Do you have a source for that, silveroak?  I was pretty sure the 'public option' got shot down pretty early, so there isn't so much a "government plan" on which to put everyone.

Katisara, do you think it would be reasonable, given those three choices, for a person to think "I'd prefer it if #1 would get the job done...but if it doesn't, I'll move on to the next best option, #2...if that doesn't work, well I'll take #3?"  That's sort of where I'm seeing things.  Yes, it'd be great if charities, families, etc., took care of everything, but that doesn't seem to be happening.  It also doesn't seem to be the case that the states are solving the problem either.  If they were, we wouldn't need a federal plan.  But they're not, so perhaps bringing in the federal solution is reasonable?

Several lawmakers have mentioned it in discussions on teh daily show and elsewhere. It isn't the Public option (government provided health insurance) but an alternative to it..

from http://docs.house.gov/energycommerce/SUMMARY.pdf



Okay, technically it's tax credits not vouchers, but isn't that actually more Republican?

Hmm, perhaps I misunderstood what you meant when you said "putting everyone on the government plan together to get a good group rate."  It sounds like you meant the health insurance exchanges, and if that's the case, that's fine.  I wouldn't have called them "the government plan" myself (since that makes me think of the public option), but I think I see what you're saying now.

http://www.latimes.com/health/...0309,0,6657163.story

Saw the above story today, and found it pretty ironic.  Apparently the lead plaintiff in the case against the affordable care act declared bankruptcy...in part due to medical bills she couldn't afford to pay.

In fairness, it sounds like it wasn't the medical bills that were the primary cause of the bankruptcy, but still she will be leaving unpaid medical bills that others will have to accept as a loss because of this.  Avoiding this kind of situation is part of what the act meant to do.  It's also somewhat ironic that she currently lists unemployment benefits as her only source of income.  Will the republicans call her a freeloading, living-off-benefits wellfare queen now?  Somehow I guess not.  It would be nice if it could be a sort of ah-ha moment for some of those on the right, realizing that small business owners sometimes need government help and can end up pushing their medical costs on to others when they "exercise their right" not to have insurance.

Yeah, she's definitely an example how NOT to do it.

Health insurance is definitely a tough issue to decide on. I can certainly see both sides. My wife is a sole proprietor of a business, and while my health insurance covers her, I can say that health insurance is a complex expense that she just would not have been able to include until recently (which is unfortunate, because she would have needed it!) I wouldn't mind a more gradual shift though. Preventative care is cheap, and saves buckets of money over the long-run. I think if we started with the goal of 'keep people out of the emergency room for preventable diseases', there would be less pushback. Then, when we have more data on the cost-savings, we could implement (or not) the next step.

I agree on the preventative care thing.  Part of the trouble, I think, is that in a capitalist system, the health service provider doesn't have incentive for providing the cheap service.  By preventing emergency room care, they're only hurting their bottom line.  They have a perverse incentive to NOT push for preventative care.  I suppose one way to fix that, while keeping a capitalist system, would be to have different agents provide preventative care from the ones who provide reactive care.  A "one doctor for your vitamins, one for your stitches" system, I guess.  So they'd be in competition, and by providing good preventative care, the first doctor would be hurting someone else's bottom line, rather than their own, so there wouldn't be that conflict of interest.  On the other hand, I guess they'd still have an incentive to over-sell preventative care?  Or perhaps provide care that has higher likelihood of unpleasant side effects?  Not sure.  But whatever the case, such a model would require putting restrictions on doctors/hospitals, and limiting them to one type of service or the other.  And we'd presumably need more doctors and hospitals for that, which might push up demand and drive up prices as well.  And I'd imagine that one type of care would end up paying better than the other (my guess would be reactive would be more lucrative), and there'd be little incentive to go into the other.  There'd also be a lot of wasted talent, since many of the doctors would be able to do both jobs if allowed.

