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Mortality and lack of health insurance

The 2012 election campaign is in full swing, and, for better or worse, health care is one of the major defining issues of the election. How can it not be, given the passage of the Patient Protection and Affordable Care Act (PPACA), also colloquially known as “Obamacare,” was one of the Obama administration’s major accomplishments and arguably the largest remaking of the American health care system since Medicare in 1965? It’s also been singularly unpopular thus far, contributing to the Republican takeover of the House of Representatives in the 2010 elections, as well as the erosion of Democratic control of the Senate. Given that this is a medical blog dedicated to discussing the scientific basis of medicine and not a political or health policy blog, I am not going to go into the reasons for a lot of this. What I am going discuss is a recent eruption of the central problem that led President Obama to make the PPACA one of the central policy initiatives, if not the central policy initiative, of his first term. That problem is the issue of people without health insurance, who number roughly 50 million, with a further estimate that 86.7 million people were uninsured at some point during the two year period from 2007 to 2008, representing about 29% of the total U.S. population under 65.

The question that bubbled to the surface last week in the form of a statement by Republican challenger Mitt Romney, and a tear-inducing op-ed piece published yesterday in the New York Times by Nicholas Kristof entitled A Possibly Fatal Mistake, is what the health impact of not having insurance is for those millions of people. This is a question that can be addressed scientifically and is, despite its politically charged nature, correctly within the purview of science-based medicine. What to do about it, in contrast, is a matter for politics and public policy. So first let’s examine the question.

A clueless statement and an op-ed that puts a face on the problem

Before we discuss the evidence regarding the health effects of being uninsured, let’s look Romney’s statement and why it resulted in so much blowback. Romney made his assertion during an interview with the editors of The Columbus Dispatch:

“We don’t have a setting across this country where if you don’t have insurance, we just say to you, ‘Tough luck, you’re going to die when you have your heart attack,’” he said as he offered more hints as to what he would put in place of “Obamacare,” which he has pledged to repeal.

“No, you go to the hospital, you get treated, you get care, and it’s paid for, either by charity, the government or by the hospital. We don’t have people that become ill, who die in their apartment because they don’t have insurance.”

He pointed out that federal law requires hospitals to treat those without health insurance — although hospital officials frequently say that drives up health-care costs.

Romney was referring to the Emergency Medical Treatment and Active Labor Act (EMTALA), a federal law passed in 1986 under the Reagan administration that requires hospitals to provide care to anyone needing emergency treatment regardless of citizenship, legal status, or ability to pay. Hospitals may only transfer or discharge patients requiring emergency care after stabilization, when their condition requires transfer to a tertiary care hospital, or against medical advice. It is highly unlikely that any person who has ever worked in an emergency room or cared for the uninsured would make such a statement. Emergency rooms are not equipped to treat complex conditions; all they can do is to treat the acute problem. In addition, tertiary care hospitals receive a lot of patients admitted under EMTALA, who are transferred at the drop of a hat. Well do I remember my days as a surgery resident rotating in the county hospital, when we used to joke about the Friday afternoon phone calls to transfer patients who had failed a wallet biopsy. We even knew what time was the “witching hour,” when we were most likely to get such calls. Of course, the problem with EMTALA was (and is) that there were no provisions for reimbursement for uncompensated care. Basically, hospitals were forced by law to eat the costs of caring for the uninsured.

Since completing fellowship, I have held faculty positions in two of the 41 NCI-designated comprehensive cancer centers in the U.S., both of which take care of a lot of uninsured patients. In New Jersey, I used to take care of quite a few illegal immigrants. Here in Detroit, it’s the uninsured and the poor, so much so that a large fraction of my practice is made up of the uninsured and Medicaid patients. I’ve seen more women than I can remember who waited far longer than they should have to see a doctor for their breast cancer because they couldn’t afford it. Over the years, all too often my patients have been symptomatic for quite some time, and when they finally do present their tumors are larger, more difficult to treat, and more likely to kill them. They represent the female equivalent of Kristof’s uninsured friend Scott, who is the human face of the issue discussed in his NYT op-ed and tells his story:

In 2011 I began having greater difficulty peeing. I didn’t go see the doctor because that would have been several hundred dollars out of pocket — just enough disincentive to get me to make a bad decision.

Early this year, I began seeing blood in my urine, and then I got scared. I Googled “blood in urine” and turned up several possible explanations. I remember sitting at my computer and thinking, “Well, I can afford the cost of an infection, but cancer would probably bust my bank and take everything in my I.R.A. So I’m just going to bet on this being an infection.”

I was extremely busy at work since it was peak tax season, so I figured I’d go after April 15. Then I developed a 102-degree fever and went to one of those urgent care clinics in a strip mall. (I didn’t have a regular physician and hadn’t been getting annual physicals.)

The doctor there gave me a diagnosis of prostate infection and prescribed antibiotics. That seemed to help, but by April 15 it seemed to be getting worse again. On May 3 I saw a urologist, and he drew blood for tests, but the results weren’t back yet that weekend when my health degenerated rapidly.

A friend took me to the Swedish Medical Center Emergency Room near my home. Doctors ran blood labs immediately. A normal P.S.A. test for prostate cancer is below 4, and mine was 1,100. They also did a CT scan, which turned up possible signs of cancerous bone lesions. Prostate cancer likes to spread to bones.

