When President Obama is re-elected!!

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AlexR
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Re: When President Obama is re-elected!!

Post by AlexR »

JScott

Your say “ACA is implemented, most Americans have seen their healthcare costs rise significantly”.
There are two issues here. The first is: will Obamacare cost more to the average person? You say yes, and significantly so. I’m prepared to believe this, but would you please cite your sources? Are sites such as this propaganda? http://obamacarefacts.com/costof-obamacare.php
I'm challenging you, JScott, but I'm also genuinely interested in knowing what's what.
However the second issue is infinitely more important: will America’s poor and underprivileged be better looked after? This trumps the first issue. By a mile. What’s at stake here is egotism vs. the commonweal. Is it morally acceptable to say, “I’ll look after myself, you needn’t be bothered, but if you can’t look after yourself, then tough luck buddy”? Can America really go down a path that’s radically different from the world’s other developed countries – at the expense of its citizens' wellbeing and life expectancy?

You say “Whether you believe it or not, I have the same goals but apparently believe in different ways to achieve them”. Please explain then: how would you reform the health care system? If Obamacare is ill-conceived, what in the world can be done to make the system less expensive, more efficient and more just? You say there are far too many rules and regulations. Simplifying that would be a start, I agree. But what of the poor people? How should their health care be funded? By the way, did you notice in the debates that both candidates kept referring to middle class voters, but never once to the poor? As mentioned in a previous post, they account for 16% of the US population.

You work in health care. I don’t and, I do, as you say, live abroad. You question my ability to know what I’m talking about. I asked you where you got your numbers from when you write such things as “I'm merely pointing out that the great majority of this country (we can quibble over 85 or 90%) will find they can't get the care to which they have become accustomed.” As a professional, is it too much to ask you where you derived these figures from?

Beghazi: You wrote “what concerns me is that if they were solely to blame, why isn't he raising holy hell with them over this mess?”. I agree with you JScott! However, please consider that Hillary Clinton has assumed responsibility (http://www.reuters.com/article/2012/10/ ... 1V20121016) but is leaving her functions and, as we all know, Petraeus was fired (or made to resign, if you prefer). So, in a sense, heads have *already* rolled. If the (expletive deleted) who overruled requests for more security lost his job, I’d be only too happy.
By the way, in today's paper, it said that the CIA compound ("within the perimeter of the consulate", whatever that means) held prisoners, in defiance of an executive order and that the attack was possbly made to free them. Who knows? But we *both* agree that something stinks here.
You write “At the risk of opening another massive can of worms, you state repeatedly and matter-of-factly that Bush lied about the Iraq invasion with not a shred more evidence than I've offered here (less in fact). Well, that’s an easy one to counter! Were there weapons of mass destruction? If there were not, weren’t we lied to?". The best answer to that is to see "Farenheit 911".
Colin Powell said the worst day of his life was when he had to go to the UN and present "proof" that there were WMD in Iraq. He knew it wasn't true...

Best regards,
Alex R.
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JimHow
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Re: When President Obama is re-elected!!

Post by JimHow »

As usual, it takes a common sense Republican senator from Maine, Susan Collins, to put this in its proper perspective.
This can all be investigated by the appropriate existing senate committee, as opposed to some big blowhard Watergate committee, etc., etc. Absolutely no temperance left in politics anymore.

http://firstread.nbcnews.com/_news/2012 ... ccain?lite
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Jay Winton
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Re: When President Obama is re-elected!!

Post by Jay Winton »

If the GOP would nominate people like Susan Collins, they might be able to win the presidency. Oh wait, she's a moderate Republican who embraces bipartisanship, there goes that notion.
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Re: When President Obama is re-elected!!

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Alex, first link I've come across: http://abcnews.go.com/Business/video/ca ... g-17229187 You can look into this more on your own, of course, but there is very little debate that costs continue to rise, despite the predictions prior to passage. Also, though it's not scientific, I see about 10,000 people a year in the office, and I universally hear from people that their costs are going up and the coverage is getting poorer. We agree, I think, that this is concerning.

Let me say first that I don't have all the answers, and health care is a huge, complicated problem. I believe a federal, centrally controlled solution is not workable. Arrangements that work reasonably well in, say France or Scandinavia are tempting, but can't translate here. I wish they would. In my view, it's an issue of scale. We have multiple times the population and geography, and the administrative and management costs swamp the system. Our best chance is to have some locally run and administered arrangement, perhaps with some very basic guidelines for continuity and some very basic rules about portability across jurisdictions.

The best chance, I believe, is to have the universal system be fairly bare bones and have a private system that overlies it. It should be such that someone can get by with the universal coverage alone if they choose, and those who desire it can buy additional coverage as they see fit. It will still not be equal care for all. I share your enthusiasm for the best for all, but I am also pragmatic enough to realize that the goal of complete equality is not possible. We will never all live in equal housing, eat the same, or have the same. But among our common goals for the common good we should all agree that there is a mechanism to provide health care to everyone.

