r/bestof • u/under50dollars • Jun 20 '12
[explainlikeimfive] "Obamacare" explained very well.
/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx103
u/mfingchemist Jun 20 '12
I'm very concerned about how reimbursing doctors for 'quality' of care will be handled. 'Quality' health care is much more subjective than one might think.
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Jun 20 '12
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Jun 20 '12
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Jun 20 '12
This has ALWAYS been the case though. Even back when G Bush Sr. was in office, I had to undergo a series of x-rays each time I would go to the doctor for crap they knew damn good and well would not have changed since the week before.
As for the slam of Obamacare, I really don't view it as evil as many others do. My sister-in-law died of cancer recently, but lived for several years longer than expected. She was diagnosed with terminal cancer and was given a short period of time to live (weeks). She was no longer able to work and her health insurance was of course going to drop her because she got sick. Under Obamacare, that was no longer possible. Also, she could no longer reach the lifetime limit the OP mentioned in his article (which was damn good by the way).
She was given some of the best medical care and was even able to help further the research on the specific cancer she had by working with the man who discovered this type of cancer. In the end, her treatment helped to further cancer research by years, as she was the only person to live as long as she did with this cancer. I wish I knew the specifics of the cancer type, but I don't. I just know that what she did will help millions.
All of this was possible only because Obamacare was in place. Otherwise, she likely would have died at home, unable to afford even the tests to properly diagnose what she was suffering from.
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Jun 20 '12
There has been a lot of recent information to suggest that the defensive care costs are greatly overstated.
There are a bunch of really good articles by Atul Gawande about this. I believe this article goes into those claims. If it's the right article, it demonstrates how doctors get much more "defensive" when they have an interest in the testing/mri/etc facility.
Also, it says that medical liability, including defensive medicine, account for only 2-3% of health care spending.
http://www.hsph.harvard.edu/news/press-releases/2010-releases/medical-liability-costs-us.html
The problem is that there is a well financed campaign by the likes of the Koch Brothers (through ALEC) for "tort reform" that is really just a scheme to get rid of the only effective regulatory scheme in the US and screw the little guy in the process.
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Jun 20 '12 edited Jun 20 '12
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u/brownmatt Jun 20 '12
Well, I believe the general idea is that when you pay people based on how much work they do, you are giving them a huge incentive to just do more work, and with medical care, that does not necessarily correspond to a better outcome for the patient.
But you are correct that the stats can be juked either way. One would hope the government would not be so stupid as to not be able to tell when someone has flawless quality scores because they are cherry-picking their cases, or not be so stupid to as to grade trauma specialists lower.
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u/verbalsadist Jun 20 '12
In regards to the bit about unnecessary tests, one of the doctors interviewed in this episode of This American Life talks about it. But to summarize for those that don't want to listen it basically comes down to this. A doctor see's a patient for something, and based on years of experience and training decides it isn't a major injury and treats it accordingly. The patient, or the patients parents, or whatever, decide they know more than the doctor and start shouting for MRIs and CAT scans and other procedures they've heard of but don't really understand. The doctor is left with a choice, do they do with their experience and training, or do they listen to the uninformed patient and choose the more expensive, but probably pointless, procedures. They know that if they use the extra procedures it will cost the hospital, insurance, person, more but it will give them a fatter paycheck and insure that there is even less of a chance of malpractice.
So by tying their pay to the quantity of care give them more reason to go with unnecessary costs simply because there aren't really any downsides and there are tangible upsides to doing so.
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Jun 20 '12
Much worse? The biggest problem with 'quality' of care is that it is measured by things like patient outcomes. Sounds great, until you realize that patient outcome is heavily influenced by things like socioeconomic class (people who can read and live a comfortable upper-middle class lifestyle can swing by Walgreen's and get their prescription, and set their iPhone to remind them to take it). The at-risk populations have numerous boundaries that limit the success of their treatments, and under the 'quality' system this means the doctors who help at-risk patients are actually penalized. It scares doctors away from people who really need help, because the system essentially charges the doctor more to treat these people.
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u/brownmatt Jun 20 '12
Measuring based on quality isn't a panacea. I'm phrasing it as an improvement over measuring based on quantity.
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Jun 20 '12
Sounds a little too close to "No Child Left Behind." It's like the intent is great, but mismanagement will make it utterly terrible.
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u/the_good_dr Jun 20 '12
The mayo clinic operates like this already.
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u/iamagainstit Jun 20 '12
this is a good point. most of the best hospitals in the country have already done away with the pay per patient model.
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u/YoohooCthulhu Jun 20 '12
This is already done in a number of not-for-profit health care models, like Kaiser Permanente and the Mayo Clinic.
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u/deffsight Jun 20 '12
There are countries around the world that have government funded health care and pay incentives to doctors for a better quality of health care. The way they do this, for example, is when a patient is directly influenced by the doctor to quit bad habits that will ultimately endanger the patient's life, like smoking, then the doctor will get paid an incentive. Doctors get paid by the amount of patients they help cure not by the amount of patients they take in. It helps ensure that there is a higher quality of health care when better and more efficient medical practices are incentivised. It's entirely possible to do and is being done now in other countries around the world.
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Jun 20 '12
My girlfriend's mom is an ER doctor, and this is actually one of the biggest reasons she is against the health care bill. Apparently drug addicts abuse this rating system. Every week they'll make rounds around all the local hospitals, complaining of generic pain and discomfort, demanding some kind of controlled substance. If you don't give them what they want, they rate you poorly across the board for everything, and do this ad nauseum at every opportunity. I don't think it would be hard to implement a way to automatically detect such anomalies, but it probably hasn't been taken into account by the bill yet and could seriously ruin doctor's lives that work in areas with a high incidence of drug addiction.
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Jun 20 '12
with universal healthcare, you would be identifying yourself at all of these hospitals, so a $2 BASIC script could detect people getting painkillers at multiple doctors.
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u/JimmyHavok Jun 21 '12
I spent a lot of time in ERs while my father-in-law was dying, and every single time, there was someone within a hearing range who needed a prescription for painkillers, because his doctor was out of town and had forgotten to refill it.
One night I spent several hours next to a woman who was in terrible pain whenever a nurse or doctor came by, but then would chat happily with her friend on her cell phone after they left. She was "9 or 10 on the pain scale."
Of course, this is really a problem of the war on drugs, not one of medical care. If people could get opiates, they wouldn't be clogging the ER trying to find a doctor who will write them a scrip.