I also had a blood disorder called disseminated intravascular coagulation, which is sometimes brought on by prostate cancer. It basically causes you to destroy your own blood cells, and it’s abbreviated as D.I.C. Medical students joke that it stands for “death is close.”

I realize that right now I’m referring to my anecdotal experience. However, one anecdote is that of a man who gambled and lost because health insurance was too expensive. The rest is my experience in a highly specialized field in a city with high unemployment and poverty. It is quite possible that such experience can be misleading, and certainly one of the key messages we promote on this blog is that anecdotal experience is inherently potentially misleading. (That’s why it’s the primary evidence used by promoters of unscientific or pseudoscientific medicine.) In a way, Kristof’s friend’s story would seem to confirm Romney’s statement, at least on the surface. Scott did, after all, end up getting excellent medical care for his stage IV prostate cancer, and, although he probably could have afforded health insurance if he had stretched a bit, did make a choice not to purchase insurance. But, then, as I said, anecdotes can be misleading.

The evidence

Before we get into the data itself, it is not much of a stretch to imagine that not having health insurance would result in worse health outcomes. What I am trying to say using SBM-speak is that the hypothesis that people without health insurance will be more likely to have health problems and die unnecessarily than people who have decent health insurance is a hypothesis with a fairly high degree of prior plausibility. After all, if you’re uninsured, you’re less likely to see a physician except when you get sick, less likely to be able to pay for your medications (particularly if they are expensive), and less likely to undergo routine preventative care. It’s thus plausible that being uninsured would be associated with an increased risk of death or poor health outcomes. None of this means we don’t have to do the research and look at the evidence; all it does is to suggest hypotheses to test and emphasize that these hypotheses have a reasonable chance of being consistent with the data.

Even twenty years ago, this question was of intense interest. One of the seminal studies examining the relationship between health insurance and health outcomes was published in JAMA by Franks et al., who prospectively followed 4,694 adults older than 25 years who reported they were uninsured or privately insured in the first National Health and Nutrition Examination Survey (NHANES I), a representative cohort of the US population from initial interview in 1971 through 1975 until 1987. They found a 25% higher risk of mortality in the uninsured after adjusting for age, smoking, alcohol consumption, obesity, education and income. This effect was evident in all sociodemographic health insurance and mortality groups examined.

In 2002, the Institute of Medicine estimated that over 18,000 Americans between the ages of 25-64 die annually because of lack of health insurance, a number comparable to the number who died of diabetes, stroke, or homicide in 2001. Among the conclusions of this report:

  • Uninsured adults are less likely than adults with any kind of health coverage to receive preventive and screening services and to receive them on a timely basis. Health insurance that provides coverage of preventive and screening services is likely to result in greater and more appropriate use of these services.
  • Uninsured cancer patients generally are in poorer health and are more likely to die prematurely than persons with insurance, largely because of delayed diagnosis. This finding is supported by population-based studies of persons with breast, cervical, colorectal, and prostate cancer and melanoma.
  • Uninsured adults with diabetes are less likely to receive recommended services. Lacking health insurance for longer periods increases the risk of inadequate care for this condition and can lead to uncontrolled blood sugar levels, which, over time, put diabetics at risk for additional chronic disease and disability.
  • Uninsured adults with hypertension or high blood cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnosed, and experience worse health outcomes.
  • Uninsured patients with end-stage renal disease begin dialysis with more severe disease than do those who had insurance before beginning dialysis.
  • Uninsured adults with HIV infection are less likely to receive highly effective medications that have been shown to improve survival and die sooner than those with coverage.
  • Uninsured patients who are hospitalized for a range of conditions are more likely to die in the hospital, to receive fewer services when admitted, and to experience substandard care and resultant injury than are insured patients.
  • Uninsured persons with trauma are less likely to be admitted to the hospital, more likely to receive fewer services when admitted, and are more likely to die than are insured trauma victims.
  • Uninsured patients with acute cardiovascular disease are less likely to be admitted to a hospital that performs angiography or revascularization procedures, are less likely to receive these diagnostic and treatment procedures, and are more likely to die in the short term.

In 2008, the Urban Institute updated the IOM numbers by applying the methodology used by the IOM to more recent Census Bureau estimates of the uninsured, and estimated that in 2006 there were 22,000 excess deaths that could be attributed to lack of health insurance. The Urban Institute also suggested that the IOM analysis might have underestimated the number of deaths resulting from being uninsured. Its rationale was as follows:

The underlying longitudinal studies on which IOM relied did not specify the impact of insurance coverage on mortality by 10-year age groups. Rather, they documented the relationship between insurance and mortality across the sum total of all surveyed age groups. The IOM’s methodology implicitly assumed that insurance reduces mortality by the identical percentage for each 10-year age band, which the underlying research did not show. More grounded in the research would be an application of differential mortality estimates to all adults age 25–64, as was done for those longitudinal studies, rather than separately to each age group within this range. For 2000–06, this alternative approach raises the estimated number of excess deaths by an average of 20.5 percent a year.