A uniquely American problem is the level of litigation. With due respect to our attorney friends here, it is a problem in the system that still has not been addressed. Some in the legal system argue that the issue is overblown and does not impact costs. It absolutely, definitely does. It is not possible these days to watch TV for more than an hour without seeing an ad for some firm suing some pharmaceutical company or device manufacturer and trolling for potential litigants. Tests are absolutely performed purely for protection for lawsuits. Most of the time when I remove a lesion in the office, I know what it is when I take it off, but I send everything to the pathologist, because if I don't, I open myself to a lawsuit down the road. People tell me the pathology fees always exceed what I charge to take the thing off. Every doctor pays an annual premium for malpractice insurance. For cardiothoracic surgeons, it can be as much as $250,000 annually. So the first quarter million cleared, after expenses, merely covers that year's insurance premium. And so on. The point is, no other country has these costs built into their system.

Regarding Benghazi, I think there is much we agree on, actually. The only real issue between you and I is whether the blame goes to the top or not. Regarding the CIA at the compound, if it's true, this may be a botched covert operation which would explain the apparent cover up. As I said, that starts to sound a little far out there to me, and I'm not buying into that aspect of it yet. That scenario actually makes this worse, not better.

Lastly, and please, let's not re-hash Bush (I will stipulate he was a moron in many ways). The fact that there were no weapons doesn't prove he lied. He thought they were there and he was wrong. It makes him wrong, and maybe a moron, but not a liar. You would have to show that he knew there was nothing there but chose to attack any way. There is no such evidence, and it makes no sense. If he was capable of lying about the WMD existence, why would he not be capable of planting the evidence and announcing he "found it" on the first day they arrived? He would still get his war (again, we need to answer why he wanted it) and he would be a hero instead of a goat. We can agree that he is responsible for a terrible call, but there's no evidence he lied in the process.

The Colin Powell angle is interesting and comes as close to proof as we have. But regarding Powell, then, I would have to say one of two things is true: either he also believed it to be true at the time and was trying to distance himself from the decision after the fact, or, if he truly knew it was false, was it not his moral obligation to stand up and say so? Should he not have resigned rather than unleash that war and kill all those people? In my view, it makes him look worse, not better.
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Re: When President Obama is re-elected!!

Post by JScott »

Jim, I will say, maybe it's the water up there, but pols from Maine are among the classiest in the union.
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Chateau Vin
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Re: When President Obama is re-elected!!

Post by Chateau Vin »

Good points JScott regarding the health system. My spouse is a physician, her side of family has physicians and my uncle is a physician, and I keep hearing stories about patients (esp of medicare and medicaid) gaming the system...Yeah, malpractice insurance is also built into the costs. Except a few states, there is no tort reform. On one hand, due to malpractice doctors usually are on top of the things, and that's what makes a better system. On the otherhand, it has gone overboard with frivolous law suits, jacking up the medical care costs...To add to that, the prescription drug plan for medicare is a joke. Rather a dole out for recipients as well as the pharmas. Why in the world you specifically create a law that does not allow the govt to negotiate the drug price even though medicare is the largest purchaser? Even VA can negotiate. In any business it's the norm...Don't you get a discount if you buy a case of wine instead of a bottle? With all the reimbursement cuttings to the physicians, it would be interesting to see the effect on healthcare...Physicians, when they graduate are saddled with huge amounts of debt, and if the reimbursements are cut, I am sure you are disincentivizing people to go to medical school. That means, the healthcare system has to be more dependent on foreign medical graduates due to shortage in the coming years...

But JScott, regarding Bush over Iraq, I have to disagree with you. I think he lied to the people. All along, the intelligence was saying that they were not sure if Iraq had WMD. That should be enough not to have the basis of waging war. You wage war only if you are certain. Remember, that was not the only basis on which we went in. American people were also told that Iraq had links with 911...The phrase 'we are fighting over there so that we will not fight over here' is still ringing in my ears... So somebody knew it was all lies. Either lower rung in the administration knew, and the President was misinformed, or President was gullible enough and did not ask for more details. Never mind the WMD stories that the administration planted in the press. Every way you look at it, it does not add up. Either he lied or he knew that his administration surrogates were perpetrating the lies...

With regards to Bush could have planted WMD to wash off the hands, it is more difficult. If we are talking about planting WMD, it is not just WMD. You have to plant the whole apparatus needed to make WMD. WMD stuff needs high technological knowhow, and you cannot just plant them without the supporting evidence, and the vast trail that goes with it. Not only that, you also need to show the evidence of human resources that have the knowhow. I don't think it is possible to plant such evidence with regards to WMD, let alone in the middle of the war. Regarding Colin Powell, he did mention later that the administration duped him (though he put it more elegantly than just saying it as is)...
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Re: When President Obama is re-elected!!

