Wednesday, January 6, 2016

Ending Obamacare

Well, the Republicans took the mirror image action of voting partisan to end a bill that with passed in a partisan manner. And for good measure, the bill will also defund Planned Parenthood. For many, I fully get why this would be boner inducing, it hits two of biggest Republican whipping issues. And, considering that the bill was basically passed solely by Democrats and also considering the Planned Parenthood helps the group of people that are not likely to vote Republican, it's got to feel good to send that middle finger. But it's a crock of shit. It will be vetoed, and there aren't enough votes to override it.

Republicans claim Obama care is making everything more expensive, as if, health care has not costed more year after year for like forever. There are things I don't like about Obamacare. But Republicans, who truly have the power to fix them, won't bother to even attempt. Ryan, conveniently, has said he will have a plan by the end of the year. Really? Six fucking years and you still don't have a plan? Idiots.


  1. You stated it perfectly before, Mike:

    "This country has become way more interested in perception than in actual outcomes."

    We now have a bunch of Pub representatives from gerrymanderied districts that have fulfilled campaign promises who can legitimately claim they repealed the ACA - and it would've worked, if it weren't for that commie Obama ...

    1. Don;t tell anyone pfunky but there are gerrymandered districts created by Democrats as well.

      I live in one. They split our district between 2 cities which we have zero in common with. The objective get rid of a solid conservative seat.

  2. Exactly Max. It ( Obamacare) may not be perfect, but where is the better idea? Like most everything else there isn't one. Of course the free markets could fix it. That is always the answer.

  3. It's time that our government began to act in the best interest of us, the people, and not in the interest of their donors (rhymes with owners) or their party hacks.

    1. So I take it mick that you are a Trump supporter as he is not accepting donations to his campaign.

    2. Nope. As Trump has stated, he can buy all the votes and politicians he wants, chump change for him William.

    3. Guess the trumopster is up for dropping 25% of his net worth.

  4. After just having passed my test for board certification yesterday, I do now truly have a stake in this. I'm not really worried I won't find a job if they suddenly repeal Obama care, but I genuinely want to help people and the system as it was and to some degree as it still is, is very inefficient IMO. For anyone who supports the ACA, it's easy to be dismissed as simply a lover of large government. I'm honestly not. That said, I'm certainly not a fan of the way private insurance companies do things. They don't, IMO, do anything to improve the quality of care delivered, nor do they do anything that makes medicine cheaper. They do manage cash flow, and admittedly, some of that process does occasionally block unnecessary waste. But, it's done in the name of saving profit rather than in the interest of improving the life of a patient or protecting the integrity of the system.

    What frustrates me is that up til now, this has been kept and framed in a purely political battle. IE the health of the individual is irrelevant, but the preservation of political ideology is crucial. In school, to some degree and with my preceptor, to a much larger degree, it was drilled into my head to not provide interventions that are not supported by research as being the most effective. We have examples in other countries of systems that provide varying levels of effective care, but we are seemingly not allowed to explore those systems and try to implement the parts that may work well in this country. So, instead we have a plan under the ACA that had one primary goal, which was to reduce the number of uninsured. In order to get this plan passed, we had to ensure that we protected the monopoly of insurance companies. Predictably, costs continue to rise because we must protect profit, rather than seek to improve health.

    At this point, my career trajectory is probably about 20 years. By the time I am done, I think things are going to look very different from how they do now.

  5. One thing to always remember Max, nothing will be changed in the ACA until the passing of Obama.

    It's his law, his legacy and it will not be changed until he's history. As a side note, why would the R's change the ACA? It's not their law and the warts are all the democratic parties warts.

    The insurance companies are involved with the ACA for 1 primary reason. The Feral Government isn't capable of managing healthcare as so aptly demonstrated with the VA system.

    Reducing the number of uninsured was a lofty goal and the results are many people with insurance that cannot afford the deductible. Nothing is free in life including healthcare.

    1. So is that the way we should do things from here on out? just sit back and complain how shitty something is without doing anything to fix it? Not hitting you with a wall of aggression here Lou, but if that is there thinking to say, "Well as long as we never try to fix it, we dont' have to own it". I think that's a load of crap. It is Obama's legacy, but I don't think the Republicans care a whit about that. I think they would love nothing more than for Obama's legacy to be that he came, got some stuff done, and then it was all undone before he left office. I just don't get that kinda bitterness and it's a cop out for them.