In 2009, in a study from Harvard Medical School and the Cambridge Health Alliance, Wilper et al. published updated estimate of excess mortality associated with lack of insurance in the American Journal of Public Health. This analysis used methodology similar to that of Franks et al. applied to the third National Health and Nutrition Examination Survey (NHANES III), specifically 9,004 patients between ages 17 and 64 with complete baseline data for interview and physical examination. They found that the hazard ratio for death for the uninsured was 1.40 (confidence interval 1.06 to 1.84) compared to those with private health insurance. This particular study is the source of a rather famous number: 45,000 patients die due to lack of insurance each year. This particular study is at the high end of the estimates of excess deaths associated with lack of health insurance, which is why it not surprisingly often comes in for the most criticism, particularly given that it was supported by a partisan group, Physicians for a National Health Program. That’s why I tend to view this study as an outlier, but even outliers can sometimes tell us something. Whether the Harvard study was an outlier or not, that same year, the IOM updated its 2002 report. One of its conclusions was:

In contrast, the body of evidence on the effects of uninsurance on adults’ health has strengthened considerably since 2002. Numerous studies have addressed some of the methodological shortcomings of past research. As discussed further below, 17 observational and 13 quasi-experimental rigorous analyses have reported significant findings related to health insurance and adults’ health (Table 3-3) (McWilliams, 2008). The quality and consistency of the recent research findings is striking. As would be expected, health insurance is clearly most beneficial for adults who need medical attention, particularly for adults with common chronic conditions or acute conditions for which effective treatments are available. Furthermore, national studies assessing the effects of near-universal Medicare coverage after age 65 suggest that uninsured near-elderly adults who are acutely or chronically ill substantially benefit from gaining health insurance coverage.

There are 13 recent studies on the health effects of health insurance coverage for children, including 5 studies that used quasi-experimental methods (Aizer, 2007; Bermudez and Baker, 2005; Cousineau et al., 2008; Currie et al., 2008; Howell et al., 2008a). These studies suggest that health insurance is beneficial for children in several ways, resulting in more timely diagnosis of serious health conditions, fewer avoidable hospitalizations, better asthma outcomes, and fewer missed school days (Aizer, 2007; Bermudez and Baker, 2005; Cousineau et al., 2008; Currie et al., 2008; Damiano et al., 2003; Fox et al., 2003; Froehlich et al., 2007; Howell and Trenholm, 2007; Howell et al., 2008a,b; Maniatis et al., 2005; Szilagyi et al., 2004, 2006).

But that’s not all. Since it’s my specialty, I’ll start by looking at some of the evidence regarding the outcomes of breast cancer patients who are uninsured compared to those who have health insurance. For example, a study published this year examining the outcomes of 2,157 hospital admissions for women with spinal metastases from breast cancer. Analyses were adjusted for differences in patient age, gender, primary tumor histology, socioeconomic status, hospital bed size, and hospital teaching status. The investigators found that women operated on for spinal metastases from breast cancer tended to do worse and have a higher risk of death if they were uninsured than if they had private insurance. The authors concluded that the poorer outcomes observed among the uninsured were primarily due to the uninsured patients being significantly more likely to have a nonelective hospital admission and present with myelopathy. Although this study had some limitations, namely that it couldn’t account for lesser quality private insurance (for instance, plans with high copays and/or poorer coverage) and variations in Medicaid eligibility by state. Also, the database used only includes in-hospital data and therefore couldn’t examine long-term outcomes.

Since surgery is also my specialty, I thought I’d also point out that there is considerable evidence that being uninsured or underinsured is associated with worse outcomes after surgery. For example, a recent study published in the Annals of Surgery from LePar et al. at the University of Virginia examined outcomes from 893,658 major surgical operations and found that mortality was considerably worse in Medicare, Medicaid, and the uninsured than they were in patients with private insurance. Adjusting for age, gender, income, geographic region, operation, and 30 comorbid conditions eliminated the outcome disparity for Medicare patients, but Medicaid and uninsured payer status still independently conferred the highest adjusted risks of mortality.

In fact, the list of conditions and procedures for which being uninsured is associated with poorer outcomes and higher mortality goes on and on: cardiac valve surgery, surgery for colorectal cancer, breast cancer treatment and outcomes, trauma mortality (including among children), and abdominal aortic aneurysms, to name a few. Moreover, analysis of survey data from patients who were uninsured but then became old enough to be enrolled in Medicare suggests that “acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.” In summary, there is a large and robust body of evidence suggesting that people do, in fact, die because of lack of health insurance.

Not so fast…

Of course, for a question as complex and prone to confounders as whether lack of health insurance is associated with poorer outcomes, including mortality, there are always those who are not convinced by existing observational data. Certainly, lack of health insurance can be a marker, not a cause, for poor health and subsequent poor outcomes, and teasing out the various confounding factors is not a trivial task. Perhaps the most widely cited study questioning this relationship was featured prominently in an oft-cited article in the lay press by Megan McArdle in The Atlantic entitled Myth diagnosis. It’s a study by Richard Kronick published in Health Services Research in 2009 that questions the IOM report from 2002:

These results demonstrate that if two people are otherwise similar at baseline on characteristics controlled for in the model presented in Table 3, but one is insured and the other uninsured, their likelihood of survival over a 2–16-year follow-up period is nearly identical. Further, I show that survival probabilities for the insured and uninsured are similar even among disadvantaged subsets of the population; that there are no differences for long-term uninsured compared with short-term uninsured; that the results are no different when the length of the follow-up period is shortened; and that there are no differences when causes of death are restricted to those causes thought to be amenable to the quality of health care.

