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NYT article about Medicaid

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8 years 2 months ago #80778 by tr_

megboo wrote:

So it's okay with you if only healthy people, and not sick people, can get care?

That really doesn't have anything to do with what I stated. As it stands, the really sick have emergent care available despite payor source. The indigent have Medicaid.


Are you making a case *for* people having to use massively expensive emergency care because they didn't get their problem taken care of when it could have been done more easily, cheaply, and effectively by a primary care provider? I don't think that will fly with anyone who's spent a day working in an ER.

And as regards Medicaid for the indigent, I thought you were against government-provided health care? Or am I missing something about your position?

I never said I was against public health in general, especially vaccines. I'm absolutely pro-vaccine.


But how would you propose to implement public health recommendations without a means for universal health care? Without a distributional apparatus, public health edicts would be useless.

I don't want the gov't telling me how to live my life, taking my income (which is property) and distributing it to others vis a vis telling them how to live their lives.


But in return for that, is it OK with you if significant swaths of the population do not have access to basic health care services (including care for infectious issues that affect the general public)?

By this position, you should also be against any past and present gov't healthcare program as well. Nothing is more bloated, more bureaucratic, or wasteful than this.


Unless you have a good reason (other than personal dislike of Paul Krugman) to dispute the figures on overhead for Medicare vs private insurance, I don't see how this position can stand.

There would be more competition, especially from smaller companies that have been forced out of existence thanks to regulation.


But this is just an article of faith. In fact, the bare fact of more competition does not always and universally move to improve product quality. (Probably the simplest and best-known example is unfettered competition leading to monopoly and thereby to the death of competition at all.) The dynamics of the insurance industry are such that competition *reduces* product quality. Therefore, more competition will not solve the problem of health care availability.

Medicaid is not a bona fide insurance model.


It's not about Medicaid being an insurance model or not, it's about private insurance models putting Medicaid in an economically untenable position.

I appreciate you taking the time to explore the different ideologies with me. I would like to hear more of your views, but I may not be able to check back in until later this week. I start my general surgery service tomorrow and I have no idea when I'm even going to sleep again LOL.


Good luck with surg!! hope you get some sleep :)

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8 years 2 months ago #80782 by asunshine

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8 years 1 week ago #82172 by DrBeckyMom
Interesting thread.

I find I am bursting with the desire to respond to some of the comments so excuse me for being rather rambly.

First of all, I am an ED doc in rural TX and see mostly Medicaid and uninsured patients. Believe me, the ED is NOT the place to go with acute suicidality. You will spend the night/day/ hours getting screened medically, then MHMR comes and chats with you, usually to send you home if you sign a no harm agreement. The wait for a follow up appt is weeks to months even if you were in the ED. There is only one truly active State Hospital in TX, in Austin, often having limited beds. Medicaid patients have it a little easier, can get into some private hospitals/facilities, but most of the folks I see needing emergency psych care for suicidality or drug-related/alcohol related problems get sent home with no hope for real counseling, rehab or psych care. They may get put on antidepressants, get some pamphlets, AA literature. They are left with few options but the ER and we have no resources, no social worker or psych nurse, certainly no psychiatrist other than one at a county MHMR clinic.

For other urgent/non-emergent issues, we are hardly adequate for the hundreds of patients that flood our doors. We are often so busy with ear aches and dental infections at 1 am that when the true emergency, the rollover with open fractures or the AMI we have to move patients out to the hallway to get the truly emergent patient in the appropriate room. This with one doc on for 12-24 hrs, one nurse, one LVN for a 12 hour overlap shift that ends at 11pm. The ED is not the place for the uninsured or Medicaid who either can't afford a visit out of pocket to local docs, or whose assigned provider is out of town, has no appointments or is in the next town down the road.

Frankly, this is the most half-baked system imaginable. Care is spotty at best, follow up is poor, specialists are virtually impossible to find who will take uninsured or Medicaid, ambulance providers can refuse transport if patients can't pay, thus forcing the rural hospital to pay, insurance companies deny services so even if you think you are in the free and clear by having employer-paid insurance forget it. You can be denied for something in your record from years back, or you may be stuck with high deductibles that in themselves are prohibitive to obtaining care.

Enough said, the real question for me is this: why is it we are the ONLY developed nation with a fee-for-service system of health care and no public option or universal program? Medicaid and Medicare do not count because they are NOT universal NOR are they an option for all. They compete with private insurers (at the payee level, with us, hospitals, clinics, other providers--there is no comparison with completely public systems). I have practiced under a socialized system, in New Zealand, and it was a blessing to never have to worry about reimbursements. We billed the gov't programs, we were paid electronically within 10 days, no questions asked. Check out the cost per capita in New Zealand. The least expensive country per capita weighed against quality of healthcare and longevity is Switzerland, a country that provides universal healthcare, home health, an affordable prescription program and excellent prenatal and birth care. Universal access is not socialism. It is providing a basic service necessary to maintain the health and well-being, and ultimately the ability of people to contribute to society.