Anyway, I tend to think healthcare is one of those areas where markets aren't as well-suited to the task as they are for most goods and services.  The average person isn't an expert on medical options, so it's tough to expect them to make well-informed decisions on the best treatment.  Add in the fact that their life may depending on the decision, and you only compound the problem.  There's also the moral issue of whether less affluent people (especially children, who's wealth is entirely outside their control) should have poorer health care (or worse, none at all) when their affliction is just a random throw of the dice they have no control over.  It's one thing to say "if you want a porche, work hard and pay for it yourself," but it's another to say "if you want to get your cancer treated, find a new job so you can afford it," and still another to say "if you want your treatable disease fixed, find some richer parents who can afford it, kiddo!"  I'm not sure where the right line should be drawn, but my general feeling these days is that there should be some level of service that everyone should have access to, regardless of their wealth, but people who the means should be able to spend more to get more if they like.  The level everyone has access to would depend on how much we have to spend on it, so it's a balance between taxes (or however we're paying for it) and minimum level of service.

I want to address another big issue expensive end of life care or care for chronic conditions that will end in death.

The twin issues are is it right to offer expensive care if your not going to cure someone or necessarily improve the quality of life or worse it could go down.

Lets say a man has heart failure and you want to put in an artificial valve that will limit his movements needing battery charging and the like. And right now the man loves to go out alot and enjoy his life. Is it right not to offer doing nothing or some minor care and let the disease take its natural course as an option. Right now it seems doctors push all the care possible and that can be done regardless of other considerations that has to drive up costs.

I know in my case if I had cancer I would want all the options and if it was aggressive and the chance of a cure was low, doing nothing would be appealing over a hellish course of treatment and then still die just maybe adding some months. But now sickened from treatments not able to enjoy what life I have left.

And if there is no chance of a cure is treatment to add months alone worth the money.

I know we are talking rationing care in some of this but someone had to say no at some point if one wants to cut costs and since this eats up ample funds it has to be on the table/

On that I do agree with you, RubySlippers.  End of life treatment is where most of the healthcare money is spent, for the least benefit, and doctors again have an incentive to draw out life as long as possible, rather than to provide the highest quality of living for the time that remains.  Largely it's well intended, I'd say, since many (both doctors and family) would feel guilty if they didn't do everything in their power to try to extend life to its fullest.  But part of it is also the incentive issue, I think.  People are aware of this problem, but when anyone's tried to do anything about it, they've gotten shouts of "Death panels!"  I do think there should be more focus on making sure the patient knows what treatment can and can't do, what the odds are, what the quality of life effects are likely to be, and generally be put into a position where they can make an informed decision.

In terms of dealing with the large costs involved with most end of life care, I think it would make sense have some of the least cost effective bits of it not be covered by 'standard' insurance, or require heavier co-pays.  Extending a life by a month, say, is arguably closer to an elective procedure than a must-have one.  I'm not sure where the line should be drawn on that, nor who should be making that decision (it's certainly not a job I'd want!), but I would like to see it dealt with in a rational way.  Unfortunately the political climate in the US doesn't really allow for that.

I've never heard of any instances of a doctor recommending the wrong treatment in order to make more profit. Perhaps part of that is because the guy who I see in the doctor's office is not the same guy who does the CAT scans who isn't the same guy in the ER, but part of it is also, I think, that the medical industry really has plenty of business as it is, and doesn't need to spend their reputation drumming up more. There is a tendency to recommend 'unnecessary' tests, but that isn't a profit so much, as a pound of cure issue, I think.

I do know that doctors may recommend the 'no treatment' option. I have a friend right now who is doing that for her cancer. In fact, I read an article just the other day about how many doctors choose the 'no treatment' option for terminal diseases. There's just something in our cultural mindset though that we can and should 'treat' anything, and fight to the bitter end. I'd start with the cultural side there, before I pin it on the hospitals.

By the same token, is it right to refuse treatment to terminally ill patients? In some cases, treatment can extend life by a matter of years - are another 2 years of life, say, not worth the expense? Is six weeks, or a month? How long must a treatment extend life to make it economically viable? In other words, how do you put a value on a life?

In addition, should we consider this differently for people in idfferent situations? For example, is it more acceptable to give treatment to a married mother of four than a single person with no children?

I think that I would take any chance at extra time that I was presented, but I can understand people's decision not to. The thing that would make me uneasy is someone else deciding that a patient cannot have that time.