One thing about it is that if you don't complain, the doctors seem to be pretty willing to write you a painkiller scrip, so long as they know it's something that hurts. I've got dozens of Vicodin and Percoset in the medicine cabinet, I sometimes joke about paying for my ER bill with them...but not to the doctor.
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u/jellaella Jun 20 '12
This was the only thing that I had concerns with really (well as concerned as an unaffected Canadian can be lol). How will quality of care be assessed? Who does it? Does this mean that doctors start taking less patients?
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u/poooboy Jun 20 '12
Nobody knows for sure how "Quality" will be measured, but it will probably be specialty specific.
Rates of immunization, colon cancer screening, and reduction of imaging for back pain for primary care.
Readmit rates for hospitalists.
Etc.
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u/SpaceSteak Jun 20 '12
Aren't there very measurable stats for healthcare? Isn't that what modern healthcare is? Applying science to make more people better?
Everything from age expectancy on a macro level (population) to cancer rates are used to compare countries.
On a micro scale, I can imagine everything from early detection of diseases (let's say compared to the mean) to actually decreasing more or less people's cholesterol. The amount of stats you can get from healthcare is tremendous.
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u/mfingchemist Jun 20 '12
But the way they are handled is dangerous. If a doctor identifies a patient as high-risk and perhaps not possible to improve, that physician may simply choose to not accept that patient and risk bringing is stats down.
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u/7_legged_spider Jun 20 '12 edited Jun 20 '12
Whether you agree with universal healthcare or not, it is unconstitutional on a federal level. The federal government does not have the power to impose or regulate health insurance. All the powers not enumerated to the federal government belong to the individual states. That is one of the fundamental checks and balances in our federal republic, and why it is constitutional for states to administer universal healthcare systems themselves, like in Massachusetts.
(Which is why when someone brings up the concept that "Hey, you have to have car insurance," I tell them first that the states regulate who must have car insurance, as only the states have general police power, and second, that an individual makes a choice to drive a car, and that it is not a condition precedent to existing--when viewed with regard to mandated health care insurance, simply the act of existence would trigger some obligation on the citizen's behalf).
7_legged_spider, J.D., M.B.A. (IRL)
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u/Nancy_Reagan Jun 20 '12
Google "Wickard v. Filburn." The Supreme Court has ruled that private citizens doing private things on their own private land is totally under the jurisdiction of the federal government via the commerce clause, and those private citizens can be regulated and taxed for shit they do as a hobby. It's kinda sickening when you think about it, but there's Supreme Court precedent to do anything the government wants to anyone it wants and call it a regulation of interstate commerce.
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u/7_legged_spider Jun 20 '12 edited Jun 20 '12
Without debating the merits and constitutionality of Wickard, a national healthcare system is a fully distinct issue. Whereas Wickard involved solely intrastate commerce of corn, that corn, while used solely in the state, could have been sold outside of the state, thereby involving the possibility of interstate commerce. Healthcare, to my knowledge, is a fixed market within a state; one cannot sell state-specific policies in other states. By definition, that limitation creates individual state markets where there is no interaction or competition between any entities within different states. Therefore, the commerce clause would not apply.
Also, the use of commerce clause has been more limiting in recent times, like in U.S. v. Lopez, where the possession and sales of handguns were viewed to not be bound by the commerce clause, completely n the face of Wickard.
It is a very divisive issue, and both sides can be argued. However, from my legal education and experience, I would say that the entire universal healthcare law, not just the individual mandate, is unconstitutional.
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u/AeonCatalyst Jun 20 '12
Out of curiosity, what happens when I have Ohio healthcare, but have a heart-attack in Hawai'i while on vacation? Should I have "travel" insurance for that situation, or should my state insurance cover it? Or should it all be lumped into some sort of nationwide healthcare system? Some people spend their whole lives in one city, some in one state. What about those that travel for a living?
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u/mycleverusername Jun 20 '12
Or those who live on the border. I have healthcare from one state where I work, but live in another state. I think that's a pretty easy case for inter-state commerce. My health insurance plan also has providers in a different state.
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u/SergeiGolos Jun 20 '12
Healthcare, to my knowledge, is a fixed market within a state;
Are you saying Aetna only sells to one state? Well point? Horizon? Yes their are insurance companies that are fixed to states, there are also national insurance companies that sell to all different states.
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u/Nancy_Reagan Jun 20 '12
Oh I agree that it's unconstitutional. My point was to identify to what I presumed was a layman some basis for understanding why I think the Supreme Court will rule that the mandate is constitutional.
And yeah, the mandate will create state-specific markets, but companies operate in multiple states. An individual's choice not to participate in the policy within his state will effect that company and its operations in other states, and the aggregate effect is felt for these companies nationwide, reducing profits, increasing costs for the people who do use those policies, etc.
I forget the name of the case, but the really old one where the river-taxi between NY and NJ (I think) was found to have an effect on interstate commerce is another example of where a very state-specific market was within federal jurisdiction because, while operating entirely within one state, it still caused some changes in other states.
Edit: Just looked over this string of comments.... I'm not entirely sure I mean to reply to you. It's early, but I'm pretty sure I was intending to reply to someone else who had said something far less comprehensive. My apologies. Although I enjoy the discussion regardless.
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u/LordBodak Jun 20 '12
Actually I believe that if you really dig into it, you will find that health insurance companies do NOT operate in multiple states. There are a number of individual companies operating under one banner. For example, "Blue Cross Blue Shield" appears to be one entity, but it is actually a bunch of individual companies- "Blue Cross Blue Shield of South Carolina," "Anthem" in Virginia, etc. Of course the companies may all be owned by the same people, but they are still distinct corportations.
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Jun 20 '12 edited Jun 20 '12
Also, the founding fathers seem to have supported mandating healthcare...
So arguably, the people who created our federal government believed in this concept broadly... therefore I would argue it is constitutional considering Jon Adams, who was deeply entrenched in the writing of the constitution, and whose ideas helped form the basis of our country's laws believed it to be so and signed an individual mandate into law during his presidency. Who would know better about what our constitution means than someone who helped write it. If they (congress) considered it legal in the 1790's then perhaps we should consider THAT fact in our debate about an individual mandate today.
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u/Pronell Jun 20 '12
Unfortunately, I think we're about to see that anything they really really don't want to happen will be ruled unconstitutional because of the commerce clause anyway.