Calling health care an entitlement is an abomination. Entitlement is the 458:1 ratio of CEO salaries to avg worker salaries. Entitlement is the expanding profits of the insurance companies despite the recession and high unemployment and foreclosures and new homelessness these past few years. The number one cause of new homelessness, loss of home to foreclosure, bankruptcy and job loss is loss of health and associated medical/hospital bills. This does not just impact the poor, the working poor and the low-middle class. It impacts the entire middle class which is most of us physicians. It impacts our families, our parents, our kids in college, our grandkids. The chance for achieving the "American Dream" is shrinking daily as we lose our respect for Humanity, blame the disadvantaged for their illness and lack of ability to pay, and refuse to take care of each other.

And for the person who thinks the overweight, bad food eaters, smokers, etc should either not be covered or pay more, that is pretty much also heartless. I've seen folks who run daily, eat perfectly and live a clean and good life yet die from a huge LAD blockage, are permanently damaged from a Berry aneurysm rupture, or develop a rare form of cancer. Lifestyle is only one aspect of health, not the whole picture, and the best way to address that is via education, not denying health care and by providing resources to weight loss specialists, bariatrics, smoking cessation resources and so forth. Addiction, binge eating disorder, alcoholism are all chemical, physical and pscychiatric issues, not simply about "choice" and behavior. Much of it is related to trauma from childhood, habits taught during childhood, lack of breastfeeding and healthy diet, etc. McDonald's is a helluva lot cheaper than Whole Foods, plus have you ever noticed where fast food restaurants tend to pop up? Most are in poor areas, providing a disproportionate amount of meals to the poor, indigent and locally bound (i.e. lack of transportation to grocery store, etc.) Judging lifestyle is as useless as judging someone based on the car they drive. We are here to help, not judge, and if helping isn't part of what you want to do as a physician, maybe it's not the best field for you.

I'm new to this forum and site in general, but am finding it very interesting! Keep up the debates. I look forward to seeing any responses to my ideas.

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8 years 1 week ago #82173 by megboo

DrBeckyMom wrote: Interesting thread.

I find I am bursting with the desire to respond to some of the comments so excuse me for being rather rambly.

First of all, I am an ED doc in rural TX and see mostly Medicaid and uninsured patients. Believe me, the ED is NOT the place to go with acute suicidality. You will spend the night/day/ hours getting screened medically, then MHMR comes and chats with you, usually to send you home if you sign a no harm agreement. The wait for a follow up appt is weeks to months even if you were in the ED. There is only one truly active State Hospital in TX, in Austin, often having limited beds. Medicaid patients have it a little easier, can get into some private hospitals/facilities, but most of the folks I see needing emergency psych care for suicidality or drug-related/alcohol related problems get sent home with no hope for real counseling, rehab or psych care. They may get put on antidepressants, get some pamphlets, AA literature. They are left with few options but the ER and we have no resources, no social worker or psych nurse, certainly no psychiatrist other than one at a county MHMR clinic.

For other urgent/non-emergent issues, we are hardly adequate for the hundreds of patients that flood our doors. We are often so busy with ear aches and dental infections at 1 am that when the true emergency, the rollover with open fractures or the AMI we have to move patients out to the hallway to get the truly emergent patient in the appropriate room. This with one doc on for 12-24 hrs, one nurse, one LVN for a 12 hour overlap shift that ends at 11pm. The ED is not the place for the uninsured or Medicaid who either can't afford a visit out of pocket to local docs, or whose assigned provider is out of town, has no appointments or is in the next town down the road.

Frankly, this is the most half-baked system imaginable. Care is spotty at best, follow up is poor, specialists are virtually impossible to find who will take uninsured or Medicaid, ambulance providers can refuse transport if patients can't pay, thus forcing the rural hospital to pay, insurance companies deny services so even if you think you are in the free and clear by having employer-paid insurance forget it. You can be denied for something in your record from years back, or you may be stuck with high deductibles that in themselves are prohibitive to obtaining care.