Basically, Kronick found no relationships between insurance status and mortality. While this study was large (600,000 subjects) and controlled, it is also an outlier, just as much as the Harvard study is an outlier. Again, that doesn’t mean it was a bad study; outliers can often tell us something, and what Kronick seems to be telling us is that the magnitude of the effect on mortality associated with lack of insurance might not be as large as previously thought. Might. It is, remember, just one study, as large as it might be. McArdle might refer to Kronick’s study as “what may be the largest and most comprehensive analysis yet done of the effect of insurance on mortality,” which sounds incredibly impressive, but the simple fact is that no single study can provide the answer, particularly to question as complex as whether having no health insurance status is associated with increased mortality and poor outcomes. Kronick’s study also has a significant problem that was pointed out in this post by Ezra Klein, namely that people in poor health are more likely to seek health insurance, which would tend to obscure any positive relationship between health insurance and health status.

McArdle also makes another argument against such a relationship:

This result is not, perhaps, as shocking as it seems. Health care heals, but it also kills. Someone who lacked insurance over the past few decades might have missed taking their Lipitor, but also their Vioxx or Fen-Phen. According to one estimate, 80,000 people a year are killed just by “nosocomial infections”—infections that arise as a result of medical treatment. The only truly experimental study on health insurance, a randomized study of almost 4,000 subjects done by Rand and concluded in 1982, found that increasing the generosity of people’s health insurance caused them to use more health care, but made almost no difference in their health status.

I hate to say it, but McArdle is drifting rather close to Gary Null territory here, in which she seems to be arguing that whatever benefit having decent health insurance might convey, it’s about the same as the harm that “conventional” medicine does. In other words, her argument seems to be that providing people more access to health care will cause as much harm as benefit, making it a wash whether one is insured or not. Of course, that argument cuts both ways, if you accept estimates of over 100,000 “deaths by medicine” per year in that it would imply that having health insurance confers a benefit in terms of mortality reduction that is much larger than the numbers we have would suggest, making the imperative to improve health care coverage and decrease medical errors a much more reasonable conclusion from such an argument than concluding that striving for universal coverage would not reduce mortality. Be that as it may, more problematic is that like many proponents of dubious medicine and science, McArdle cherry picked the literature, choosing one study that is an outlier and a thirty year old study from the RAND Corporation that showed what she wanted and in essence dismissed the rest. In refuting McArdle, by J. Michael McWilliams, MD, PhD, Assistant Professor of Health Care Policy and Medicine at Harvard Medical School and an associate physician in the Division of General Medicine at Brigham and Women’s Hospital points this out and speculates:

How many lives would universal coverage save each year? A rigorous body of research tells us the answer is many, probably thousands if not tens of thousands. Short of the perfect study, however, we will never know the exact number.

Indeed.

Policy implications

The very term “science-based medicine” was chosen intentionally. Medicine itself is not a science. It can’t be. There are too many other factors that influence treatments, including patient preference, resource allocation, and level of skill of individual practitioners, to name just a few. Our central thesis is that medicine should be based on science and that the best health care is based on science. My purpose in writing this post was not to advocate for any specific solution to the problem of the uninsured, although people who know me know my politics and my position on the matter. Rather, it is to lay out the science studying the question of the relationship between health insurance status and health outcomes. While we do frequently say that correlation does not necessarily equal causation, in some cases the correlation is so tight that it strongly suggests causation. This is one such case. Given that there is no ethical way ever to do a randomized clinical trial in which people are randomly assigned to be insured or uninsured, much as is the case for examining health outcomes between vaccinated and unvaccinated children, we are forced to rely on observational and quasi-experimental data. Those data support the hypothesis that providing health insurance to as many people as possible is associated with better health outcomes and that lack of insurance is associated with poorer health outcomes. That is the science. When someone like Mitt Romney claims that no one ever dies from lack of insurance in the U.S., he is demonstrably wrong.

What we as a society decide do with the results of the science examining this question is less a matter of science than it is of politics and policy.

Posted in: Politics and Regulation, Public Health

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300 thoughts on “Mortality and lack of health insurance

  1. Wow – an entire blog post to support a VERY narrow point of view, that has a ridiculous number of obvious “co-explanations” (for lack of a better word.) David, I hoped that by no longer following you on Twitter I could avoid your douchey political posts, it looks like I was wrong. SBM should be ashamed to publish such ridiculous crap. Where is your post about the negative aspects of Obamacare?

  2. Janet says:

    SH–I just lost all respect for you even though I have defended your “colorful” language in the past. Dr. G went out of his way to make this post apolitical and you’ve responded with no facts and a personal attack that is entirely unwarranted.

    The post is not about Obamacare–it is about LACK OF HEALTH INSURANCE AND MORTALITY.

    Here’s an anecdote you can chew up and digest:

    My granddaughter, aged 23, works full time (no health insurance offered), goes to college part time (pays her own tuition), and has had a nasty case of psoriasis since age 9. Now it’s psoriatic arthritis and she can barely walk. Thanks to OBAMACARE, she can be on her parents’ insurance. Please inform me of the negative aspect of that.