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CV, interesting. Totally agree the Medicare Part D was another flamingly poorly conceived piece of legislation. There is quite a bit of concern about doctor shortages going forward, but honestly the plan appears to be that they will be replaced by Nurse Practitioners and Physician Assistants. With no slight intended to those good folks, they aren't a substitute.

Regarding Iraq, I haven't seen anything that suggested there was significant doubt on the WMD. Maybe there was and it was covered up, or I just plain missed it. My impression was that there was certainty beyond reasonable doubt, and that was what was moved on. There is no doubting it was wrong in hindsight. It would be rare, I think, to have 100%, lock-tight intelligence, so some ambivalence still doesn't rise to the level of deceit, in my view. But let's assume that's correct for a minute. I still have some questions, if you don't mind.

The vote in Congress was nearly unanimous to go to war. There were, what, 40 other countries involved as well? Certainly they must've all seen the same intelligence? Or are we proposing that the administration scrubbed the intel before presenting it? How on earth could they have all had the wool pulled over their eyes? And a deceit on that scale would've had to involve the CIA, the Joint Chiefs, the DoD, everyone. Was everyone lying? And after all this time there's not one person to come forward and reveal the big lie? Bush just ain't that clever. And if he was clever enough to perpetrate that kind of lie, planting the WMD would've been child's play. There literally wasn't anyone left on the ground when they were done who could've refuted anything they would've made up.

Beyond that, I've never heard a plausible explanation of why he was supposedly so hell bent on waging war for no reason and forever tarnishing his legacy. Theories have included "for the oil" (we never took it); "for his father" (wha?? - this one sounds like it came from kindergarten), and "for Haliburton" (they made money, but so far as we know Bush didn't get any of it).
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AlexR
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Re: When President Obama is re-elected!!

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JScott,

Is it possible to analyze rising health costs to see those that have occurred since the change in the law (or is too recent)? In other words, to what extent has Obamacare accentuated a curve that was already spiralling out of control. How much can it specifically be blamed?
Are we talking about projections or statistics?

Please tell me why a federal, centrally controlled solution is not workable in the US? What makes it so different from other countries with federal systems and states/provinces/regions that don’t even speak the same language! You say management costs would swamp the system. But didn’t America *invent* modern management? Why should this be so outlandishly difficult? When I see the doctor, he swipes a smart card. Social security then reimburses part of the cost and my mutual insurance automatically reimburses the remainder. It’s all computerized.

I was puzzled by your comment, “I share your enthusiasm for the best for all, but I am also pragmatic enough to realize that the goal of complete equality is not possible. We will never all live in equal housing, eat the same, or have the same. But among our common goals for the common good we should all agree that there is a mechanism to provide health care to everyone”.
You seem to blow hot and cold on this: optimistic, then pessimistic, then optimistic!

I feel that health care is a right, not a luxury. Honestly. But, like you, I can see that people with much more money will always spend more on their health and look after themselves better. Yes, the heart of the issue is indeed equality. As in “liberté, égalité, fraternité”... However, the theme of equality is somehow upsetting… Alexander Solzhenitzyn once gave a speech in France warning against striving for equality, as this is impossible. Needless to say, this went over like a lead balloon… I think we should consider it like justice: perhaps unattainable, but worth aiming for.
Which is really no different from what you said…

I hear you about the problem with malpractice suits. That is a big issue in America to which there is perhaps no solution. It’s quite simple in France: everyone in the medical profession covers up for everyone else! It is nearly impossible to win a court case against a doctor. There’s an omerta.

As for Colin Powell, I fully agree with your way of seeing things “Either he also believed it to be true at the time and was trying to distance himself from the decision after the fact, or, if he truly knew it was false, was it not his moral obligation to stand up and say so? Should he not have resigned rather than unleash that war and kill all those people? In my view, it makes him look worse, not better”.

I remember the start of the Iraq war very well. I was in Malta at the time. The whole world was on the edge of its seat. People had seen the war coming for *months*. The fake issue of WMD had been blown (the English were even worse at this than the Americans, claiming that Saddam had a giant cannon that could be used against the UK - ! - also bogus), but the war machine was set into motion...
In time, the archives will tell us who exactly was responsible for this disaster. But the records are surely classified as “top secret” for the next 75 years or so…

Yes, yes, as you say “The vote in Congress was nearly unanimous to go to war”. This decision is to the eternal shame of the US congress (except a rare few people such a certain Barack Obama). There was a general hysteria at the time and the association was planted in people’s minds between Saddam and the 9/11 terrorists. Yes, as you say, a number of nations joined the war effort. To her eternal credit, France indignantly refused. The coalition nations who (other than the British) sent only a symbolic number of soldiers, withdrew as soon as they could.
You ask “How on earth could the intelligence community have all had the wool pulled over their eyes?”. I don’t see it that way at all! It's the other way around... Intelligence was doctored to fit a political agenda. The New York Times apologized for being duped into supporting the war. But it was too late.

Best regards,
Alex R
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Re: When President Obama is re-elected!!

