Obamacare 5 years later. Crow, anyone?

[Nihilianth]

You're right, they are still just recommendations. The unfortunate truth, however, is that medical recommendations are a morass of profit-seeking and ignorance. Most people will do whatever their physician tells them they should do. Physicians generally get paid more for doing more stuff. So the doc says "get a mammogram every 2 years from age 30 on", and people do.

Here's a slightly more concrete example, that also shows where some of the medical community is starting to change their practices (for the better). All my life, it was "recommended" that women get a gynecological exam once per year, every year, no matter what. It's preventive - it checks for all kinds of things that can go wrong, ranging from cervical cancers to STDs to breast cancer. The recommendation was so strong, that doctors won't renew an oral contraceptive prescription without the exam. For many years, women were tied to a pelvic exam every year, no matter what.

Just within the last few years, this has started to change. If you're in a monogamous, long-term relationship, and over the age of 30, they're now recommending every 2 to 3 years. That's a step in the right direction.

Unfortunately, the prescription writing practices haven't yet caught up!

I see your point. I guess it's because the physician I have always gone to since I was a child, and still go to to this day as an adult, I trust. I'm now 32, and get regular check-ups, about twice a year. He has yet to tell me to get a prostate exam, or go through any sort of expensive testing. In fact, last time I went to see him, I asked him about it. He said the reason why he has made no recommendation to me, is because I am very low-risk. He couldn't see the need for any major testing, beyond basic blood tests very periodically.

Because of my experience, I tend to trust the idea of seeing "family physicians" on a regular basis.

No worries - good conversations always wander a bit!

 

[sunmaster14]

<snip>

He has yet to tell me to get a prostate exam, or go through any sort of expensive testing.

I found this kind of funny. Perhaps you will too, once you learn what a prostate exam is.

 

[Trebuchet]

Whatever happened to all those death panels, anyhow?

 

[johnny karate]

Whatever happened to all those death panels, anyhow?

Still totally a thing.

 

[Emily's Cat]

How else do you solve an income/wealth inequality problem except through taxation?

Figure out a way to enable people to increase their wealth on their own, through increased agency and opportunity in a sustainable fashion.

In other words... teach a man to fish.

 

[Emily's Cat]

If Oregon is an outlier, it's not a problem. Even if there are a couple states that approve 20-30% hikes by big carriers, it's not a problem.

The problem arises if a non-trivial amount of states approve huge premium increases, and most of the other states approve larger than expected increases (say, in the high single digits, or low double digits).

It's too far out to say if Oregon is unique or not, but other states also have companies asking for very high premium hikes.

I'm leaning towards Oregon being a canary in a coal mine (i.e., large premium increases being a systemic problem in a lot of states) because the mandate doesn't have enough "teeth", and the cheapest entry-level product available to avoid having to pay the penalty is Bronze level insurance, with it's very high deductible.

Fair point - I don't know enough about other states; they're outside my area.

I will say, there are a LOT of moving parts, that makes it incredibly difficult to draw any sort of general conclusion from Oregon's situation. Each state ends up being fairly unique in terms of their actions this early in ACA.

For example... some states chose to retain their existing High Risk Pools, and supplement the costs in a more direct way. Some chose to wind those high risk pools down over a set number of years.

In some states, there's a very large employer presence, so the Individual market is small relative to the Employer market. This makes the Individual market much less stable, and much more subject to effect from the High Risk Pools joining in that market. Other states have a large small business segment, and have a large number of early retirees, or have a large volume of independent contractors - all of which means they have a larger than normal Individual market. Then they're more stable in terms of projections for cost and premium, as well as fluctuations in actual experience.

 

[DavidJames]

Figure out a way to enable people to increase their wealth on their own, through increased agency and opportunity in a sustainable fashion.

In other words... teach a man to fish.

The only viable option for the vast majority is to work for someone. Everyone can't be a boss, at least outside of Libertopia.

This country has existed quite nicely when business shared their success with their workers. They mostly stopped. For the most part people haven't given a **** about the wealth gap because they were riding the rising tide. Now they are being pushed under water.

 

[Emily's Cat]

Why?

At least you're paying for it via taxes, rather than artificially inflating wages until they have no relationship to the amount and quality of the work, and no relationship to the demand for the work.

Just FYI, wages ALREADY have no connection to the amount or quality of work. The substantial majority of wage levels is explainable by simple supply and demand.

But paying for it with taxes also divorces the payment from considerations of amount, quality, and demand--the things we normally use to estimate the value of the work.

So at this point, you're not really paying a person for working full time. You're just paying them for being a person. You're basically arguing that every citizen should receive a stipend from the government regardless of the amount, quality, or demand of the work they do, or even if they do no work at all. This policy has the benefit of making minimum wage irrelevant and unnecessary (and redundant).

True, it makes it completely irrelevant.

I marginally prefer an EITC or Guaranteed Minimum Income to minimum wage. But I don't particularly like those options either. In my personal opinion, the only way to effect long-term change is to find a way to increase agency with respect to work - increase the negotiating power of the individuals in the labor market. I tend to think that education is the key to this... but some recent information has caused me to question the validity of my assumptions. So now I'm a bit stuck. I *think* I know what the solution should do... I just don't know what it looks like. If I could come up with a solution, I would.