      The VA is not a good example. I get that you are making a ton of hay out of that fiasco in Colorado, but I think the issue is a lot more complex than that. I think there are many problems with the model of the VA, and it was not designed to be what it has become. We are going on what now, 15 years of being in conflict? The VA flat out does not have enough resources to manage the care of the massive influx of new patients in addition to the ones they already had. Your knocks on the government are fair enough I guess, and yet, you will never answer me what good insurance companies do. You never explain by what mechanism they save money or improve the quality of life of those insured.

      I get a lot of your views Lou. You get annoyed, rightfully so often enough, at people who fuck their lives up and then turn to the government to bail them out, whether it's with their health, or their finances. From my experience from the inside, even when people are not being unreasonable, what they want from their doctors and other providers is a feeling that the provider actually gives a shit about them. They want providers to explain things to them. They want them to spend time with them. Time=money, and no matter who is paying the bill these days, time is one thing in particular they do not want providers spending with patients. As long as this discussion remains wrapped in ideological parameters, things may change, but we will not get a result we want.

    2. Fixing the ACA is like repairing a seven year old Yugo.

      Fourteen months from now the same bill Obama is about to veto will be signed. Dispite your carping max that the pubs have nothing to replace it with new more market oriented systems will be developed.

    3. That's entirely possible William, I don't discount that. We will not, however, have market systems. As a genuine curiosity, I would like to hear what your version of free market means. Ending all government input will not, by default, create a market driven system. In brief, this is what a TRUE free market system means to me,

      1) No employer subsidies. Period. Just as we pay higher taxes for government paid healthcare, we pay higher costs for goods to pay for employee insurance. If an employer is allowed to offer insurance, and if the employee is allowed to pay their share with pre tax dollars, it is not a free market plan. If you willing, explain to me what is incorrect in this premise

      2) If people with chronic disease don't pay more money, it's not a free market plan. Further, if we don't take away your medicare and make you pay whatever the insurance companies believe someone your age should pay, it's not a free market system. If you want your medicare, you don't want a free market.

      I get that many who believe in just the parts of Adam Smith that fit into their political ideology also believe that people left of center just don't understand how free markets can fix everything. I won't deny that a true free market system would drive costs down, it would drive them down because people would never go the doctor. Eventually, the people who engage in unhealthy behavior would die early, pretty much like they used to before technology allowed us to extend their lives in spite of unhealthy habits. And we would save a ton of money.

      I think William, that people like you conveniently fixate on and unload on people like me as being the root of everything you believe is wrong. The people I have taken of as a nurse, however, want something far different from the system. They don't want to be treated like some stiff buying a TV. They don't want to be treated like they are just a revenue stream that needs to be treated with as little time and attention as possible. And they aren't all liberals. Mark my words, whatever the Repubs come up with to replace the ACA might save money, and then people will bitch about how indifferent healthcare providers are.

    4. Many of the candidates are advocating types of Fair and Flat Tax methods. Health care has to part of an overarching tax and spend make over. Treating everything separately leads to the same old results of special interests making insider deals. Health care is vitally important but has to be part and parcel of massive reform.

    5. As to changes in to the ACA:
      Until there is compromise, nothing changes. Obama is totally unwilling to compromise on the ACA. Compromise means you have to give and he is unwilling to give anything. There will be no changes until he has become nothing but a distant memory. The issue at hand today is neither party offers a candidate that can and will compromise.

      As to the VA Hospital in Aurora, it has little to do with the mismanagement of the healthcare for veterans and is more a perfect example of our government, mismanaged to the extreme. No one held responsible, no one fired, a few people retired early. The taxpayer pays the bill.

      The veterans are most important and are not receiving the care they should in a timely basis.

      The Department of Veterans Affairs, long touted by experts as providing health care superior to most private providers, is suddenly engulfed in scandal.
      Records on wait times for appointments were allegedly falsified at the Phoenix VA, and the department is investigating whether long wait times contributed to the deaths of 40 veterans at that facility. Similar stories about other VA facilities have been bubbling up for months. This is a ghastly problem involving potentially criminal behavior.

      WASHINGTON — More than 600,000 veterans — 10% of all the Veterans Affairs patients — continue to wait a month or more for appointments at VA hospitals and clinics, according to data obtained by USA TODAY.

      One year after outrage about long waiting lists for health care shook the Department of Veterans Affairs, the agency is facing a new crisis: The number of veterans on waiting lists of one month or more is now 50 percent higher than it was during the height of last year’s problems, department officials say. The department is also facing a nearly $3 billion budget shortfall, which could affect care for many veterans.