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Alex, see we do agree on many things! Some of your questions you have answered yourself, specifically regarding my view on equality. If you are cold and calculating or are a mathematician at heart (Stefan, I am not remotely implying that these things go hand in hand! :) ) you can actually think of the issue mathematically. Life is constantly evolving, minute by minute, fortunes won and lost, luck ebbing and flowing, there is no way to account for it all. There are those (von Hayek and more recently Sowell, among others) that actually propose it is destructive to try, and they make a compelling case. Arthur Okun (Chairman of the Council of Economic Advisors for the Johnson administration and Senior Brookings Fellow) in his work Equality and Efficiency: The Big Tradeoff actually surmised that inequality is not only acceptable, it is desirable and necessary (among other themes). His thesis is essentially that without inequality there is little incentive. This is an interesting area, actually, philosophically speaking. But I digress.......

Regarding centrally driven healthcare, the larger the population and the greater the geographic area, the more people, offices and agencies required to maintain and direct it. Americans invented modern management in private industry, but perfected the development of its evil twin in government!! Remember, I also worked in and for the government (I was in the military for 11 years). I don't want to bore you with stories about day to day operations, but let's just say that incentives are upside down from private industry and the results show it. I am deeply envious of countries with a more manageable setup. Denmark, for example, has a population smaller than the county in Ohio I live in (there are 88 counties just in Ohio) and an area not much larger. It is intuitively obvious that their task is much simpler than ours.

Regarding Obamacare, there is in my view no concrete evidence that it has yet directly created increased costs (though I believe some evidence is forthcoming). Rather, at this point, I think it's fair to say that it may be increasing some costs indirectly and hasn't slowed the increases, as it was predicted to do. Some will say it's too early, and not fair to judge it. Remember, it was the proponents who claimed we'd see the decline, and more time isn't likely to look pretty. All the funding was front-loaded, and even the CBO now already scores it as progressively moving into the red. And government estimates on costs and revenues are notoriously rotten.

We agree that Iraq was a blemish on humanity. Ditto Afghanistan, and now Libya and on and on and on.
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Re: When President Obama is re-elected!!

Post by DavidG »

Obamacare has not been implemented yet to a degree that it has had any significant effect on costs to the patient. Commercial insurers have been raising premiums consistently (while cutting payments to providers) independent of Obamacare, and many employers have passed the increased costs on to their employees. That said, Obamacare will cost plenty when and if fully implemented. Despite Obama's re-election, there are plenty of devilish details to be worked out. So far it's mostly the popular provisions that have been implemented.

A good deal of the increased costs to the payers is related to imaging and drugs. Agree with comments above about the stupidity of the part D prohibition against negotiating prices. That was pushed through, by the way, in a quasi-legal fashion by a spend-and-no-tax Republican Congress.

The past year or two has actually seen a bending of the health care cost increase curve, so things are heading less rapidly in the wrong direction. Lots of debate on why this is - anomaly, recession, govt efforts, etc. Who knows.... but I learned this week that payment for sight-restoring cataract surgery, one of the best operations in the history of mankind, is getting cut another 13%. When I started practice in 1985 I got >$2000 (1985 dollars, about $4300 in 2012 dollars) for that procedure. It's a much better procedure now, but in 2013 it will pay about $600. Another reason it's easy to boycott 2010 Bordeaux.
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Re: When President Obama is re-elected!!

Post by DavidG »

Alex, you asked Scott for his solution to the health insurance conundrum. I'll give you my VERY BASIC outline...

First: Basic insurance for everyone. Basic means no frills, not the best of the best that America can offer to the haves, but what you need to keep you alive and functioning. There would have to be vigorous debate over how to define that and who pays what. Oregon made a good start years ago but sadly the debate would get sidetracked in partisan bickering and jingoism ("death panels" anyone?) in today's environment.

Next: Allow balance billing. Currently illegal (Medicare) or contractually prohibited (commercial insurance). You want the best, you can have it, at a price. Yes, a two-tiered system, but a better two-tiered system than the current one in which 15% get no coverage. Free market - Republicans rejoice! But there will need to be regulation to prevent snake oil salesmen from ripping off the naive public - Democrats rejoice! Again, not likely this is going to go anywhere in the current climate of no-compromise politics.

If I were King of the World we would have this system tomorrow. And Bordeaux prices would drop to 1980s levels...
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Re: When President Obama is re-elected!!

Post by JimHow »

Excellent David! Now that you have health care resolved, what can you do for us court appointed criminal defense lawyers?
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Re: When President Obama is re-elected!!

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They're talking about increasing our hourly rate from $50 hour to $70. Everyone is excited!
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Re: When President Obama is re-elected!!

Post by JScott »

David, your system sounds very much like mine except I would have local administration and tort reform.

Also, regarding Obamacare, as I said above, any costs currently are indirect, in the sense that they are mostly a result of employers making adjustments in advance of full implementation and passing along more cost to individuals.
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Re: When President Obama is re-elected!!

Post by DavidG »

Going way off topic here...