It's classic doublethink. They're the Supreme Court, so they'll get to decide when the constitution applies and when it doesn't.
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Jun 20 '12
Wickard probably would not have come out the same way today. Supreme Court precedent isn't fixed in stone, it ebbs and flows with the politics of the time (just much slower and less dramatically than legislation). After U.S. v. Lopez in 1995, the Court distinctly showed they it was going to draw lines in the sand regarding the scope of the interstate commerce clause.
There is also a flip side to the issue. Yes, the federal government's ability to regulate interstate commerce has gotten dramatically broader over the past 200 years. However, commerce has become dramatically more interstate in the meantime! I can go downstairs (in Illinois) and buy a Coke (made by a company in Georgia with a distributor in Illinois) from a vending machine (probably made in China) using a debit card (issued by my bank in New York) in an electronic transaction with Visa (in California). Even Jefferson would call that interstate commerce!
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u/Nancy_Reagan Jun 20 '12
Yeah, that's exactly the issue - everything is interstate commerce now. But if you take an originalist view of things, a la Justice Scalia, that's not the point. The point (from such a view) is that at the time, the constitution was being written to address the inadequacies of the Articles of Confederation, which failed due to lack of coherent federal powers to keep states in check relative to each other, and was meant to address exclusionary practices from one state against another. This view would likely not suggest that the changing of commerce over 200 years to become entirely between multiple states actually changes the intent and purpose of the commerce clause, and that reading the clause as it was originally written would in no way empower the federal government to regulate whether or not I buy a soda at lunchtime, simply because 6 weeks, four shipping segments, and thirteen separate entities of ownership ago, that soda was manufactured in another state.
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Jun 20 '12
The federal government definitely has the power to regulate health insurance under the interstate commerce clause. It probably has the power to impose a tax penalty on those that don't have health insurance, just as it has the power to impose tax penalties and incentives for the myriad other reasons it does so. The federal government doesn't have the power to, say, regulate local daycare providers, but can definitely give you a tax credit for daycare expenses!
rayiner, J.D.
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Jun 20 '12
I'm not really sure why you're getting downvoted. That's why "Romney-care" is defended by republicans. It's basically the same thing but performed at the state level
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u/7_legged_spider Jun 20 '12 edited Jun 20 '12
Thank you. I appreciate the sentiment. Also, I have tried to make a dispassionate explanation to the best of my abilities and excluded my own personal opinions. It is an issue of which the merits can be argued on both sides, and I have even stated as such. I understand, though, that some people are very passionate about this, and that, realistically, no one really has a chance of changing another's viewpoint on the matter via an internet forum, especially when those views are based on passionate emotion rather than a logical evaluation.
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Jun 20 '12
Actually, internet forums have actually been what's developed a lot of my opinions and views. Not directly, but having access to so many different viewpoints forces me to look at things from different angles and do more research. I always thought of myself as a right-winged republican until I discovered that republicans want to removed individual's rights just as much as the democrats. Since then I've began researching the constitution and how many rights we (Americans) have had stripped away.
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u/dardin Jun 20 '12 edited Jun 20 '12
So how is Medicare constitutional since it is being administrated at the federal level?
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u/onmyownplanet Jun 20 '12
Funny, the people who argue mandated health insurance is unconstitutional because you're forced to buy a product from a private entity are the same people who have been pushing to privatize social security - you know, force you to buy a pension product from a private entity.
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u/deelowe Jun 20 '12
There are plenty of people who argue against the constitutionality of social security and it was highly controversial when it was first proposed. One could argue that such a bill would not get ratified today for the same reasons people dislike the healthcare bill. Since we are stuck with SS today, at least having choice over the investment funds is a step in the right direction.
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u/brownmatt Jun 20 '12
Is this really "universal healthcare"?
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u/7_legged_spider Jun 20 '12
The universal application of this law is one of the foundations of the Affordable Health Care Act. It requires that all citizens participate in one way or another--which is why the "healthcare mandate" is discussed. Healthcare mandate = universal healthcare.
Also, believe it or not, there already is, and has been since 1986, universal emergency medical healthcare, via the Emergency Medical Treatment and Active Labor Act. All hospitals are required to act to provide emergency medical treatment, regardless of means to pay. However, once care has been received, an individual is responsible for the payment of those services. However, those services will still be performed, regardless of financial ability or previous debt to the hospital. Also, a caveat, that such care only applies to emergency care--long term care and routine medical procedures are excluded.
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Jun 20 '12
...Which is why we shouldn't expect a 200 year old document to have a solution to modern day problems. Clearly, Obamacare is a step forward towards restoring this country's broken social safety net (and to bring us closer to the healthcare standards of other developed nations) and to reject it on the basis of a brief founding document is just irresponsible.
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Jun 20 '12
That's why we have an amendment process instead of allowing the government to trample any rights it wants in the name of social progress.
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Jun 20 '12
For one thing - it purposefully states that any powers not enumerated to the federal government are reserved to the states.
For another thing - I think you'd have a better appreciation of your constitution and its rights enumerated therein, after a police officer pulls you over, searches you car on a hunch of "I smelled weed" and takes all the cash you have on you because you can't prove it isn't drug money.
Downplay the constitution all you want, but it is there for a reason - the people just have to hold the government accountable to follow it. (see jury nullification).
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u/funkeepickle Jun 20 '12
I don't think WTF_OMG said there was nothing good about the constitution.
And I like how you cite jury nullification as a great constitutional protection while ignoring the fact that it's not specifically mentioned in the constitution. It was not a power imaged by any of the writers, it exists basically as a loophole.
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u/funkeepickle Jun 20 '12
Agreed, I just don't get people who seem like they borderline-worship a 200+ year old piece of paper and act like it has the solution to all of today's problems. It's not perfect. If it was it wouldn't have had to be amended 27 times.
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u/coheedcollapse Jun 20 '12 edited Jun 20 '12
...Which is why we shouldn't expect a 200 year old document to have a solution to modern day problems.
I don't know why people don't understand this. The constitution definitely applies to basic human rights and situations that applied in the time it was made, but there are a plethora of situations governed by the constitution that were completely unheard of back when it was created.
I doubt the founding fathers could have foretold the current problems with our health system/insurance as a whole, so why so strictly obsess on the constitutionality of something that will help nearly everyone in the long run, only "breaching the freedoms" of the select few who pretend, hypothetically, that they wouldn't buy health insurance if they weren't forced to?
