name and who are they? You seem to have the entire 2000+ pages of the law handy, yet you do not address the main policy issue I keep making, why is that?

Let me emphasize:

The government is the problem with the system, not the solution.

If you want to debate anything about policy, that is the part I want to focus on. Feel free to refute my position.

 

[Greenbeard]

How many people are behind your screen name and who are they? You seem to have the entire 2000+ pages of the law handy, yet you do not address the main policy issue I keep making, why is that?

Let me emphasize:

The government is the problem with the system, not the solution.

If you want to debate anything about policy, that is the part I want to focus on. Feel free to refute my position.

It does help to be familiar with the object of discussion, doesn't it? I don't demand that you actually read it but I can at least assume you've read an in-depth summary of its provisions, can't I? I would've naively assumed that sometime over the past year or so, the bill's contents would've been explored by posters on this forum (since it's, you know, about health care). That would appear to be wrong.

That said, I think you're using "policy" in a bit of a different way than I am. The way I'm using it, a policy is a specific idea or proposal for achieving a desired end. For example, right now CMS and state Medicaid programs are implementing a program of incentive payments to safety net and Medicare providers who invest in and become "meaningful users" of electronic health records. This is a specific policy that fits into a larger framework of health information exchange capacity building that's going on in every state in the country right now.

Or another example: Ron Wyden and Robert Bennett developed a famous proposal a few years back that would effectively decouple health insurance from employment by ending the unique tax privilege it currently enjoys. That's a policy idea whose implications could be fleshed out and discussed.

"The government is the problem with the system, not the solution" is an ideological statement. There may be specific policies you have in mind to back it up and I'd be happy to discuss those. But the statement by itself is useless to me.

 

[Quantum Windbag]

How many people are behind your screen name and who are they? You seem to have the entire 2000+ pages of the law handy, yet you do not address the main policy issue I keep making, why is that?

Let me emphasize:

The government is the problem with the system, not the solution.

If you want to debate anything about policy, that is the part I want to focus on. Feel free to refute my position.

It does help to be familiar with the object of discussion, doesn't it? I don't demand that you actually read it but I can at least assume you've read an in-depth summary of its provisions, can't I? I would've naively assumed that sometime over the past year or so, the bill's contents would've been explored by posters on this forum (since it's, you know, about health care). That would appear to be wrong.

That said, I think you're using "policy" in a bit of a different way than I am. The way I'm using it, a policy is a specific idea or proposal for achieving a desired end. For example, right now CMS and state Medicaid programs are implementing a program of incentive payments to safety net and Medicare providers who invest in and become "meaningful users" of electronic health records. This is a specific policy that fits into a larger framework of health information exchange capacity building that's going on in every state in the country right now.

Or another example: Ron Wyden and Robert Bennett developed a famous proposal a few years back that would effectively decouple health insurance from employment by ending the unique tax privilege it currently enjoys. That's a policy idea whose implications could be fleshed out and discussed.

"The government is the problem with the system, not the solution" is an ideological statement. There may be specific policies you have in mind to back it up and I'd be happy to discuss those. But the statement by itself is useless to me.

I am familiar with the law.

I am familiar with the fact that the insurance industry was right there behind those closed door with the people who wrote the law. I am familiar with the fact that at least one small insurance company has already folded as a result of this new law. I am familiar with the fact that this law imposes regulations on industries that have nothing to do with health care. I am familiar with the fact that this law was so bad that the only way it passed is that the leadership of the Democratic party bought the votes of its own members.

I am familiar with the law, and I don't like it, and the policy I like least about it is that there is more government in health care, not less.

I guess that makes my desired end less government, and the policy would be less government.

 

[Bern80]

I'm curious about something. I frequently find that conservatives will say something like "no one opposes health care reform, I just want to do it differently." And then they usually clarify that their goals are roughly the same as people in the center or on the left: improving cost, quality, and access.

True......

But then a story like this comes out and a common reaction among conservatives I've interacted with has been an attitude something like "see, the goal of expanding access is misguided because we don't have the capacity for it." The implication there being that our system's strengths arise in part because a fair number of people are excluded from it and bringing more people into it is a fundamentally bad idea.

I'm not yet sure how to reconcile this. Is that an admission that health care reform suggestions coming from conservatives are (or ought to be), by their very nature, not designed to allow more people to access care? One would think that would extend to affordability, too (i.e. making care more affordable would also put strains on provider capacity). So I'm let wondering what, philosophically, a conservative reform would be designed to do? What's the aim there?

The right says 'see' because the way one attempted to reform the system did not work. And no our solutions are not dependent on people being excluded. I see two over arching problems. One some seem too believe less cost (to the consumer) somehow equates into better service and better access. Whether you can afford a doctor and whether you can actually get into see one are two different things. Improving the cost to the consumer is not going to, in of itself, improve access. Basic supply and demand says it will probably make things worse. The number of people demanding service has gone up, but the supply of doctors has not. No 'side', left or right really has brought that up. It isn't that reform can't work and get everyone served that needs it, it's that we have to account for ALL of the variables and if that means we need to improve the supply of doctors, one way or the other we have to figure out a way to do that.