I'm not really complaining, just giving some references. I'm one of life's lottery winners, making a great living at something I love to do. But there's a LOT of overhead in my business, and these cuts will actually start to hurt physicians who are not as efficient. It's interesting to see the responses.

Now, as to you court appointed criminal defense attorneys... You already have the system I've just described for health care! Basic representation for all, and the best money can buy for wealthy individuals, corporations and the mob. Guess the debate over defining "basic" and who pays for what didn't work out so well for the legal system. Maybe we could learn from that. As King, i would do a little redistributing. Until then, Jim, perhaps you've just got the wrong clients. Or not...

We're looking to hire an associate/future partner. As we're talking to applicants, I find myself looking very closely at the candidates' goals with respect to income vs spending time with patients. There are ophthalmologists who see 2-3 times as many patients as I do per day. I don't want those guys. I get a lot of satisfaction from talking to my patients. It's getting harder to do that, but I'd still rather be happy than rich. Not that I'm starving, but each of us has our own balance in that.
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Re: When President Obama is re-elected!!

Post by JimHow »

Tort reform!
So a few years back, a woman came into my office with her 17 year old granddaughter.
The girl had given birth to a baby boy that had been born with cerebral palsey.
The boy was profoundly disabled, destined to live a life (average lifespan 35 years) 100% on his mother.
She was looking for a lawyer because a doctor down at Maine Med in Portland had told her she should probably talk to a lawyer.
The mother had been in Central Maine Medical Center in Lewiston, in labor for 7 hours, attended to by a midwife.
All vital signs indicated that the baby was completely healthy.
It had been an uneventful pregnancy.
About 5 hours into labor, the fetal heart monitor started to fluctuate.
For 45 minutes, the baby's heart rate went basically out of control.
For some reason, the doctor did nothing.
The umbilical chord was wrapped around the baby's neck, suffocating him.
Oxygen cut off from the brain.
C-section should have occurred immediately, but, for reasons never really explained, it didn't occur til an hour later.
Too late.
During those 45 minutes he went from a life of health and normalcy to a life of profound retardation.
As you know, medical malpractice cases are incredibly expensive to litigate. Expert witnesses, etc.
I got a firm next door involved.
The case went to a three person medical malpractice screening panel, loaded with political appointments that favor doctors.
The panel found no negligence by a 3-0 vote.
This has evidentiary consequences that I won't go into, but they do not favor the plaintiff.
So the case was taken to a jury trial.
The firm next door spent $196,000 of its own funds to litigate the case, hiring numerous out of state experts, etc.
Had they lost, they would have been out $200k.
After a two week trial, the jury came back with a verdict of $7.96 million.
I shared in the one-third contingent fee.
What about this situation do you think should be reformed Scott?
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Re: When President Obama is re-elected!!

Post by JimHow »

I'll ever forget when my 90 year old Polish grandmother looked in the mirror, David, after having cateracts removed, and seeing herself clearly for the first time in like 20 years. An incredible moment.
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Re: When President Obama is re-elected!!

Post by DavidG »

Scott, I think so far there's been more talk than action amongst employers in response to the ACA. Up to now, most of the increase in premium costs passed through to employees is a reaction to the rise in commercial insurer premiums, and those premium increases are mostly reactionary rather than anticipatory. If the ACA is implemented as envisioned, costs will really explode. As Randy Bachman (no relation to Michelle) sang "B-B-B-Baby, You ain't seen nothing yet!" The increase would be dramatic enough to cause significant discontinuities in responses from employers and providers. We've all been like the frogs sitting quietly in the pot as the heat is gradually increased. A fully implemented ACA would get the frogs hopping. But where will they land? Legislators have to worry that if all this hopping pisses off enough patients/voters, the legislators themselves will be the ones in hot water. No more Congressional power and perks once you're voted out. This is where hope lies for some reasoned moderation. Otherwise it could be HMOs all over again, just with a different acronym (ACOs) and with Congress rather than commercial insurers to blame.
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Re: When President Obama is re-elected!!

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Tort reform...

It's easy to quote anecdotes on either side of the issue. Though the system finds in favor of the doc the vast majority of the time, even winning is no picnic. Docs are not lawyers. It tears at them, regardless of culpability. All of which is irrelevant to the economic/moral/ethical/legal question.

We docs have a hard-on about tort reform in part because it is so emotional and in part because professional liability premiums are so expensive. But most arguments that defensive medicine is a significant driver of excess healthcare spending don't survive an economic analysis. Of course you can find an economist that can prove just about anything, as you can find an attorney to argue anything (they have an excuse, that's what they're supposed to do!) or a physician to testify as an "expert" to just about anything. My reading of the various analyses suggests that malpractice and defensive medicine are small contributors to the overall healthcare cost equation on a macro level. However, on a micro level, malpractice premiums have driven many a good doctor out of practice. The OB that delivered my daughter threw in the towel and switched to doing hair transplants in the '90s, because of the malpractice crisis. And he didn't have any big settlements against him.
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Re: When President Obama is re-elected!!