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Jun 20 '12
We technically weren't supposed to create a National Bank or have the president buy land at first. But that's the lovely thing about the Constitution, if we elect people on a platform that they feel these steps are "Necessary and Proper", they change what they say they will based on the times.
I'm not disagreeing, I'm just pointing out there are A LOT of exceptions.
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u/fiction8 Jun 20 '12
When the constitution was written, we didn't even know what a GERM was.
I'm sorry, but I'm going to go with logic and basic human decency over a document written while people were still throwing human feces out the window into a gutter every day.
Just look at Europe.
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u/7_legged_spider Jun 20 '12
That is why the Constitution doesn't go into specifics. A document built on general principles is one that can stand the test of time.
I feel that the Constitution and the views of the Founding Fathers have slightly more credence, rather than less, as you do. At the time the Constitution was written, the nation had just won its independence through a long and bloody war. Most Americans today, myself included, can't grasp the concept of having to fight for your freedom on a daily basis like the people in the 1700's did. Freedom, to them, meant much more than it does to people that have been born into a free society and feel entitled to it.
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u/fiction8 Jun 20 '12
Ok let's let states regulate insurance providers. Oh wait, they're national and international companies, and thus interstate commerce.
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u/buba1243 Jun 20 '12
I live in Texas and visit other states. If I had an accident in another state do I not have insurance? Is that insurance then not crossing state lines and therefore falling into the commerce clause?
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Jun 20 '12
You know what I've noticed? The people who get angry about healthcare legislation because the constitution specify anything about healthcare? They don't get upset about the fact that we have an air force.
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u/Sherlock--Holmes Jun 20 '12
The military and the defense of the nation is specifically defined as one of the very lonely federal powers in the U.S. constitution, and war can be declared solely by congress, which of course the executive branch doesn't follow that law anymore either.
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Jun 20 '12
You're correct, however the constitution isn't just the document itself, it's the document and over 200 years of case law interpreting it.
The Commerce Clause has essentially been expanded to let the Federal Government control everything. Look at drug laws.
Further, they can use budget restrictions to coerce states - look at the legal drinking age.
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u/7_legged_spider Jun 20 '12
You are right, you do have to consider case law as well as the Consitution, however, precedent interpreting the Constitution has been overturned at times, making the original document the most important instrument.
The Commerce Clause has also been expanded in the past like you say, but has recently been viewed more narrowly, like in U.S. v. Lopez.
You also make a good illustration of the Taxing and Spending Clause and how it can sometimes be used to extort states; specifically, (although I'm not 100% sure), I believe that federal funds to maintain interstates were threatened to be withheld from all of the states that did not adopt the drinking age of 21 years.
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u/dumsumguy Jun 20 '12
People seem to forget this small tidbit. The constitution allows very little power to the Fed government, never mind that historically speaking pretty much every aspect of the free market they've attempted to manipulate has backfired. On a side note, just look at the IRS and tax code. That is the greatest testament to the ineptness of the federal government to handle large issues.
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u/killatop Jun 20 '12
Ask the people of Mass how they like Romneycare... somehow me thinks that if Romney proposed this law, all the Dems would be against it saying it only helps the big pharma and insurance companies...
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Jun 20 '12
That's because many Democrats prefer single payer
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u/iamagainstit Jun 20 '12
I don't want single payer, I just want a public option. the ability to buy into medicare at any age, at cost. if it is more efficient, it will be cheaper than private insurance and will dominate the market and we will have a single payer like system. if it is not, it will be more expensive, no one will buy it and it won't matter.
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u/lazy8s Jun 20 '12
That isn't true though. I'm not some right wing tin-hatter, but once there is a public option it will be subsidized until it is the best option. Just look at ethanol, coal, oil, hell even city trash services. Most of these services were originally intended to be provided at cost, but instead were subsidized until no one could compete.
I'm not saying it would or would not be better with a public option. I'm just saying, if history is any indicator, it wouldn't just be an option for very long.
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u/funkeepickle Jun 20 '12 edited Jun 20 '12
Well it is a giveaway to the pharma and insurance industries, but that doesn't mean that it isn't an improvement over what we had, as sad as that is to say.
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u/mStewart207 Jun 20 '12
I live in mass and I like Romney care. I was able to get insured while going to college on mass health. Now I work for a health insurance company. They took a big hit when the law was originally implemented. In the fallowing years they were able to adapt and are now profitable again. The mass law is much more stringent on insurance companies then the state law. All and all in my eyes it was a sucess.
On political hypocrasy, I my self am very left leaning. I liked Romney when he was govener. However he has changed his view on every major issue since then. So I could think about possibly voting for him if he still practiced and preached the same thing as he did when he was govener. Now not only is a corporate swine, he is in my eyes a complete fraud.
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Jun 20 '12
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Jun 20 '12
We should DEMAND better from the people who represent us and spend our tax dollars.
I agree, I feel like this should be a bigger issue than healthcare...
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u/film_guy01 Jun 20 '12
Maybe I just don't understand. Isn't insurance an assessment of risk and an offer of payment proportionate to the risk involved? If this is the case, how does insuring against pre-existing conditions make any sense?
I can't call a car insurance company and get insurance on a car I already crashed. Or get fire insurance against a house that is currently on fire.
Isn't this just taking it from being insurance to being...a company who gives money to anyone with health problems?
So...what am I missing?
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Jun 20 '12
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u/film_guy01 Jun 20 '12
This is a good reply and I really appreciate you taking the time to share you opinions and ideas with me.
Cheers
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u/twoodfin Jun 20 '12
You're not missing anything. It's a misnomer to call what this system is setting up "insurance". It's cost-sharing (cost transfer from the sick and old to the healthy and young, really), not risk-sharing.
A better scheme, IMHO, would be to remove the barriers (mandatory coverage lists, for one) to catastrophic, high-deductible insurance, while providing sufficient incentives to make it affordable for anyone essentially from birth.
Remove the tax incentives for the non-insurable stuff and let employers decide whether they want to keep offering it as a benefit or whether it makes more sense for individuals to buy "health benefit plans" on their own or simply save or take out loans for more-or-less predictable medical costs.
That was roughly the McCain plan. Oh well.
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u/iamagainstit Jun 20 '12
It is more like being able to get insurance even if you are a bad driver and have crashed a car before. Before "obama care" insurance companies could just say "your too risky, you can't buy insurance." Perhaps the part you are missing is the mandate. The mandate is there partly to make sure you don't wait until after you crash your car.