  3. mousethatroared says:

    Thank-you Dr. Gorski. Excellent post. I even liked it on FB…in spite of the lack of kitten photos. ;)

  4. weing says:

    I think Obama is trying to defend the status quo. Maybe Romney could do better. There are still millions that are uninsured under Obamacare. Will Romney give coverage to those that fall between the cracks? Will Obama?

  5. Ceratius says:

    As someone from the UK I find the state of healthcare in the US as something of a mystery. The BBC recently did a couple of documentaries called ‘Health before the NHS’ which showed that prior to the formation of the NHS the situation here was similar to that in the US, with rich people able to afford healthcare and poor unable, and suffering poorer health and higher mortality as a result. It seems incredible to me that something that could be so obvious to British politicians almost a hundred years ago still eludes those in the US. Universal healthcare was not set up because we suddenly had a load of ‘bleeding-heart liberals’ in power, it was because politicians realised that an unhealthy workforce was bad for the economy.

    My neighbour has recently been treated for breast cancer, something that was painful and stressful for her and her family. I can’t imagine what it must be like for those in the US who have to go through all that with the added stress of wondering how they will afford it. A series like ‘Breaking Bad’ could never “(hopefully) translate to the UK because the fear of paying for healthcare doesn’t exist.

    Please can someone explain why there is such a fear of universal healthcare in the US? What is wrong with paying, in taxes, into a collective pot and then having the security to know that if you break your leg, or get cancer, etc, you can get treated without the fear of loosing all your savings? What am I missing?

  6. @Janet,

    How about the hundreds of thousands of Americans that can no longer afford health insurance thanks to Obamacare changes like forcing insurance companies to allow “kids” on their policy longer (thus increasing the cost of insurance from private companies for everyone?)

    Here’s an anecdote. My parents-in-law can’t afford healh insurance but don’t qualify for Medicaid. The increased cost of care secondary to Obamacare has made it that much more impossible for them to afford insurance. Where’s the positive in that?

    Here’s another. Mother calls 911 to have ambulance being her and 1 month old to ER bc baby fell one inch onto carpet without injury, but mother was “worried.” You paid for that ambulance ride and the ER visit. Mother didn’t pay a dime – either out of pocket or in taxes (she never had a job.) Repeat story but substitute nose bleed for non-traumatic fall.

  7. mousethatroared says:

    SH – So nothing substantive to say on the actual topic of the article, “Mortality and lack of health insurance”?

  8. Scott says:

    @ Ceratius:

    A large part of the resistance, I think, is because people are used to health insurance being associated with their job rather than thinking of it as a more general concept. The historical accident of employers trying to get around wage controls during WWII has become The Way Things Are Done.

    Another large part is that Americans are on average much less welcoming of centralized government-provided services than Europeans. It’s the whole individualism/self-reliance thing.

  9. In order for us to live in a civilized society, sacrifices must be made. We all get car insurance, we all wear our seat belts, look both ways before crossing the street and obey traffic laws. Our taxes are used for security and infrastructure, education….. and they should be used for health too. It’s not about everyone being socially equal. It’s about equal opportunity.

    Regarding your last comment #skeptichealth… they might have called an ambulance, but at least they should be paying insurance. Not everyone reacts equally to falls, big or small. Some people fall from 10 feet and say, “i’m fine”, some fall from 2 feet and want to see a Dr.

    But if we all have insurance, the cost is reduced for all. Regarding those who “can’t afford”… then they should sacrifice having an iPhone 4, HDtv or other luxuries and concentrate first on necessities.

    Sure, there are people that are going to have problems anyway, but it’s not going to be worse than now, where if you have a heart attack, you might for sure end up with over 400k in debt. How are they going to pay for that? People critizice social security until they start cashing it. Then, suddenly, they can’t live without it because they realize a lot of their savings were blown due to medical bills.

    The second problem with healthcare, other than insurance, is the medical/dental students debt. And the Obama administration is rightfully trying to deal with it.

  10. DugganSC says:

    @Ceratius:
    Interesting question. I think it is, in many ways, a matter of lack of trust. First, there’s lack of trust in our fellow man. As SkepticalHealth illustrated above, there are many people who fear that universal coverage will lead to people bringing in frivolous cases which have to be absorbed in the costs of everyone else (presumably the “hard-working tax-payers” who are complaining). Personally, I think it’s more likely that we’re going to get increased costs in terms of unnecessary and or false-alarm procedures and diagnostics. Take the arguments made on this blog about prostate and breast cancer screening, routine physicals, and pelvic exams. The figures show that routine screening such as this are not only driving up costs, but also aren’t showing any success in terms of increasing survival rates, and might even be hurting mortality due to false positives resulting in unneeded surgery (and, as I understand it, making these routine diagnostics free for everyone is one of the central tenets of the legislation). The lack of trust in government is in implementation. On one side, we fear the costs being driven up by everyone getting the top medical care and passing the costs on. On the other side, we fear “government death panels” deciding that at age 50, the cold equations mean that we can’t get a heart transplant, those being reserved for people under 30 who are more likely to survive the operation. Looking at other countries who have universal health care, we also hear stories of people waiting months or years on waiting lists for routine procedures or having to wait for hours to get into an emergency ward. Notwithstanding the plural of anecdote not being data, it’s enough to frighten people used to immediate access to doctors. And, frankly, the government track record in providing good service for reasonable cost is pretty dismal, so I don’t know that I hold it against people to fear that. *shrug* I’m sure there’s other factors, but those are the two I see people express the most.