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JimHow wrote:I'll ever forget when my 90 year old Polish grandmother looked in the mirror, David, after having cateracts removed, and seeing herself clearly for the first time in like 20 years. An incredible moment.
When we're in Dallas, remind me to tell you the story of the 95 year old one-eyed patient of mine who finally overcame his fear of surgery to have his cataract removed. It's the essence of why I love my profession.
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Re: When President Obama is re-elected!!

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I think the world of doctors. I love my doctors who treat me for my various health problems. Several young ER and trauma doctors came through big time for my client the girl charged with double manslaughter. Very inspiring. We've had nothing but top notch, tremendous care for my father's various health problems. Very caring individuals. Now the nurses on the other hand.... I had to abuse a nurse on the witness stand very badly who was making stuff up about my client, so much so that the father of the girl who was killed came after me in the middle of my cross examination, four court officers had to escort him out, if was pretty dramatic. We had this one fourth year trauma surgeon resident from Georgia who was an absolute hero in my case, he basically saved my young client from going to prison for many years, I was very inspired.
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Re: When President Obama is re-elected!!

Post by Chateau Vin »

JScott wrote:CV, interesting. Totally agree the Medicare Part D was another flamingly poorly conceived piece of legislation. There is quite a bit of concern about doctor shortages going forward, but honestly the plan appears to be that they will be replaced by Nurse Practitioners and Physician Assistants. With no slight intended to those good folks, they aren't a substitute.

Regarding Iraq, I haven't seen anything that suggested there was significant doubt on the WMD. Maybe there was and it was covered up, or I just plain missed it. My impression was that there was certainty beyond reasonable doubt, and that was what was moved on. There is no doubting it was wrong in hindsight. I personally think you don't need hindsight to see it correctly in the first place. There was plenty of doubt raised by the echelons of CIA, but it was the VP office and DOD office put pressure to go their way. The intel was saying yes/no and was sitting on fence, unable to determine if Iraq had WMD for sure. Remember the trips Cheney was making to the pentagon and CIA, while at the same time peddling the idea of WMD on network televisions? Why peddle that idea even before Powell presented it to the UN? On top of it was the bogus British intelligence (The Iraqi dossier, which turned out to have no legs). And then we had a bunch of Iraqi dissidents who lacked integrity and would do anything to pull the regime down. And they did by giving false information so that we could go in. Yes, they duped us! The war drums were so loud that even the media forgot their duty and stopped asking tough questions. When people started questioning the WMD story, they suffered paybacks. Remember outing of CIA agent? If the intel is that good and they had solid evidence of WMD, why these paybacks? If we cobble all these patchworks of intel and look at the big picture, it's hard to commit American lives.

It would be rare, I think, to have 100%, lock-tight intelligence, so some ambivalence still doesn't rise to the level of deceit, in my view. But let's assume that's correct for a minute. I still have some questions, if you don't mind.

The vote in Congress was nearly unanimous to go to war. There were, what, 40 other countries involved as well? Certainly they must've all seen the same intelligence? This is easy to answer. After 911 the whole nation was hysteric, and congress was no exception. If anyone questioned anything, he/she would have been branded unpatriotic, and some of them did get that label for questioning. In that situation do you think any congressman would even question for details let alone oppose "response to 911"? Come on, we saw the congress pass the patriot act without the members even reading it. And again, it's easy to sell if it is told that Iraq had a connection to 911 and that going into Iraq is a response to 911. And that's what we were told. Regarding the 40 countries, the answer is even more easy. The 40 countries are the 'coalition of the willing', primarily through NATO. For the first time in history, US invoked Article 5 of NATO which says 'attack on one is the attack on all' after 911. That means all the member states have to be part of the war, even if some of them have reservations. And some countries did have reservations. The fact is, from 911 to the run up to the war, US did not get along well with some our European allies, and the reason is they did not fully buy into the intel. But still they had to go along...

Or are we proposing that the administration scrubbed the intel before presenting it? How on earth could they have all had the wool pulled over their eyes? And a deceit on that scale would've had to involve the CIA, the Joint Chiefs, the DoD, everyone. Was everyone lying? I don't think you need to lie explicitly to carry out this. Instead you can make the people believe in the wrong thing. It is simple. It has been over and over in history. You must have heard about Chomsky's 'Manufacturing Consent'. One might discount his writings as left wing, but if you look deeply, what he says in the book is true. You can manufacture and manipulate people's thinking using linguistics. And half the people already got bought into it by Faux.

And after all this time there's not one person to come forward and reveal the big lie? I don't think anyone can come forward and say it's a lie, since no one knows what was the true intel. Only the inferences that can be made from the intel were changed IMO to fit the decisions. And moreover, we could always point to the faulty British dossier or the dissident report, and say 'sorry someone else dropped the ball'.