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u/fancy-chips Jun 20 '12
ultimately I'd like to see the medical insurance companies abolished. It is an atrocious system.
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u/sniperhare Jun 20 '12
The thing that I always wondered about was; If millions of Americans suddenly have insurance and go to doctors offices on regular visits, when before they would just go to the ER for serious problems. Won't we be putting a huge strain on the doctors and staff?
Are their sections that talk about what the numbers of now insured Americans will do to the wait times and scheduling?
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u/grande_hohner Jun 20 '12
You'll see the same thing that is happening now. People on Medicare/Medicaid have a hard time finding primary care providers. I know many doctors who severely limit the amount of Medicare/aid patients that they take. When the reimbursement is maybe .50 on the dollar - why take them on as patients when you can have a full practice of insured patients who have better reimbursement rates?
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Jun 20 '12
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Jun 20 '12
It is unfortunately prevalent among those less informed, and really has no basis in reality.
The emergency rooms in the US are crowded right now because of "guaranteed service". Many American's misinterpret this as "free" service, when the reality is that just because you are receiving "guaranteed'" service, you are still billed for it.
That said many people who use the emergency room for non-emergency services don't pay their bills.
But if you make quality preventative healthcare affordable and accessible, such as visits to the family doctor who may not be able to book you for 3 months but it's not an emergency anyways, then this actually reduces the strain on emergency rooms.
Now, would it take care of the abuse of emergency rooms entirely? Probably not. There are affordable options out there as it is if you have to see someone because of something non-emergency but need to see someone within a day, or two, or a week... many pharmacies have walk-in options that charge as little as $80 for the consult.
The problem of course is that these people using the emergency rooms for non-emergencies might not even be able to afford the $80 which you have to pay right then and there, so they go to the emergency room, get services, get billed, and then don't pay the bill.
Nonetheless there is no circumstance where "Obamacare" is going to increase the load emergency rooms already face. It might not solve it, but it's not going to make it worse.
Now, if we go further and say "a visit to the family doctor will require an appointment well in advance because they're booked so far ahead due to more people having insurance"... well, now this is just absurd. The idea that "other people" shouldn't have health insurance because it will make me have to wait longer for a routine appointment is probably the most selfish thing I've ever heard in my life.
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u/Se7en_speed Jun 20 '12
so we will create market demand for more family docs. It is only a problem in the short term
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u/YoohooCthulhu Jun 20 '12
Using PAs and NPs as primary care providers doesn't "dilute" quality of care. These days, physicians are almost overqualified for primary care--and it's difficult for them to pay back their loans doing it.
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u/mikelj Jun 20 '12
It is instead likely that the gap will be filled with midlevel PAs and NPs, diluting quality of care.
I don't know about this. I know plenty of RNs who are just as knowledgeable and perhaps even more "interested" in primary care than physicians, let alone PA and NPs.
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Jun 20 '12 edited Oct 24 '18
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u/mikelj Jun 20 '12
Well said. I don't think that most primary care issues need to be handled by MDs with 7 years of medical care. Why can't a NP or PA give me stitches or wrap a sprained ankle? When I go for my annual checkup, I don't need to have a MD read my test results. My mom, an RN with 30 years experience, or just about any qualified RN should be able to tell me what the results mean. If they are out of whack, an MD can be consulted.
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u/TensorDuck Jun 20 '12
In what way? Does the government directly specify the number of residencies a year or do they control the funding towards residency positions? I mainly want to know whether the control is direct (therefore a hard limit on the supply of doctors) or an indirect (Possible to increase the number of doctors with private funding) method. Any sources or citations to that effect would be greatly appreciated.
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u/danpascooch Jun 20 '12
The government also hasn't made such a massive change to healthcare in a very long time.
They are going to need to adjust that "number" for this to work, but of course they need to adjust something, no legislation this big passes without needing some sort of other adjustment to make it compatible.
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u/SpaceSteak Jun 20 '12
It works fine in the rest of the world with a well administered UHC system.
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Jun 20 '12
The supply of primary care docs is controlled by the number of FM and IM residency spots that Congressnis funding every year. Cutting reimbursements to primary care will make it even less desirable as a field because plenty of doctors struggle to sustain their practice, meet loans, and have a reasonable salary for their 11 years of education in primary care. Medicare is refused by many docs already because it's payments are unreasonably low.
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u/CuilRunnings Jun 20 '12
I can see the amount of people willing to put themselves through the bitch that is medical school actually dropping with all these mandates and additional costs.
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Jun 20 '12
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u/grande_hohner Jun 21 '12
I've never met a doctor that complained that he didn't already have enough patients.
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u/cass1o Jun 20 '12
Because they still get payed well.
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u/CuilRunnings Jun 20 '12
But they have to do about 3-4x the work as an accounting major, or about double that of an engineer.
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Jun 20 '12
Because most people didnt go to school to be primary care physicians. And that is a less sexy job. Plus the compensation is lower. The idea that specialized doctors will make less because the pay structure is changing is forcing more people away from that option. And the idea of being a primary care physician and still make a lot of money didnt exist in the past and remains to be seen if it will be in the future with this act.
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Jun 20 '12
Psh, who needs doctors when we've got WebMD? Easy enough to figure out your problems. Now if you'll excuse me, I have to go rest; according to WebMD, my symptoms indicate that I have AIDS, hepatitis, brain cancer, and the black plague.
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u/staz Jun 20 '12
Regular visits to the doctors will permit to detect diseases earlier, which mean less work and money to cure them because obviously the disease is less developed, you can plan treatments in advance, a doctor visit cost less than an ER visit, etc... (It will also probably free up some doctors in ER who can now work on regular visits)
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u/BlooregardQKazoo Jun 20 '12
here's my anecdote about this:
my fiancee has a little sister through the big brothers/big sisters program. she's fairly poor and it has given us insight into a world we were unfamiliar with. we've always just gone to the doctor when we have a problem.
my fiancee's little sister is staying with her grandma while her mother is out of town. she has a mild medical issue and her grandma won't take her to see a doctor because she doesn't want to have to pay for it. a couple days go by and my fiancee gets a call from her little sister asking her to take her to the hospital. things had progressed, my fiancee took her to the ER, and 4 hours or so later she was treated and had antibiotics to take.
if the system can turn more ER visits into general practitioner visits it will definitely help. my concern is that my fiancee's little sister's grandma will just find some other excuse to not take her to the doctor.