    As for my own personal anecdotage, my mother-in-law is missing a large chunk of muscle in her shoulder due to skin cancer that migrated while she was uninsured. Her fear was was that, even if she got emergency medical care, because she had some assets, she believed that the doctors would seize those small assets vice the classical case cited of the uninsured being people who had no money to take. I don’t know if her fears were unfounded. My impression did sync with hers that if you turn up in emergency medical care, they do immediately tend to you, but there’s nothing preventing them from then proceeding to harass you with the follow-up bills much like any bill collector. So, she gambled, and lost her pound of flesh rather literally.

    Frankly, I don’t believe it’s going to be possible to implement universal health care without cutting some corners. As medicine has advanced, it’s become progressively more expensive (the Monty Python sketch on “the miracle of birth” involving the multi-million dollar machine that “goes ping” and teams of doctors has become the truth of the matter), and we literally cannot afford to give everyone the best care. I think that eventually, things will stabilize where everyone gets some modicum of care and upper levels will become the province of the rich, much like how richer people in countries with universal health care fly to the United States for procedures not covered by the universal care. And eventually, one day, we’ll make the breakthroughs that will make the upper levels more affordable and it will be something better that’s too expensive to give to everyone. I think, ultimately, that’s the best case scenario.

  11. DugganSC says:

    On a side note, outside of routine physicals and such, is there anyone who’ll actually be getting free health care? My understanding was that the legislation provides subsidies for the annual costs of subscribing, but deductibles, percentages, and “out of pocket” costs are barely touched. So the person falling and getting a nosebleed will still be paying their deductible and some percentage of costs up to a maximum, so there’s still no free ride. My experience is that you get the “free ride” people in workplaces and college campuses with an infirmary on-site.

  12. ConspicuousCarl says:

    Romney probably runs around offering overstated claims like this because of the common hillaryesque belief that mothers in labor are being locked out of hospitals and newborn babies are dropping in the street.

    We don’t know the actual context because the Dispatch article is just those editors noting the parts of the interview they want to bring up. There is a big difference between saying “this is a good system” vs. “this is the actual situation in contrast to a common claim”, and we don’t know which it was.

  13. lilady says:

    Here’s what “Obamacare” does for disabled kids and adults, individuals with pre-existing conditions and adult children who will have medical insurance coverage under their parents’ health care plan…up to the age of 26:

    http://specialneedsplanning.net/2012/07/what-obamacare-really-does-for-individuals-with-disabilities/

    You don’t have to be a political animal to be following the news on Obamacare. And for those with disabilities, the Supreme
    Court’s recent ruling to uphold the bill could certainly impact your life.

    For the most part, the bill accomplishes the needs of people who live with disabilities – and a number of organizations such as the National Council on Disability, Easter Seals, the National Council on Independent Living and the United Spinal Association are on board and in favor.

    One huge element of President Obama’s Affordable Care Act is that people with pre-existing conditions can no longer be denied insurance coverage – an issue that affects more than 17 million children in the U.S. alone. In the past, the risk of this happening was very real – and it could affect the medical care and even the happiness of an individual or entire family. Take for instance, someone who worked long hours at a job they hated. If that person – or their spouse or child – had been treated for certain conditions within a given period of time, that health concern would be considered a “pre-existing
    condition.” So if the employee wanted to find a new job, they might get the job offer – but not be eligible to get health
    insurance. So they stay where they are because they can’t afford not to. Under the new law, it would be illegal to deny that coverage.

    Obamacare also prohibits policies that put a cap on coverage limits. In previous years, some insurance policies just plain stopped when certain coverage limits were reached. This amount may be determined as an annual amount or over a lifetime,
    but when a patient has a disability and needs ongoing treatment, costs can add up in a hurry. So previously, after that limit was reached, the insured was on their own. And the old pre-existing condition caveat made it hard for the person to get a different insurance, many times leaving them with no insurance at all.

    And lastly, Obamacare increases the age of young adults on the parent’s policy to 26. This is potentially a huge cost savings for young adults with or without a disability. In addition, depending on the health insurance carrier, an individual with
    special needs may be able to stay on that coverage for life. This last statement is not new information, but important to recognize and check out prior to the age of 26 for an individual with disabilities.

    Now, insurance plans have to provide decent coverage, too. Sounds simplistic, but it’s important. You want insurance that provides a certain level of care – annual physicals, mental health coverage and rehab services. Yearly check-ups help your doctor to find and keep on top of any health problems. Rehabilitation after an illness or injury gets people moving up and out and back to work sooner. And while people often think they don’t need mental health coverage, all it takes is a serious illness or loss (of anything from a loved one to a job) to turn your world upside down. You might be glad you have it.

    The nation’s healthcare debate continues to rage on – with Democrats and Republicans each adding their own spin. And each of them has some very valid points. But one thing is clear – the ruling as upheld by the U.S. Supreme Court will certainly have a positive effect on the lives of many people currently living with a disability.