      The agency is considering furloughs, hiring freezes and other significant moves to reduce the gap. A proposal to address a shortage of funds for one drug — a new, more effective but more costly hepatitis C treatment — by possibly rationing new treatments among veterans and excluding certain patients who have advanced terminal diseases or suffer from a “persistent vegetative state or advanced dementia” is stirring bitter debate inside the department. That ought to shorten wait times.

      Here's my reality Mike.
      I have had excellent care from my PCP, Oncologist, Urologist, and Orthopedic surgeon. I have never waited a month for an appointment as a new or existing patient. My insurance that you hate, has done an excellent job negotiating the costs of treatments down. I have never been turned way because of my insurance and every facility I have had to rely on including Johns Hopkins have accepted my insurance. What's to hate???

      The amazing thing is every physician has taken the time to explain my issues as it pertains to them, solutions and possible outcomes with the negative ramifications that are possible.

      As to the VA, why not give them access to doctors instead of a dedicated hospital and medical system which is woefully run by our government?

    6. Besides being the most expensive America also has the least efficient healthcare system in the world and it wasn't the ACA that made it that way it has always lagged behind other industrialized countries. Lou you bitch about our VA system constantly. There was a time that the VA was one of the best , most efficient, and well run systems in the world. What happened? (Obama didn't do it). Our VA system is overtaxed because of a decade and a half of constant war, war in which instead of bring home dead bodies we have brought home severely mangled and dis-formed human beings who are going to need care for the rest of their lives. And what has your republican congress done about it ? Cut funding. Congress controls the purse strings not the president. And congress in their little hissy fit of the past few years have punished our citizens and especially our wounded warriors because they don't get their way.

      Lou don't shoot the messanger (Huff post) on this one it is a matter of public record.

    7. Told you Max. The answer is market based systems. We have used market based systems since the beginning of the country. It hasn't worked out so well has it. The most expensive least efficient system of healthcare in the world, which ranks what 18th in life expectancy and outcomes. We can do better. There should not be enormous profit made in keeping people healthy and alive. Life is all we have that is sacred. it is the one thing that money cannot buy for us when it is gone. Why should companies profit from that?

    8. I agree fully Rick, and that is part of what I wanted to say to Lou's comment.

      Lou, you ask, "What's not to like about your situation?" You mention that the insurance companies negotiate down the price. What I take away from that is this, they aren't making healthcare cheaper, they are just telling the doctor, "You will take X figure, and we will take a profit for doing nothing more than telling you that you will make less money."

      My gripe Lou is that insurances companies do nothing. They don't deliver the care, they don't spend money on research to improve care, etc. I don't hate profit, but I just don't understand what exactly it is they do that deserves profit. And that's my frustration. There is room for providers, hospitals and even insurance companies to make a living and basically break even. As Rick mentioned, I just don't understand why we can't seek to run healthcare at a break even point.

      I just had an exchange with a patient today here at work that I think is going to stick with me for a long time and Ill probably do a different post on it. The government to me, is not a solution per se, that said, I do not see it as the enemy. If I had a choice between making less money to work a system that intends to deliver care for as many as possible versus making less money to preserve profit for some insurance company, it's not a hard decision. IN all honesty, I believe this is exactly the decision I will have to make.

    9. From my perspective, the negotiate the proice. I may be able to negotiate a small discount however, with the numbers can negotiate a far better price.

      As with everything, the doctors, providers can say no thanks. My PCP did exactly that with Cigna who put unreasonable conditions on him. Take ACA patients and receive less than regular insurance patients. He dropped them as did my Orthopedic surgeon.
      As to the profitability, 4-5% is far lower than business in general and a bargain.
      The government would cost far more to do what the insurance companies do today as clearly proven day in and out through out government.

      For me, I pay my PCP a 1500 concierge fee. I see the physician when I make an appointment. The PA comes in does the how are you feeling routine get the vitals and then the doc comes in. To me it;s worth the extra every year.

    10. Rick,

      The Congressional Budget Office score of the Comprehensive Veterans Health and Benefits and Military Retirement Pay Restoration Act of 2014. shows it would cost roughly $24 billion over ten years. As drafted, the bill would be paid for almost entirely from the overseas contingency operations (OCO) fund, which is not recognized as a real savings by the CBO.

      The bill would greatly expand eligibility for certain veterans to receive services from the VA health care system, which is generally reserved for veterans with service-connected injuries, disabilities, and lower thresholds of income. This massive expansion of eligibility would further prevent those truly in need from receiving the care they need because the program would have to service a much larger pool of veterans.