Consciously/intentionally?  Yeah, I'd say that'd probably be pretty rare.  But the system is set up such that the "normal" behavior can often lead to it being done without thinking about it.  For example drug companies are primarily about making money, not saving people.  They spend a lot of effort making tiny changes to existing drugs so that they can get it approved as a new drug, and thus get more exclusive use of it, which drives up costs.  They're not consciously thinking "hey, we'll give these people worse service just so we can make more money!" they're just thinking "hmm, this drug is a big money maker for us, but our patent is about to expire!  What can we do to keep making money off it?"  It's not intentionally malicious or devious, it's just that the profit incentive causes them to think in certain ways that they wouldn't if their only goal were to get the best health care to as many people as possible.  Another example is what drug companies will bother researching.  They're much less interested in researching health benefits from natural products because they often can't patent them.  And doing expensive research on something that anyone will be able to copy once you've done the work isn't something they're likely to be interested in.  Again, it's not them being sneaky or underhanded, its just that they don't have much incentive to do the research.


Not profit, but part of it is fear of loss, which I'd say is largely the same thing.  Doctors do a lot of "defensive" testing, covering their bases so they can't get sued.  Not the only reason for excessive testing, but I think it plays a role.


I'd agree with all that.  Though I'd perhaps say that addressing the cultural issue will probably involve hospitals, since that's where most people come face to face with such issues.

It depends a bit on what we're giving up by treating them, I'd say.  Is the patient just spending their own money, so only just reducing their kids inheritance?  Sure, let'em have any treatment they want.  Or is it tax-payer financed, and thus taking money away from someone or something else where it might cause a lot more good?  Then it's a much more difficult question.  When it's private insurance covering it, it's a bit of both.  If everyone gets to choose if their insurance covers such treatment, then no real problem, because you end up paying for it yourself before you get there (at least on average).  But if we're talking about looking at insurance is required to cover, then it's a bit of the second situation, because everyone ends up paying for the persons end of life treatment, even if they don't think it's a good buy themselves.


It's certainly not easy to do, and I don't envy the people who have to make such decisions.  But people certain do have to, and there are ways of going about it.  In a very simple example you can say things like "For $X we can extend this guys life for 2 months, and he'll be in extreme pain the whole time.  OR we can cure 50 toddlers of a life-threatening disease and give them a very good chance of a normal life."  When you come at it less from a "is this worth $X" point of view, and more from a "what are we giving up by spending this $X on this" point of view its because more tractable of a problem.


In a perfect world, yeah, probably we should.  Will it be practical to do so in many cases?  Probably not.


I'd say it's less an issue of anyone deciding that a patient cannot have that time, and more of an issue of someone deciding that if a patient wants that time, they'll have to pay for it themselves.  It's not so much being told "you can't get this treatment" and more "we can't afford to buy this treatment for you, but feel free to buy it yourself if you can."  Still not nice news to hear, especially for people who simply can't afford it, but better than a simple "you're not allowed," I'd say.

Okay seems to me with the Affordable Care Act out of the courts its pretty clear most of it is on some grounds constitutional save for the Medicaid expansion which has been declared not obligatory by states, but they can opt in.

Now it comes to the odds of a repeal that is November and how the elections turn out from my study of this its not looking good on repeal grounds for the Republicans.

1. Obama gets re-elected its over.

2. Democrats hold a majority of at least 51 seats in the Senate its over.

3. They take one seat in the Senate and take the White House (only light in the dark tunnel)

3A. They can repeal through reconciliation the financial parts leaving those non-financial and then try the rest this includes the mammoth mandate insurers can't refuse customers due to medical issues (the king kong on the bills back). The democrats the filibuster the parts they can as they come up on the grounds they will look at the Republican replacement before deciding on that matter.

OR

3B. They go for a full repeal and smack into a filibuster by the Senate Democratic minority until hell freezes over.

4. Romney does his waivers to states and then some states will still want to do the ACA provisions and must get the funding anyway and other states do some of it or none of the ACA.