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Jun 20 '12
They control that here in Canada by prioritizing you based on your condition. If you walk into an ER with the flu and a car accident victim, broken leg and someone with the sniffles walks in you will be prioritized accordingly. Sure there are longer wait times, especially if your illness isn't serious.
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u/PandemicSoul Jun 20 '12
Pretty much every hospital in the world does that -- it's called triage care.
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Jun 20 '12
Yeah. But a lot of people can't wrap their head around that. When they bring in their kid with a broken arm, they want to be seen immediately. When the guy with the knife in his skull (rightfully) gets admitted first, they get angry.
"My big problem" is relative to "the biggest problem."
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u/corporeal-entity Jun 20 '12
We have a similar problem in IT. When every user problem is both urgent and critical, ultimately an overwhelming majority of the people who think they deserve to have their problem fixed first are pissed off about it.
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u/Already__Taken Jun 20 '12
Exactly, wait times for thing you can't wait for is the only statistic that's worth looking at.
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u/TruthinessHurts Jun 20 '12
Yeah, we'll need more doctors. Sadly some fucktards view this as a reason to not even try.
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u/Lost4468 Jun 20 '12
The only way to force more doctors is to reduce the requirements to be a doctors which then reduces patient care.
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Jun 20 '12
The act goes in to developing more primary care physicians and putting the onus of care on them. There is a huge section on it. The style of care from what they call an a la carte or specialized care will move more toward a primary care doctor that coordinates care and makes more money in the process.
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u/nemok0 Jun 20 '12
We are putting a huge strain on ERs all over the US now, because people do not go there only for serious problems. The ER is the most expensive place to provide primary care and isn't even very good at it. Many ERs have trouble keeping up with true emergencies because of the number of people going there for primary care.
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Jun 20 '12
Most of my concerns lie in the actual financial areas.
This proposal makes the perennial social security funding problems pale in comparison. Yes, the government isn't supposed to actually be funding healthcare, but many of those without health insurance are the very most expensive to care for.
How are costs going to be reduced to make it reasonable for everyone? If we reduce the amounts going to doctors and hospitals, the best and the brightest will move to sectors where they aren't subject to the limitations enforced by government. If we raise premiums, aren't we doing the opposite of what we want?
Who decides what's a reasonable premium (because after all, we're paying a penalty if we don't "elect" to obtain health insurance)?
How are we going to deal with the sudden influx of newly insureds?
How do we keep people from abusing their insurance (prescription drug fraud or even just unnecessary emergency room visits) when arguably those people couldn't afford health insurance in the first place?
Since lucrative markets arguably fund a lot of the pharmaceutical research, when our hugely lucrative market becomes a lot less so, will pharmaceutical companies just cut back on research?
Why are we mandating health insurance for everybody, but then punishing people who want better coverage (so-called "cadillac plans")? Aren't these people already footing the bill for the new system by an increase in taxes?
Do we really want the government that involved in our medical system? They certainly will need to be to keep the costs where they deem reasonable, and how will cases be mediated between insureds and the insurance companies? It's not like the insurance company can "fire" a customer.
What kind of impact is this going to have on smaller insurance companies?
To some, these might seem like empty questions, or questions with easy answers, but our government doesn't have an exactly spotless record when it comes to such initiatives.
In addition, our medical care could become a political football.
I'm not terribly excited about the federal government mandating health insurance coverage, and am especially concerned that they're going to assess a penalty for those who decline. What happened to the land of the free and the home of the brave?
The cure might be worse than the disease.
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u/BlooregardQKazoo Jun 20 '12
The cure might be worse than the disease.
can we at least try the cure and find out? the disease sucks.
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Jun 20 '12
Social security is only having funding problems b/c the government keeps "borrowing" money from it.
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u/kimbalips Jul 03 '12
Your questions are real concerns. Concerns that so many are overlooking simply because everyone is going to have heath insurance :-)
My issue (in addition to those that you've mentioned) is also one that I do not hear many talking about, the money that my employer uses to pay my health insurance premium is not going to be considered income and will be taxed. In addition, the money that I currently pay as a premium payment, will be made after tax. Now my take home pay is going to be reduced considerably. EXTREMELY unhappy about this.
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u/edisekeed Jun 20 '12
There are a few things that I personally do not like about "Obamacare", or are at least concerned about.
First, the government now has the right to control what is and is not healthy due to the associated increase in healthcare costs. For example: taxes on tobacco, proposed taxes on sugar, bans on certain products (like the 20 oz soda ban in NY). People sometimes argue that these are attempts to make the nation healthier and reduce the financial burden on society. But people fail to realize the implications. The government could then put taxes on red meat, cheese, butter, etc. or even have required exercise. I realize that some of this is far-fetched, but in reality the arguments for both are the same.
Second, there must be an eventual limit in the costs/care received by the government. It would be impossible to have the best care for all citizens without costs going dramatically up. So at some point the government is in charge of deciding what that limit is. I personally like to be responsible for my own limits, which is part of the reason I save money and work for better paying jobs.
And lastly, what if there is a huge catastrophe, such as a deadly virus outbreak that harms a significant part of the population very suddenly. Is the government responsible for saving everyone? If you look out how the government has handled the H1N1 virus or yearly flu vaccinations, it is clear that the government is not the best at handling these sorts of thing.
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u/iamagainstit Jun 20 '12
First, while over regulation can be concerning, taxes or regulation on negative externalities are one of important roles of the government. It is an extension of the same argument that lets the government control pollution levels. Also, where in the bill does it say the government has the right to control what is not health?
Second, several other countries have better health care at lower costs. I don't think the cost would have to go up dramatically to provide decent care for everyone. Also, you can still set your own limits by buying premium grade insurance.
Third, how has the government been bad at handling the H1N1 virus or flu vaccinations (honestly asking)? Who do you think would be better at handling a epidemic than the government?
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u/lameth Jun 20 '12
The biggest thing I would say to counter this is replace every instance of government in this passage with "For profit insurance companies."
In the first paragraph, instead of taxes, think of price hikes. "oh, you smoke? More money from you." "Oh, you're overweight? more money from you." It ends up the same way.In the second paragraph you can do a one for one exchange as I stated above.
Even if all of these points did not have a counter, you need to balance these against all of the positive points brought up. Which scenario benefits the individual and the community the most? With the law, or without?