      The bill would interfere with the states’ autonomy, most critically with a mandate for colleges to offer blanket in-state tuition for veterans.

    11. Rick,
      p.s. I read the bill, you read the headline.

    12. The ACA did nothing to change the cost of healthcare.

      The ACA did nothing to improve the outcomes for healthcare.

      If you measure my outcomes they are spectacular. But then again every circumstance is different.

    13. Respectfully Lou, I'm not sure your assertions here about the ACA are really fair. Through the use of subsidies, the ACA has undoubtedly made insurance more affordable for individuals who previously could not afford it. Some people still can't afford the premiums, but many can. The cost of healthcare, like everything else, goes up every year. If we are going to have an honest discussion about this, I think people like you and me both need to focus on more substantive aspects of it. If we are talking about the costs in excess of typical yearly healthcare inflation, then we are maybe on to something.

      Reading the discussions that you and I keep having on this, there are a few major repeating themes. From your side, seemingly, if it has anything to do with the government, it's needlessly inefficient and expensive. From my side, seemingly, insurance companies do nothing useful and basically just bundle payments and generate a profit. We hyperfixate on these points quite a bit, but I think they are truly beside the point.

      I believe it is in all of our best interest to have a health care system that everyone can access in a cost effective way. The ACA does not offer that, and neither does private insurance. For our elected leaders, there is no agreement that this should be a goal. At best, for the moment, I think there are those on the left, probably me included, who just want to see universal care "forced" and then fix it once it is an insecapable reality. And of course, there are those with the 180 opposite view. I don't think that's going to change anytime soon.

    14. And Max the subsidy for a person making 90K a year certainly is a boon to them. Was the intent to help the people making 60-90K a year or was the intent to buy acceptance?

      The ACA was designed to insure people, nor change the cost of insurance. Having said that what will people do as premiums continue to climb? Will they dump the insurance as affordable which is where we began 6 long years ago?

      As we discussed before, nothing is free. physicals, immunizations, etc. Te cost of insurance is rising as government demands no charge items for every insurance policy.

      Does a free physical help reduce the over weight/obese epidemic in America? It may find High blood pressure, cholesterol issues due to the epidemic however instead of treating the root cause we dispense more pills pat the person on the head and move on.

      We need a catastrophic plan. period, No bells, no whistles. People are adults and can make their own choices. We don;t need government dictating what we will have and pay for. If people chose not to go to the doc, so be it, it's their choice.

      As far as the insurance companies who manage the financial aspects of healthcare, i believe they are worth it where as you believe government should and can do the same job. We disagree as the fraud in medicare and medicaid are perfect examples of government managed healthcare. Fraud can be found and the healthcare is far from cheap.

    15. "As far as the insurance companies who manage the financial aspects of healthcare, i believe they are worth it where as you believe government should and can do the same job"

      This is actually not entirely true, but admittedly, my opinion on this has evolved a bit. What I am interested above all other concerns is outcome. IF insurance companies could deliver what I'm looking for, that would be great. But again, the goal of insurance companies is to generate a profit for running a risk pool. If we had a plan where people basically paid for insurance from the time they started working, as we do with SS, I think we could get everyone covered at a reasonable rate. That said, here is an inescapable reality you and I both agree on, millions of people do not make an effort to be healthy and we all pay a heavy price for that.

      The only reason I consider a government run plan as a strong consideration is because I believe our fractured payer system is horrible. I studied a lot of plans from other countries while I was in school, and one conclusion that I came away with is that no plan is perfect. That said, other countries can and do get better value for the money they spend. Whether public or private run, I believe we could offer the basic universal catastrophe only coverage, and then let the insurance companies make their bones on selling expanded coverage. I also, believe it or not, favor a bit of a market approach wherein there is actually some consequence for not being health or reward for meeting certain goals. But, as long as we have employer sponsored plans, paid for with pre tax dollars, there won't be a market influence.

      I think I believe a little more than you do in providing evidence based coverage that has been shown to save money. There is a ton of research available on what sorts of screenings save lives and money, and what ages they do so. A discussion you and aren't really having here is what might actually save some money. For example, if we say an age appropriate colonoscopy screening should be paid for fully out of pocket, that's great for saving costs on the payer side, and if they pass those savings on, that's great for the insured who pays premiums. If it's too expensive to get one though and people skip it and subsequently get a cancer that could have been treated much sooner, they will either go bankrupt or then rack up a huge hospital bill that subsequently drives up the cost of catastrophic insurance. I'm genuinely not asking for the alleged free lunch, but I am asking for a rational look at the way we spend healthcare dollars and how we fund them. I won't deny the fraud that is within the medicare system, but lets be honest, if an oncologist continues chemotherapy and radiation treatments knowing full well that they will not do an ounce of good, as that not just a better looking version of fraud?