Seems to me regardless of the expected outcome barring a massive shift in the Senate of elevel seats a repeal is not going to be easy if it can be done at all depending on how stubborn the Democrats are in the Senate. I would think with the clear mandate of their re-election to office or election to office they might play hardball.

I just don't see how they can repeal this even if they do gain technical ability to do so.

I agree with you. I think ACA is here to stay. And honestly, it's not that much of a bugaboo. They were way kinder then they could have been, and most of the changes are good ones.

Oh there needs to be some changes I would lower the Medicaid threshold to the poverty line only, the rest can afford to get into an exchange with the subsidies and you can tweak those easily. But a full repeal would be remote.

I'd also support those changes. I'm still not sure how I feel about requiring people to hold insurance either (since the other option is to refuse care and let people die in the streets).

Well the problem is you cannot have insurers have to take anyone that applies and not have the mandate to get the risk pool far lower for them, otherwise here is what one local hospital will do. I know I gave them the idea and know the hospital financial department head.

They will apply for the insurance for the poor person paying the premium if the cost benefit ratio is high, provide the care getting the most generous plan they can then let the coverage drop upon the patiant leaving. The hospital taking their share of the payments. So if John Smith has cancer, they will pay for Blue Cross Blue Shields best plan for the Mr. Smith and the insurance the best plan they have and get the treatment on what profit they get. Then at the end of care stop paying for it.

It would be legal and the hospital for say a investment of two months premiums even if high say $5000 for two months and would get say 70% paid of the bill say its $200,000 instead of zero so for $5000 they make $140,000 its an option that could be there. And they could always go after tha patiant if they wanted to but if very poor why would they bother its still more than Medicaid would pay. Its also the reason the law must stand how long would medical insurers survive this if its what people and hospitals are doing with the law? A year or two, maybe three?

Oh wow, I hadn't even considered that. But the current law doesn't change that. If I have Cheapo Ins. which caps payments at $100k, and my treatment will cost $200k, what's stopping the hospital from doing that again anyway?

Under the new law there will be no review and denial Homeless Bob has major heart issues costing alot to treat the insurers can still refuse, when they cannot and all he needs is the payment covered starting 1/1/14 barring a repeal of the law. And my state is not expanding Medicaid so far this is likely going to be the thing that forces the state into the ACA barring a repeal which is a long shot. And only a repeal of the insurance company mandate will stop that and they cannot reconcile that out.

Add to that the Senate majority can reconcile once a year they use it on Obamacare they lose it for the rest of the year say at budget time when they likely will have to have it.

I'm sorry, I don't understand what you're saying here.

Oh the mandate to cover everyone kicks in in 2014, until then a hospital for an adult cannot assure Homeless Bob with the bad heart needed care can get insurance when sick. In fact they would refuse. So at the start of the year the hospital in question can cover the premium and he would have to be insured regardless of the bad heart, which makes the scheme work. Its intended for those who would have been in the Medicaid expansion under 100% of the poverty line since the ones over that could be expected to have an exchange based plan (state run or federal run).

This quote from a physician in the U.S. captures Obamacare in one sentence:

"We're going to be gifted with a health care plan we are forced to purchase, and fined if we don't, which purportedly covers at least 10 million new people without adding a single new doctor, but provides for 16,000 new IRS agents, written by a committee whose chairman says he doesn't understand it, passed by a Congress that didn't read it but exempted themselves from it, and signed by a President who smokes, with funding administered by a Treasury chief who didn't pay his taxes, for which we will be taxed for 4 years before any benefits take effect by a government which has already bankrupted Social Security and Medicare, all to be overseen by a Surgeon General who is obese, and financed by a country that's broke.

So what the ____ could possibly go wrong?"

--Dr. Barbara Bellar

Bat Man would kill the United States Congress if he were real.

Your quote would carry significantly more weight if you were to provide Dr. Bellar's sources for all of that information.



Batman doesn't kill people.

As a Canadian who does not follow politics, I am amazed at how angry/happy people get over this Obamacare thing in the US.  I was in Washington State for work at the time when it was first passed and people were either freaking out excited or foaming at the mouth angry.  It was interesting to watch.