 

[Emily's Cat]

No one dies. Since the 1970's the government is required to provide health care coverage to prevent people dying in the streets.

This is incorrect. Emergency rooms are required to stabilize any emergent condition that enters their doors. But they don't provide ongoing treatment for chronic conditions - they don't treat cancer. Heck, most ERs don't even actually cast broken limbs anymore - they splint, provide pain meds, and have you make an appointment with a regular doc for the cast.

 

[Emily's Cat]

What part of that statement do you have a problem with? Do you dispute that patients are queued up and ready to go? Do you dispute that you don't have a problem with no-shows in the ER? My statement is true on its face. When you asked for evidence, I thought you wanted studies showing actual cost comparisons (as opposed to price comparisons) between clinical care and ER care.

None of that makes it an efficient use of resources, though. Perhaps an efficient use of time... but time is not the only resource in question.

 

[sunmaster14]

None of that makes it an efficient use of resources, though. Perhaps an efficient use of time... but time is not the only resource in question.

Actually, the most precious resource is time, particularly in the medical context. What resources in the ER do you think are not used efficiently?

 

[Emily's Cat]

The only viable option for the vast majority is to work for someone. Everyone can't be a boss, at least outside of Libertopia.

This country has existed quite nicely when business shared their success with their workers. They mostly stopped. For the most part people haven't given a **** about the wealth gap because they were riding the rising tide. Now they are being pushed under water.

I don't think you need to be a boss in order to increase your wealth. You do, however, need a way to increase your bargaining power- which means either decreasing the supply of people who are fungible with you or increasing the demand for your specific skill set. It means making your skills somewhat less of a commodity item, and somewhat more unique.

 

[Emily's Cat]

Actually, the most precious resource is time, particularly in the medical context. What resources in the ER do you think are not used efficiently?

That's really confusing me.

ER uses a lot of resources very heavily, because they're dealing with trauma cases. They use more blood than is *strictly* necessary, more gauze, more testing. But that's the nature of emergent care. It's not really a very good comparison to routine or preventive care. Having people walk in and get queued up for their regular checkups would mean that patients are wasting huge amounts of their time doing nothing but waiting.

I really don't know how to address your premise. I'm fairly sure there's a fatal flaw in it, trying to compare ERs to routine care on a framework basis. It's very apples to ducks. But I can't really find a specific point to say "Aha - you should have taken that left turn at Albuquerque"

 

[sunmaster14]

That's really confusing me.

ER uses a lot of resources very heavily, because they're dealing with trauma cases. They use more blood than is *strictly* necessary, more gauze, more testing. But that's the nature of emergent care. It's not really a very good comparison to routine or preventive care. Having people walk in and get queued up for their regular checkups would mean that patients are wasting huge amounts of their time doing nothing but waiting.

I really don't know how to address your premise. I'm fairly sure there's a fatal flaw in it, trying to compare ERs to routine care on a framework basis. It's very apples to ducks. But I can't really find a specific point to say "Aha - you should have taken that left turn at Albuquerque"

That's because you're not getting my point. We need ERs for emergency care. That's obvious. Of course that's expensive. But there's no getting around that. The claim has been made, however, that non-emergency use of ERs is costing the system a lot of money. People going to the ER for a sore throat instead of making an appointment at a doctor's office, for example.

My claim is that because ERs do triage and make people wait based on immediate need, the patients with non-emergency needs only get seen when there is a lull in demand. Thus, it is not wasteful to have people go to the ER for non-emergency care. At least not wasteful to the hospital. It is wasteful of the time of those patients, obviously.

To sum it up, "inappropriate" use of the ER by uninsured patients is not costing the system any more money that it would to supply them with subsidized insurance. The prices in the ER are fictional. They bear little relationship to actual costs. For instance, it does not use $800 of medical resources to treat a sore throat in the ER and only $50 in a clinic.

 

[Emily's Cat]

That's because you're not getting my point. We need ERs for emergency care. That's obvious. Of course that's expensive. But there's no getting around that. The claim has been made, however, that non-emergency use of ERs is costing the system a lot of money. People going to the ER for a sore throat instead of making an appointment at a doctor's office, for example.

My claim is that because ERs do triage and make people wait based on immediate need, the patients with non-emergency needs only get seen when there is a lull in demand. Thus, it is not wasteful to have people go to the ER for non-emergency care. At least not wasteful to the hospital. It is wasteful of the time of those patients, obviously.

To sum it up, "inappropriate" use of the ER by uninsured patients is not costing the system any more money that it would to supply them with subsidized insurance. The prices in the ER are fictional. They bear little relationship to actual costs. For instance, it does not use $800 of medical resources to treat a sore throat in the ER and only $50 in a clinic.

I'm not sure I have a good way to address this. I will say, however, that ER costs have reduced with the advent and increased use of stand-alone urgent care centers. This suggests that your logic is off a little bit somewhere.