  14. ConspicuousCarl says:

    And while Romney was incorrect to say that it never happens, note that 20,000 is about 1% of annual deaths from heart attacks, strokes, cancer, infections, etc, while 17% of those who die have no insurance. Death due to a lack of insurance, though it sucks, is actually not generally happening even to uninsured people.

    The real problem is that there are really nasty things short of death (such as untreated chronic conditions) which are not represented by those numbers (as Gorski mentioned already).

  15. rork says:

    I’m worried about the details of putting co-morbities in the models when those themselves may be effects of lack of insurance, and causes for the worse outcomes. For example say I’m looking at heart-attacks. Those uninsured folks are more likely to not be having their lipids controlled or be lectured about their diets or have gotten angioplasty. That could be the problem rather than something to control for. It’s a tough problem.

  16. evilrobotxoxo says:

    @SH: I think you should have a thicker skin. Dr. Gorski is clearly making an effort here to discuss the facts without being overly political, and there is nothing “liberal” or “conservative” about acknowledging that the US healthcare system has a problem with respect to access to care.

  17. rork says:

    SkepticalHealth: If single-payer is the option, completely decoupled from your employer (why are they in this business), then I’m not so fond of the current system by comparison either.
    We do have to decide who to tax how much to pay for it. Good news: I know how.

  18. nwtk2007 says:

    Interestingly, there are a few “studies” or surveys/polls, in which when asked about the specifics of Obamacare separately, they are generally liked and applauded by both liberal and conservative alike; both from a common sense and economic point of view. But when it is referred to in its entirety, it is quite disliked. Like any good chiro, I haven’t read the entire article and have only scanned it. So if this point was made then I apologize.

  19. Janet says:

    @SH

    “How about the hundreds of thousands of Americans that can no longer afford health insurance thanks to Obamacare changes like forcing insurance companies to allow “kids” on their policy longer (thus increasing the cost of insurance from private companies for everyone?)”

    Got any evidence for that?

    Just what do you recommend for my granddaughter and your in-laws, by the way? In 2014, your in-laws will be able to get into the new exchanges. Sounds like a reasonable solution to me given that we can’t get people like you to support real reform.

    I have a feeling the baby in question fell more than one inch, but in any case, it is better to make sure, is it not? If the ambulance had refused and the baby had a brain bleed, the lawsuits would cost more than the ambulance ride. And what has the mothers’ status got to do with a baby who didn’t ask to be born needing care?

  20. Quill says:

    I appreciate this post and find the conclusions valid. Examining the evidence by scientific means didn’t used to be called political or narrow, but we now live in interesting times.

    As for SkepticalHealth’s demi-screeds on politics, I find it comforting, as a former manipulator of public opinion, to see the repetition of carefully crafted talking points rather than any useful remarks or original thoughts. Should I want to return to my old profession, I know there will still be jobs waiting.

    Twain had it right in his Autobiography: “In religion and politics people’s beliefs and convictions are in almost every case gotten at second-hand, and without examination, from authorities who have not themselves examined the questions at issue but have taken them at second-hand from other non-examiners, whose opinions about them were not worth a brass farthing.”

  21. David Gorski says:

    Dr. Gorski is clearly making an effort here to discuss the facts without being overly political, and there is nothing “liberal” or “conservative” about acknowledging that the US healthcare system has a problem with respect to access to care.

    SH clearly is either trolling and/or has highly partisan leanings. I don’t know what he would have me do. It’s not as though I advocated a single payer system or a government takeover of the health care system (which, whatever its benefits versus costs, “Obamacare” does not do). Also, I did point out that one study widely cited by supporters of either a national health care system that claims that 45,000 people a year die due to lack of health insurance is an outlier that was funded by a partisan group that does advocate a single payer health plan.

    Also, did I not point out that what science shows (that lack of health insurance is associated with higher mortality and many other health problems) does not tell us what we should do about the problem. It only tells us that the problem exists and that to lessen it we need to find a way to allow as many people as possible to have health insurance. As I said, how we accomplish that (or if we even want to accomplish that) is up to the political process. Perhaps SH would like to deny it, but he certainly hasn’t presented any concrete evidence of sufficient quantity and quality to call into doubt the current scientific consensus on this issue.

    Oh, and, regardless of one’s politics, it’s hard not to conclude that what Romney said about the issue was really ignorant.

  22. rmgw says:

    Ceratius: I’m with you – it’s simply a mystery to me (born and brought up in the UK, resident in Spain for 30 years) how anyone can regard socialised medicine as anything but the greatest boon ever brought to illness-prone humankind! Waiting lists – ok, not but what you can supplement your National Health Care for a rate of private insurance which would make US eyes water with its cheapness if you want something done in a hurry. Unfortunately creeping neoliberalism is infecting these superb Health care systems, inflicting upon them the effects of a recession coupled with capitalist values. This is to be lamented – if these systems are dismantled, it will be extremely difficult to bring them back up to scratch.

    The problem with Obamacare seems that it has come too late in the day: even still, surely a step in the right direction!