Bush just ain't that clever. And if he was clever enough to perpetrate that kind of lie, planting the WMD would've been child's play. There literally wasn't anyone left on the ground when they were done who could've refuted anything they would've made up.

Beyond that, I've never heard a plausible explanation of why he was supposedly so hell bent on waging war for no reason and forever tarnishing his legacy. Theories have included "for the oil" (we never took it); "for his father" (wha?? - this one sounds like it came from kindergarten), and "for Haliburton" (they made money, but so far as we know Bush didn't get any of it).I don't know if W truly believed in Iraq's WMD, but he surrounded himself with wrong people who gave him wrong advices. And I know that he was not that bright to realize it.
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JScott
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Re: When President Obama is re-elected!!

Post by JScott »

JIm, regarding tort reform, I am not remotely suggesting doctors should be exempt from lawsuits. There is ample evidence, at least in Ohio, that the strong majority of cases are without merit. A bad outcome does not equal malpractice, as you know. As David points out, there is a significant cost in defense, personally and in real terms, and a number of insurers prefer to settle cases rather than litigate because it is the more cost effective route. I am not a fan of the contingency fee. In the case you were mentioning, based on what you've described, it sounds like the doctor screwed up, and obviously the jury thought so. Here's the other part I have a problem with, and I hope I can do this without offending you. Proponents of contingency will point out that it provides access to those without means. Fair enough. But when a jury decides the plaintiff has suffered and deserves compensation at some level, purportedly for the suffering they've endured and to compensate for future costs associated with their disabilities, after the attorney takes a third, aren't they again being short changed? I know the argument is that they wouldn't have had anything if not for the hard work of the attorney, but why not an hourly rate plus expenses? To put this in perspective, what should someone like David be compensated, then, for that moment your grandmother had in the mirror? What is a third of her new vision worth? My proposal wouldn't even be to do away with contingency, but a "loser pays" law would cut down on suits without merit that just seek settlements. For the record, I have quite a few friends and relatives who are attorneys, and I think the world of them, too.

David, it depends on where you look, as you point out, as to whether defensive medicine adds costs. I mentioned a number of examples above. Most studies don't look at the kind of things I mentioned or take them into account (e.g. they assume that much of the testing would take place any way, that I would continue to send off all path, etc.). Curious on that end - when you extract a cataract, for example, does it go to path typically?

Regarding ACA, look around this week. Headlines are full of layoffs in anticipation. In my area at least, for the past year many if not most employers have made substantial changes to health plans as a direct result of coming legislation. Regardless, we both agree the costs of this are going to be massive. I wonder, after all the arm wrestling we are about to witness on the vaunted fiscal cliff, how it will be dealt with.
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JScott
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Re: When President Obama is re-elected!!

Post by JScott »

CV, again, for the record, the very last thing I want to be here is the token Bush apologist. That whole saga was one hot mess and I am not a fan of his years in office. My point is a finer one, I think, and probably not worth all this attention. You, and Alex above, and almost everyone on this subject, seem to be able to forgive Powell, the NY Times, all of Congress, the DoD, the other nations involved, all of whom who were enthusiastically involved at the time but have expressed regret in hindsight, as players who were duped, pawns in a bigger scheme. The narrative is that Bush lied about this to the universe, fooling everyone, and he therefore is uniquely culpable. I just have a hard time accepting him as the mastermind of international duplicity on a scale never witnessed in human history. I'm not saying he shouldn't be held accountable, but how do you know Bush wasn't fooled, too? After witnessing 8 years of the man, is it easier to see him as the fooler or the fool? My only point is that there was enough ineptitude on his part to be disdainful of the man, but it doesn't seem like enough - he has to be a liar, too. What I find especially interesting is that the same people who insist that he lied can't seem to admit that Clinton did, cut and dried, very much on the record, in court and wagging his finger at the population. (Let's not go there, too! And also for the record, despite his many failings, Clinton was a more successful and effective President than Bush, in my view.)

All that said, your points are well taken, accurate and thorough. No argument from me.
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Re: When President Obama is re-elected!!

Post by DavidG »

No doubt defensive medicine adds costs but it's a tough argument to win with policy makers because the numbers in enough of the studies don't favor us. So the discussion often gets turned to the costs (emotional and economic) to the doctor, which is a losing argument since docs are regarded as wealthy and whiney (not wine-y). Or it turns into a discussion about lawyers and/or turf. Aside from the difficulty convincing legislators to vote against the interests of lawyers, there is also a strong tendency for them (legislators) to avoid taking sides in a turf battle unless they have a covering rationale.

No pathology on cataracts. This used to happen 30 years ago and it was pointless - like you needed proof you actually took out the lens? I'd like to say we stopped because it was unnecessary, but in truth now with ultrasonic phacoemulsification there's nothing to send but a bag of cloudy water. I suppose we could send that, and we probably would if we were convinced it would keep us from getting sued. A real waste of money is the pre-op history and physical for routine cataract surgery on healthy individuals. This is pure and simple defensive medicine. Sure I've had a few patients whose heart disease was found to need intervention because of the pre-op H&P, but they weren't in the healthy group to begin with. The number of cases of new systemic disease uncovered is so low as to make the screening far from cost-effective. Our Academy is working to get some traction on doing away with this.
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JScott
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Re: When President Obama is re-elected!!