In most ERs, they can't completely prioritize every patient. If someone comes in with a headache, they're not going to sit there for days until the doctors have nothing else to do. They still get wedged in to the mix, even if everything else is more urgent than a headache.

Beyond that, a single patient in an ER will see many more providers in one visit than a patient at a doctors office. In the ER, they'll see an intake nurse, a triage nurse, an ER doctor (which is a higher paid position than a generalist, usually), and usually at least one other nurse. They use at least one chair in the waiting room, as well as a bed or other exam area. The exam areas must contain the devices necessary to treat most emergent issues, so much more than just a thermometer and a bp cuff.

A single patient in a doctor's office will see a receptionist (who is often not a medical professional at all), a nurse, and a doctor (sometimes only a PA or an RN). They use a chair in the waiting room, and a chair in the exam room... which doesn't include all the other instruments.

Overall, a visit to the ER uses more actual supplies and resources than a visit to a doctor's office would for the same condition. In addition, the cost of lights-on-doors-open is higher for an ER, due to the need to have all the supplies and devices needed to stabilize emergent conditions.

All in all, I think it really is more expensive to treat a sore throat in the ER than in the doc's office.

 

[Elf Grinder 3000]

I'd like to see data that shows that modern industrialized nations (Democratic) with public health care spend more and have worse outcomes than nations without public health care.

Why is it that we cannot get that kind of data on a skeptics forum? Why is it that many if not most arguments made against the ACA are just philosophical or lacking sources?

Canada and the UK have horrible health care systems.

My insurance is better than the two countries and we don't have a 100% government run system.

 

[RandFan]

Canada and the UK have horrible health care systems.

My insurance is better than the two countries and we don't have a 100% government run system.

[citations missing]

Argument by assertion is the logical fallacy where someone tries to argue a point by merely asserting that it is true, regardless of contradiction. While this may seem stupid, it's actually an easy trap to fall into and is quite common.

 

[sunmaster14]

I'm not sure I have a good way to address this. I will say, however, that ER costs have reduced with the advent and increased use of stand-alone urgent care centers. This suggests that your logic is off a little bit somewhere.

In most ERs, they can't completely prioritize every patient. If someone comes in with a headache, they're not going to sit there for days until the doctors have nothing else to do. They still get wedged in to the mix, even if everything else is more urgent than a headache.

Beyond that, a single patient in an ER will see many more providers in one visit than a patient at a doctors office. In the ER, they'll see an intake nurse, a triage nurse, an ER doctor (which is a higher paid position than a generalist, usually), and usually at least one other nurse. They use at least one chair in the waiting room, as well as a bed or other exam area. The exam areas must contain the devices necessary to treat most emergent issues, so much more than just a thermometer and a bp cuff.

A single patient in a doctor's office will see a receptionist (who is often not a medical professional at all), a nurse, and a doctor (sometimes only a PA or an RN). They use a chair in the waiting room, and a chair in the exam room... which doesn't include all the other instruments.

Overall, a visit to the ER uses more actual supplies and resources than a visit to a doctor's office would for the same condition. In addition, the cost of lights-on-doors-open is higher for an ER, due to the need to have all the supplies and devices needed to stabilize emergent conditions.

All in all, I think it really is more expensive to treat a sore throat in the ER than in the doc's office.

Well, remember first of all that ERs have to have spare capacity to meet peak demand which can easily be an order of magnitude higher than average demand and can happen randomly. That means there must be a great deal of unused capacity in the ER, on average: rooms, beds, equipment. Maybe not so much doctors because you can have doctors on call at home.

So that mitigates greatly the problem of the guy with the sore throat taking up too much space. On those rare days when there is a multi-car pileup on the highway, the guy with the sore throat is SOL. He's also probably SOL on Saturday night when all of the victims of barfights, alcohol poisoning, and shootings get brought in.

As for the number of providers one sees, I'm not sure that seeing two people is better than seeing four people for half the time each. I've been to the ER twice in the last four years for moderately serious issues: broken arm and sprained ankle. Both times I felt like I was on an assembly line, and things moved really quickly. For my arm, I was half way out the door with a wrap, a sling, some Vicodin, and a referral to see an orthopedist before I even found out the ulna was broken. I mean I thought it might be broken, but I wasn't sure. And the PA was like, oh, yeah, sorry I guess I forgot to tell you. It's right there on that computer printout I just handed you.

 

[RandFan]

My insurance is better than the two countries and we don't have a 100% government run system.

I apologize. I missed one of your fallacies.

Your logical fallacy is anecdotal

You used a personal experience or an isolated example instead of a sound argument or compelling evidence.

 

[Elf Grinder 3000]

[citations missing]

Argument by assertion is the logical fallacy where someone tries to argue a point by merely asserting that it is true, regardless of contradiction. While this may seem stupid, it's actually an easy trap to fall into and is quite common.

Its evidence

1. I have the freedom to purchase the insurance I want in the US, this is better than being forced to purchase a government plan.

2. I don't have to pay as much as people in CA and UK for other people's health insurance. My taxes are lower, this is also better.

3. I don't have to wait for 6 months to get an operation like I would in CA or UK. THerefore its better in the US.

Based on the evidence.

You don't have either evidence or proof