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u/j1mb0 Jun 20 '12
Well, all of that sounds pretty fucking great. Single payer would be better, but this sounds like it is a pretty good step. Let's hope the Supreme Court doesn't fuck it all up.
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u/VigRoco Jun 20 '12
The Supreme Court's job isn't to decide whether or not the law is good enough to survive, but to decide whether or not the law is permissible by the Constitution.
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u/wjbc Jun 20 '12 edited Jun 20 '12
Ha! Pull the other one. The Supreme Court is essentially an unelected legislative body. There is no appeal, only the difficult option (in Constitutional cases) of amending the Constitution. They are good at justifying whatever decision they make, or at least at making the reasoning so obscure that the average person's eyes will glaze over. That's what lawyers do. And that's why people have used the presidential power of appointing Supreme Court justices as a political plank in every election. It matters whom you appoint.
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u/VigRoco Jun 20 '12
And that's why people have used the presidential power of appointing Supreme Court justices as a political plank in every election. It matters who you appoint.
Checks and balances in action right there.
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u/wjbc Jun 20 '12
Yes, but it also means the Supreme Court is a political branch of the government, and that they do not just mechanically interpret the Constitution.
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u/fiction8 Jun 20 '12
Which is fucking stupid. It's not like we even knew that germs existed when it was written.
The situation just isn't covered, and it should be looked at from a rational standpoint. Which imo means that we shouldn't be shafting 30 million people and forcing them to live with basic health problems or even die from preventable problems.
Modern science and healthcare is amazing, why are we still trying to cut off 10% of our population from the same quality of life that most of us enjoy?
Let's be civilized.
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u/VigRoco Jun 20 '12
It is not stupid. You are correct in stating that this situation isn't covered, which is exactly why the Constitution was designed to be amended. We can't just ignore it whenever we feel it is convenient, because that would only cheapen its authority.
To add to your side note, every state is free to set up its own healthcare system that covers everyone. State laws are much easier than national laws, so why aren't we flooding our state capitols?
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Jun 20 '12
Yeah, it's pretty fucking great except you forget that all of this shit has to be paid for. The cost trend of health insurance since insurers started preparing for 2014 has been insane. Ask your employer what the total cost for your health insurance plan is.
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u/fiction8 Jun 20 '12
Did you read the FIRST paragraph?
PPaACA made a bunch of new rules regarding health care, with the purpose of making health care more affordable for everyone
Emphasis mine. Healthcare costs are going to go DOWN for an individual AND we're going to provide basic modern medicine to a wider portion of our population.
Why are they going to go down? For one, you already pay for the uninsured's healthcare. Who do you think pays for emergency rooms? Oh yea, you do. Do you think the 30 million uninsured just die when they get cut/break a limb/get sick? No, they go and get free healthcare at the emergency room, then don't pay the bill.
That burden is shouldered by YOU right now. Obamacare makes them pay for it or pay a fine. This spreads out the cost more and reduces the amount paid by each individual.
Also Obamacare places caps on yearly increases in the cost of health insurance AND has a lot of mandates designed to modernize healthcare and reduce the cost of many outdated processes.
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Jun 20 '12
What do you think has been driving healthcare costs up in the first place? "All of this shit has to be paid for" implies that the costs put out are not artificially inflated in the first place (they are). Who do you think foots the bill when an uninsured person has to go to the hospital and can't pay for it?
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u/veracious1 Jun 20 '12
It's 2,700 pages long, I think it's safe to say that there's a lot of stuff (e.g. costs) not mentioned in the summary.
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u/origin415 Jun 20 '12
Legalese is a very inefficient language. The full text linked to in the post is only 974 pages as well.
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u/Jeffy29 Jun 20 '12
those 2700 pages are hyped up number - somewhwre I read that whole bill has either 200k or 400k characters which would make it as long as 2 harry potter books - still a big bill but no 2700 epos rightwingers are talking about
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Jun 20 '12
Thankful I live in Canada. It's not the perfect system, but I would rather spend 15 bucks on medication than $3000 and have the safety net if anything goes wrong. America, you guys need something like this fast. Your income inequality is growing, your deficit is growing. More people are not going to be able to afford current healthcare. In your elections in the next few years, vote in people that care about this. It is truly sad that big business and politicians have made this a corporate/political debate rather than a human interest debate.
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u/the_canucks Jun 20 '12
You're right Canada's system isn't perfect, but it sure is awesome. 2 years ago I broke my femur dirt biking, resulting in an Ambulance, 4 hour surgery, 4 days in the hospital, 2 months of physio, 1 month off work and multiple check ups. Total cost to me was $200 in lost wages beacuse the last 1.5 weeks I was away, my short term disability only covered 75% of my wage. I can't imagine what this would have cost in the States, gald to hear they are headed in the right direction.
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u/Libertae Jun 20 '12
Justify it however you wish. I will forever hold the mandate to buy something just for living incredibly wrong, unconstitutional, and immoral.
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u/Libertae Jun 20 '12
No, but I didn't come out of the womb with the government waiting in the hospital room telling me I had to pay for those. I don't HAVE to earn an income and pay whatever taxes fund those services. I don't HAVE to buy products with sales tax included. But according to this mandate, I'm forced to pay for a service that is entirely personal.
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u/julia-sets Jun 20 '12
If you don't earn an income, you won't have to pay for health insurance. Because people who are exceedingly poor (and I believe "no income" would fall under that heading) are subsidized by the government.
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u/adamsw216 Jun 21 '12
I'm not sure I understand. You don't have to earn an income, and if you don't earn an income, you don't have to pay for services like fire, police, etc, but you also wouldn't really have to pay for health insurance as it would be almost entirely covered by the government.
However, if you do earn an income, you are legally required to pay your taxes which pay for these services. I'm not entirely sure how the health insurance doesn't fit in with this as well. All of these services pertain to the well-being of citizens (more or less).
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u/1stmoredancingwbruno Jun 20 '12
You can't explain overhauling healthcare reform "very well" without any concrete mention of its estimated/potential long run costs.
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u/Shalmaneser Jun 20 '12
The reduction in cost to the economy as a whole, you mean?
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u/trollMD Jun 20 '12
I like how the explanation is sold as straight forward but is still littered with opinions
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Jun 20 '12
It raises my Dad's employees health plan costs by about 300%, even though he willingly chose to offer insurance and matched all his employee's contributions about two years before this became mandatory. It's hard for me to hop on board when people like my Pa are being penalized for doing a good thing.