  6. if an oncologist continues chemotherapy and radiation treatments knowing full well that they will not do an ounce of good, as that not just a better looking version of fraud?
    Is it done because of our litigious society?

    My brother inlaw, now a former doctor was requested to see an 80 year old man in the hospital for cancer related issues. He deals with muscles and muscle atrophy which the patient had. The 80 year old died 2 days later and the family sued everyone that saw their father. His expensive insurance doubled the first year and again the second year. The 3rd year the lawsuit was dismissed as frivolous as he died from cancer related issues. His insurance never went to the original price. There in lies the issue of over treatment.

    Catastrophic means catastrophic. If people chose not to have a colonoscopy, isn't it their issue, not the governments issue? Where does government intervention and personal responsibility

    As far as outcomes, until people take responsibility for themselves and their health nothing will change. Cost will continue to rise, outcomes will continues to be poor.

    1. In all honesty Lou, I don't think there is a single answer. Sometimes it is a cover your ass thing, sometimes it's because a family is combative and it is easier to give them what they want to make them go away and sometimes it's because a doctor just doesn't want to take the time to tell a family firmly but compassionately that it's time to stop.

      My experience as first an ICU nurse and then hospice nurse has given me a perspective that I think people outside of medicine would consider uncaring. I've seen truly harmful futile care that borderline gave me nightmares at time for how cruel it was. The death panel characterization did not help. I think there needs to be limits on what types of care we are going to do. In hospice, I have seen countless demented patients who are literally skin and bones, completely unable to communicate, who are being fed through a tube into their stomach because they can no longer eat without choking to death. Is it really human to extend someone's life that way? My preceptor was actually very good at being blunt with his patients in telling them why it was not a good idea to have a surgery. If we had more doctors like that, I think it would help a little.

      I'm going to have a very interesting opportunity coming up because I'm going to work for my current company in palliative care. Palliative care is really a gray zone between not ready for hospice, but still sick enough that it's time to really think about how aggressively you want to continue pursuing treatment. In a lot of cases, I think MD's consult us in to be the bad guys and have the coversation they don't want to have. Still, I as part of the changes I envision, I think everyone needs to be better educated on the limitations of medicine. We CAN keep a person with ruined lungs alive on a ventilator with a tracheostomy and feeding tube in the stomach. I don't think anyone envisions that they would be okay with that 10 years before it happens. But, most also don't know that's what the end of the line looks like. The litigiousness and stubbornness are always going to be an issue, but I think education and frank discussions from MD's can help to reduce futile care.

      To the point about catastrophic, what I'm saying is that if people can't afford the colonoscopy and wait until it's late stage cancer, we will all still pay a price for that. Doesn't matter if it's insurance or the government paying it.

    2. My point is, why should half society prop up the other half especially when they refuse to take care of themselves?

      One day soon this country will need to make choices. As we will soon discover we cannot have everything.
      Do we keep SS to ensure seniors who paid in all their lives are ok?
      Do we keep medicare to ensure seniors do not die on the streets?
      Do we keep the safety net as it is today or re-evaluate it and reduce the people qualified. Do we time limit the safety net?
      Do we maintain the ACA and the medicaid allowed under the ACA?
      Do we allow illegals to stay and collect benefits from the US including healthcare?
      One day and I see it coming sooner than later we will be faced with choices.
      Where do we draw the line when it comes?

      Once you start the entitlement it's nearly impossible to end it.

    3. "My point is, why should half society prop up the other half especially when they refuse to take care of themselves? "

      It's a fair question Lou. I don't think it's our responsibility to do so. If we are talking solely about health care, I would contend that we are doing this with any form of insurance because it subsidizes the treatment of those who are unhealthy. As I've also said before, if society is not willing to say we will not give you treatment if you don't have money, the question is kind of moot.

    4. There is a difference between helping those that cannot help themselves, those that are working to better themselves and those that chose to do nothing but what they are doing today.

      I see a marked difference between people 10-20 years ago that refused to settle for little and the defeated people we have today. And society is tired of handouts to those that chose not to participate and work to pay their own way.

      No one suggests that we should not help those that cannot help themselves or those temporarily down.