 

[Greenbeard]

The number of people demanding service has gone up, but the supply of doctors has not. No 'side', left or right really has brought that up. It isn't that reform can't work and get everyone served that needs it, it's that we have to account for ALL of the variables and if that means we need to improve the supply of doctors, one way or the other we have to figure out a way to do that.

I'm not sure how to respond to that other than to quote myself from a few posts up:

I suppose "nothing" is a relative term. For example, some of the primary care workforce development provisions of the law (from the excellent Kaiser summary):

• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013)
• Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)
• Improve workforce training and development:
  • Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)
  • Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011); increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community-based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for payments for the expenses associated with operating primary care residency programs. (Funds appropriated for five years beginning fiscal year 2011)
  • Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)
  • Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010) Provide grants for up to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011)
  • Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

That's a flavor of it. I would encourage you to spend some time on the 262 pages in the law on workforce development (that would "Title V -- Health Care Workforce") if you want a bit more.

 

[Bern80]

The number of people demanding service has gone up, but the supply of doctors has not. No 'side', left or right really has brought that up. It isn't that reform can't work and get everyone served that needs it, it's that we have to account for ALL of the variables and if that means we need to improve the supply of doctors, one way or the other we have to figure out a way to do that.

I'm not sure how to respond to that other than to quote myself from a few posts up:

I suppose "nothing" is a relative term. For example, some of the primary care workforce development provisions of the law (from the excellent Kaiser summary):

• Increase Medicaid payments in fee-for-service and managed care for primary care services provided by primary care doctors (family medicine, general internal medicine or pediatric medicine) to 100% of the Medicare payment rates for 2013 and 2014. States will receive 100% federal financing for the increased payment rates. (Effective January 1, 2013)
• Provide a 10% bonus payment to primary care physicians in Medicare from 2011 through 2015. (Effective for five years beginning January 1, 2011)
• Improve workforce training and development:
  • Establish a multi-stakeholder Workforce Advisory Committee to develop a national workforce strategy. (Appointments made by September 30, 2010)
  • Increase the number of Graduate Medical Education (GME) training positions by redistributing currently unused slots, with priorities given to primary care and general surgery and to states with the lowest resident physician-to-population ratios (effective July 1, 2011); increase flexibility in laws and regulations that govern GME funding to promote training in outpatient settings (effective July 1, 2010); and ensure the availability of residency programs in rural and underserved areas. Establish Teaching Health Centers, defined as community-based, ambulatory patient care centers, including federally qualified health centers and other federally-funded health centers that are eligible for payments for the expenses associated with operating primary care residency programs. (Funds appropriated for five years beginning fiscal year 2011)
  • Increase workforce supply and support training of health professionals through scholarships and loans; support primary care training and capacity building; provide state grants to providers in medically underserved areas; train and recruit providers to serve in rural areas; establish a public health workforce loan repayment program; provide medical residents with training in preventive medicine and public health; promote training of a diverse workforce; and promote cultural competence training of health care professionals. (Effective dates vary) Support the development of interdisciplinary mental and behavioral health training programs (effective fiscal year 2010) and establish a training program for oral health professionals. (Funds appropriated for six years beginning in fiscal year 2010)
  • Address the projected shortage of nurses and retention of nurses by increasing the capacity for education, supporting training programs, providing loan repayment and retention grants, and creating a career ladder to nursing. (Initial appropriation in fiscal year 2010) Provide grants for up to three years to employ and provide training to family nurse practitioners who provide primary care in federally qualified health centers and nurse-managed health clinics. (Funds appropriated for five years beginning in fiscal year 2011)
  • Support the development of training programs that focus on primary care models such as medical homes, team management of chronic disease, and those that integrate physical and mental health services. (Funds appropriated for five years beginning in fiscal year 2010)

That's a flavor of it. I would encourage you to spend some time on the 262 pages in the law on workforce development (that would "Title V -- Health Care Workforce") if you want a bit more.

Making it way, way, WAY more complicated than it needs to be. I don't need a 262 page report to tell me what is fairly intuitively obvious. To reach equilibrium you have to do a couple of things. Increase supply of physicians and/or decrease the demand for them. Some of your bullets address getting more people onto the supply side of things. I big part of whether that's possible is the standards by which one can even get into medical schools. Only a fraction of applicants are accepted into any major medical program. Now is that because there isn't enough room or because not enough people can get in academically. Without any stats I would lead more toward there not being enough room for all who qualify to be accepted. In short, increase the supply of resources.

Next, decrease the demand on resources. Now I have witnessed a lot of lefties citing a lot of stats such as the U.S. low life expectancy as a reason why the health care system needs reform. While it does, reforming it is NOT going to improve life expectancy. Well another thing that should be intuitively obvious is that as a country in general, we don't take real good care of ourselves. Over half of us are considered obese. One might conclude that those two things go together. Ironically this later part of the equation is the one most easily addressed because it is in most everyone's power to influence, yet it is the one that get's the least talked about even though it has the greatest chance of improving access AND cost. That's the way we are as a people it seems. We want things to change but none of us our willing to put in the work to effect change. That and no politician can afford to look in a camera and say YOU are part of the problem.

 

[SFC Ollie]

And in the mean time the IRS will hire 1600 or more new people to make certain that we all go out and purchase health insurance.....