Post by JScott »

David, very similar scenario on my end. When I take out a cyst, there is not a shred of doubt about what it is, but it always gets sent. Not just because of CYA, but also because I have actually run into cases where the insurer wouldn't pay if there wasn't evidence something was extracted! Here I am trying to save the system - them! - the thoroughly unnecessary expense. Since we're straying not just off the subject but off the reservation, it also chaps me a little that there is now an inherent supposition in the system that you're cheating until proven otherwise. I know fraud is a massive problem, but it's annoying for those truly trying to do the right thing. You have my nomination as King for a day to deal with some of this silliness!
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Re: When President Obama is re-elected!!

Post by DavidG »

I lecture for our Academy on how to avoid the RAC, OIG, ZIPC, etc. The OIG work plan for 2013 lists an investigation into all ophthalmological billing as a priority. I can't wait! Don't get me started on the guilty until proven innocent deal...
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JimHow
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Re: When President Obama is re-elected!!

Post by JimHow »

I don't do med mal, Scott, because those cases are cost prohibitive and I don't have any great desire to sue doctors. Maine may just have a different culture but we seem to see very few frivolous medical malpractice cases because they are too expensive to litigate. And the insurance companies here rarely settle in part because of reporting requirements and also to deter future claims. If you eliminate the contingent fee, there will be zero medical malpractice claims filed. The firm next door would not have fronted $196,000 of its own money, with a substantial risk of losing it all, if the best result were a fee for hourly services rendered. An enormous amount of work was put into that case over four years, flying all over the country to depose about ten expert witnesses, etc. It's funny, most on the lawyers' side feel the system is skewed in favor of doctors because of the screening panels that no other defendants are afforded, the prohibitively high upfront costs of litigating the cases, etc.
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Re: When President Obama is re-elected!!

Post by JScott »

Jim, there certainly doesn't seem to be a shortage of personal injury lawyers, though. Maybe it's one of those high risk-high reward kind of things? Do you think a "loser pays" system is workable? There are absolutely cases filed that are utterly without merit, yet there is still a cost borne by the defendant, which doesn't seem fair. Maybe there is a mechanism to have an agency or panel determine whom should bear the costs of a particular case? My understanding - and maybe I'm wrong here - is that contingency is a uniquely American convention. How do other countries deal with this sort of thing? Are costs to bring a case higher here than elsewhere?

I'm warming up to the notion of Maine as a hidden paradise..... :)
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Bacchus
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Re: When President Obama is re-elected!!

Post by Bacchus »

Interesting video about Rove and the Ohio vote:
http://www.youtube.com/watch?v=REn1BnJE3do
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Jay Winton
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Re: When President Obama is re-elected!!

Post by Jay Winton »

and then there are the docs that are also businessmen and will order every test regardless of whether the patient really needs it (MRIs come to mind) as they are sent to a facility which the dr either outright owns or has a financial stake. I think correcting this type of scenario would help decrease healthcare costs but I realize devising the mechanism will require negotiation and take time to implement.
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Bacchus
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Re: When President Obama is re-elected!!

Post by Bacchus »

Jay, that's called single payer, universal health care. :-)
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Racer Chris
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Re: When President Romney takes office....

Post by Racer Chris »

I just found this quote while rummaging around and thought it was interesting given the current state of politics.
Jay Winton wrote:not quite ready to throw Obama under the train-there have been some positives i.e. Bin Laden, ending the war in Iraq. I think the true star of his administration is Hilary Clinton-one of the best SOS the country has ever had but I'm sure she will leave if Obama is reelected. Too bad the GOP can't nominate someone who could give us voters a real choice and real debate about the numerous issues facing the USA.
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Comte Flaneur
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Re: When President Obama is re-elected!!

Post by Comte Flaneur »

Maybe Jay had one too many glasses of Chateau Du Chesselais when he wrote that...or was he on the Koolaid? Only kidding...
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Racer Chris
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Re: When President Romney takes office....

Post by Racer Chris »

JimHow wrote:Romney clinched the nomination last night.
Nobody in this field can beat him.
I'm sticking with my prediction:
Mitt Romney is the next President of the United States.
I hope I'm wrong.
...
You were wrong.
Just like you're wrong that DJT will be re-elected in 2020.
:D

Note: I found this thread searching the word Echo to find out if anyone had previously written about the second wind of LB.
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Jay Winton
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Re: When President Obama is re-elected!!

Post by Jay Winton »

Comte Flaneur wrote:Maybe Jay had one too many glasses of Chateau Du Chesselais when he wrote that...or was he on the Koolaid? Only kidding...
mr vino overserved????? Impossible
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