Enough said, the real question for me is this: why is it we are the ONLY developed nation with a fee-for-service system of health care and no public option or universal program? Medicaid and Medicare do not count because they are NOT universal NOR are they an option for all. They compete with private insurers (at the payee level, with us, hospitals, clinics, other providers--there is no comparison with completely public systems). I have practiced under a socialized system, in New Zealand, and it was a blessing to never have to worry about reimbursements. We billed the gov't programs, we were paid electronically within 10 days, no questions asked. Check out the cost per capita in New Zealand. The least expensive country per capita weighed against quality of healthcare and longevity is Switzerland, a country that provides universal healthcare, home health, an affordable prescription program and excellent prenatal and birth care. Universal access is not socialism. It is providing a basic service necessary to maintain the health and well-being, and ultimately the ability of people to contribute to society.

Calling health care an entitlement is an abomination. Entitlement is the 458:1 ratio of CEO salaries to avg worker salaries. Entitlement is the expanding profits of the insurance companies despite the recession and high unemployment and foreclosures and new homelessness these past few years. The number one cause of new homelessness, loss of home to foreclosure, bankruptcy and job loss is loss of health and associated medical/hospital bills. This does not just impact the poor, the working poor and the low-middle class. It impacts the entire middle class which is most of us physicians. It impacts our families, our parents, our kids in college, our grandkids. The chance for achieving the "American Dream" is shrinking daily as we lose our respect for Humanity, blame the disadvantaged for their illness and lack of ability to pay, and refuse to take care of each other.

And for the person who thinks the overweight, bad food eaters, smokers, etc should either not be covered or pay more, that is pretty much also heartless. I've seen folks who run daily, eat perfectly and live a clean and good life yet die from a huge LAD blockage, are permanently damaged from a Berry aneurysm rupture, or develop a rare form of cancer. Lifestyle is only one aspect of health, not the whole picture, and the best way to address that is via education, not denying health care and by providing resources to weight loss specialists, bariatrics, smoking cessation resources and so forth. Addiction, binge eating disorder, alcoholism are all chemical, physical and pscychiatric issues, not simply about "choice" and behavior. Much of it is related to trauma from childhood, habits taught during childhood, lack of breastfeeding and healthy diet, etc. McDonald's is a helluva lot cheaper than Whole Foods, plus have you ever noticed where fast food restaurants tend to pop up? Most are in poor areas, providing a disproportionate amount of meals to the poor, indigent and locally bound (i.e. lack of transportation to grocery store, etc.) Judging lifestyle is as useless as judging someone based on the car they drive. We are here to help, not judge, and if helping isn't part of what you want to do as a physician, maybe it's not the best field for you.

I'm new to this forum and site in general, but am finding it very interesting! Keep up the debates. I look forward to seeing any responses to my ideas.


Earaches and dental abscesses aren't ER-worthy visits in rural TX?

The rest, I need to walk away for a while lest my libertarian head explodes ;)

"Some of it's magic and some of it's tragic but I had a good life all the way."<br />- He Went to Paris by Jimmy Buffett

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8 years 1 week ago #82174 by Doc201X

DrBeckyMom wrote: And for the person who thinks the overweight, bad food eaters, smokers, etc should either not be covered or pay more, that is pretty much also heartless.


Heartless is not taking care of yourself so that your loved ones are either: 1) Left behind to deal with life without you and/or 2) Required to take care of you when you didn't love yourself enough to live a better lifestyle.

If you and everyone who agrees with you are willing to PAY for the healthcare for these individuals AND let them live with YOU through chronic/debilitating illnesses which could have been prevented, then by all means PLEASE do!

What's heartless is expecting other people to pick up medical tabs for people who make poor lifestyle choices. Actually, it's heartless AND selfish and I don't want to pay for it for ANY adult to whom this applies.

My Scientist/Physician Journey
www.Doc201X.blogspot.com

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8 years 1 week ago #82175 by Doc201X

DrBeckyMom wrote: Judging lifestyle is as useless as judging someone based on the car they drive. We are here to help, not judge, and if helping isn't part of what you want to do as a physician, maybe it's not the best field for you.


You've been on this site 2 minutes and here you are JUDGING AND CRITICIZING who should become a Physician and who should not, based on personal opinions. SHAME ON YOU!!!!!

My opinion on this doesn't have a darn thing to do with my desire to become a Doc. And if requiring a modicum of personal responsibility of people who want free health care is my opinion, perhaps you should respect that because I'm not the only one who feels this way. Maybe YOU should find another career since you don't believe in personal responsibility!!!

Speaking of freebees, are you this "high and mighty" about women who purposely have lots of kids to get welfare checks, free housing, and food stamps? Because if they can't have freebees without criticism, why should anyone have free healthcare without requiring personal responsibility?

URGH, democratic "principles" are going to be the death of this country! :mad:

My Scientist/Physician Journey
www.Doc201X.blogspot.com

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