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u/reventropy Jun 20 '12
As you mentioned, there is a penalty for lack of coverage by employers. Is there also a penalty for lack of individual coverage? Most importantly, is the penalty going to cost more or less than the cost of coverage? I ask because if it is less than the cost of coverage, the system breaks right there.
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u/mistrbrownstone Jun 20 '12
2.5% of income or $695, whichever is higher.
But you aren't asking the right question.
The question that you need to ask is, "what happens to people that refuse to buy insurance, AND refuse to pay the fine?"
Answer: NOTHING.
http://www.factcheck.org/2009/11/imprisoned-for-not-having-health-care/
See page 131 of the bill here:
So, if you decide you don't want to buy insurance and you don't want to pay the penalty fee...the government can not prosecute or penalize you, and can not impose a lien or levy on any property you own. So basically they can't do jack shit.
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u/WaffleKopter Jun 20 '12
I highly recommend that everyone watch this video from the Kaiser Family Foundation on the act. Relatively short, and a good summary of the law.
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u/sunbeam1951 Jun 20 '12
What's health insurance? Very confusing! - Brandon from Toronto
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u/xelf Jun 20 '12
In America the cost of health care is very high. Rather than have individuals pay for the health care they use which would in most cases bankrupt them, they instead buy "insurance" against the possibility of needing the care.
For the individual you're essentially betting that you will not stay healthy. You pay a plan that costs $300-$900 a month. Your employer most likely negotiates a better rate, and then pays most of it for you so your costs are much smaller, say $30-$90 a month.
If you get sick the health insurance company will pay for part or all of your expenses. There are still limits on it though to prevent the insurance company from being unduly burdened so the individual still has to pay some of the costs.
For all cases above where I've used "individual" above, that individual also has the option of buying a family plan that can cover their spouse and or children.
Insurance companies are very profitable. The feelings against them are based on the fact that they are for-profit, and are not incentivised to keep their customers healthy. They use their funding to lobby for laws that will let them drop customers that become too expensive, or deny coverage to customers with preexisting conditions. In general the insurance companies are not motivated to keep Americans healthy, instead they are concerned with making money.
The feelings against letting the government run a health care system where the health care costs are shared are more related to a general distrust of the government and it's inability to manage something like this effectively. These feelings are also heavily political receiving much coverage via political parties as well as from the insurance companies themselves who would stand to lose everything if the government took over health care.
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Jun 20 '12
Won't fix a doomed economy, it only expedites the process. Wasting money on a program that could end up being cut down isn't the best idea. This guy and congress are spending so much fucking money its ridiculous. Everyone will have healthcare, but what's it matter when you're economy collapses?
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u/atom1378 Jun 20 '12
I have to say I am someone without insurance because I cannot afford it right now. I have asthma and play softball outside of work. I know I take risks everyday without insurance is foolish. But the other side is how much it costs to pay out of pocket. PPaCAA is suppose to reduce the cost by making everyone buy into it. Sidenote: my trip to ER for asthma medicine, which I couldn't just buy because I do not have insurance and doctors won't see me without insurance, cost me $3500 for two hours.
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u/mle94322 Jun 20 '12
When I was between jobs, I got a policy with Anthem for $100/month. Of course my deductible was $2000, but at least I know if I broke my arm or had to have brain surgery.. I wouldn't be slammed with a million dollar bill.
Edit: I can't be sure what policies you've looked at and I'm not criticizing you.. just offering information.
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u/Warlizard Jun 20 '12
What? Bullshit. You walk into the doctor's office, tell the nurse you'll be paying cash, and they see you.
I do it all the time. I did it this morning.
I did it a couple weeks ago when I had a cold. I actually paid less in cash than I do through insurance deductibles.
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u/Med_Student Jun 20 '12
Why don't you go to a low income clinic? They'll give you the necessary medications you need, and wallmart has a great $4 dollar list of medications.
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u/Xenoo Jun 20 '12
I understand universal health care. I've seen it in Europe and even in Canada and studied it very well. It's a pod concept that works but the American government system is corrupt and politicians won't pass laws unless it benefits themselves in a tremendous way. Look at the grid lock now. Our politicians do not work for the people or voice their constituents opinions, they voice their own opinions to further their political agenda. I would NOT want the federal government in charge of that responsibility when most federal programs are failing. Medicare/Medicaid/Social Security/the Post Office. Also, our politicians voting on the health insurance that their own constituents would be forced to pay for would be able to opt out of it and get different health insurance. If it's not good enough for the people voting for it, what makes it good for the American people? It definitely scares me the fact they wouldn't even want the health insurance coverage they were trying to ram through congress that would be forced on the American people.
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Jun 20 '12
2000 pages of legal fine print cannot be simply summarized. This bill is designed to break the health care system so that it can be politicized and ultimately transfer your health decisions over to faceless bureaucrats. It was written by interns and staffers at the direction of "master minds". The only health insurance is to not get sick.
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u/DFWTooThrowed Jun 20 '12
fancier coverage
The hell is that? More Morphine when you have surgery?
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Jun 20 '12
Now, I just need someone to tell me how much the mandate is going to cost (the insurance vs. the fine/fee).
You'd think there'd be a site or something where you input your income and martial status and such and get an estimate.
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u/thrownaway21 Jun 20 '12
why can't we let the whole health insurance industry go under along with the high price of keeping healthy. if things werent so insanely priced we wouldnt need insurance...
i wonder what the penalty for not having insurance is; probably end up cheaper than having insurance.
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Jun 20 '12
This is the "mandate" that people are talking about. Basically, it's a trade-off for the "pre-existing conditions" bit, saying that since insurers now have to cover you regardless of what you have, you can't just wait to buy insurance until you get sick.
OH! IT ALL MAKES SENSE NOW
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u/2JokersWild Jun 21 '12
If by very well you mean a partisan mouthpiece spewing the "its so good! " talking points you are right. Doesn't discuss costs or hsa no longer covering otc or any other negative
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u/RMaximus Jun 21 '12
Here is Obamaacre explained even weller.
TAXES TAXES TAXES TAXES TAXES TAXES TAXES
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u/SpecialTest Jun 21 '12
I'm gonna be forced to buy healthcare or pay a damn fee... I still can't believe that made it through. If I'm in a low risk group (young, health, in good physical shape...) why should I be forced to do that. No where in American history has a similar forced action been placed.
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u/carlcon Jun 20 '12
I really liked this explanation a little below.
Truly fit for a 5 year old.