  23. Lytrigian says:

    @Those from the UK: The entire American system is founded on the premise that a powerful central government is not to be trusted, and we erected one only with the greatest of trepidations. From the beginning, the government has had constitutional fences set about it, and there are some thing still it may not do. (This is nonsensical to a Brit, where any act of Parliament is by definition valid under their constitution.) While most Americans have become more or less comfortable with a central government far more powerful than that envisioned by the Framers, its intrusion into new areas of American life is still regarded with an enormous amount of mistrust by a very large segment of the population.

    If this goes the way of very large programs in the past, it is first met with denial, then resistance, then compromise, and finally acceptance.

    If I may step into political territory for just a moment, I don’t believe Romney is in earnest when he talks about repealing Obamacare. We might recall that his institution of a similar system for the state of Massachusetts was an issue during the primaries: he must know that such a system in fact results in better care and at more affordable cost all around. I think that if he wins, he’ll make a show of an attempt to repeal it, which he’ll allow to devolve into a series of tweaks and improvements, followed by an announcement that he did all the Democrats of Congress would allow, and that it’s best now to just drop the matter and move on in the interests of certainty about the future of healthcare.-

  24. I feel like I’m having a conversation with a bunch of naive morons.

  25. I mean seriously, of course some of the ideas in Obamacare sound good, but all they do is increase the operational cost of health insurance companies, which of course gets passed on to the customer (look at the average health insurance premiums over last 5 years), which makes it more difficult to afford, which means fewer people pay for healthcare. In fact, I’d argue that people who have never worked a day in their life have better access to healthcare than many families that have two jobs but don’t qualify for Medicaid/Medicare. I know that the example I gave of an idiotic non-working mother using an ambulance to take her baby to the ER for no reason is a huge waste of tax payer money that she will never have to pay a dime for (and she’s never worked a day in her life or paid a dime in income tax), and that my father in law drove himself to a charity hospital with his thumb hanging off after he severed it with a tablesaw because he could never afford the ambulance ride because he doesn’t qualify for Medicaid.

    Obviously there is not a single simple solution. Not even close. I appreciate whomever foreigner wrote in this thread or another about the vast delays in their healthcare system. I don’t have the answer.

  26. Re: David’s post. You have to actually consider the population you are studying. Sure, I believe that the poorest population probably has the worst outcomes after a surgical procedure. How many of us have had patients that have repeat infections, repeat DKA, repeat MI, repeat practically everything simply because they refuse to be compliant with medication, or because they refuse to take a bath? The mere argument that the poor, or that those on Medicaid, do worse after a procedure or anything else because they have reduced access to healthcare is incredibly naive and short sighted. In fact it makes me question just how much “medicine” someone is practicing who would suggest such a ridiculous position. (David, do you actually do medicine? Or are you all research?) It’s the exact argument that David would argue against under any other circumstance. His argument carries the same weight as any positive homeopathic study – sure, it may correlate, but it doesn’t mean causation.

    Anyways. I’ll keep on treating diabetic people on Medicaid who are given free healthcare and free medications when they come into the hospital with DKA because they can’t be bothered to take their medications or to eat a reasonable diet. And I’ll keep treating the MI of the person who “doesn’t have access to healthcare” because he was too busy using cocaine to take his heart meds.

  27. Harriet Hall says:

    @SkepticalHealth,

    You have been warned, yet you still continue to use insulting language.

    David wrote as nonpolitical a post as is humanly possible and you chose to misinterpret it as political opinion, called it “ridiculous crap” without responding substantively to the content of the post, and now you are calling other commenters “naive morons.”

    After you were warned, you behaved well for a while, but now you are backsliding. You are very close to being banned.

  28. Quill says:

    Anyways. I’ll keep on treating diabetic people on Medicaid who are given free healthcare and free medications when they come into the hospital with DKA because they can’t be bothered to take their medications or to eat a reasonable diet. And I’ll keep treating the MI of the person who “doesn’t have access to healthcare” because he was too busy using cocaine to take his heart meds.

    So are you now just in it for the money? You express a moralizing financial sense and delight in pronouncing on the worth of others based on their relative bank balances. You’ve also made it clear you sure don’t mind treating “diabetic people” on generous executive health plans “who are given free healthcare and free medications” courtesy of other people’s sweat “when they come into the hospital with DKA because they can’t be bothered to take their medications or to eat a reasonable diet” free of veal, foie gras and martinis.

    And I suppose you’ll happily “keep treating the MI of the person who” has access to full private insurance” and takes advantage of that to keep “busy using cocaine” with a paid-for Viagra chaser and forgetting “to take his heart meds” while looking down at you as yet another annoying lackey that keeps him alive.

    You have expressed a clear preference for treating people who have money of their own, preferably of the kind that is imaginatively called “self-made,” so that you can feel much better lecturing about the Dickensian surplus population clogging up the system and bothering paying patients.

    How did a doctor become so embittered and find that one way to deal with it all is to show up on this blog and act like a jerk?

  29. mousethatroared says:

    SH – what are you on about? Welfare to Work laws we’ve had since 1996 limit welfare payments. Recipient are required to work after two years of receiving assistance and there is a five year lifetime maximum on benefits. How are ALL these people who have never worked a day in their life eating and finding shelter? Or are you talking about people who are on disability, since age 18?

    And how do you know when ambulances are paid for by an individual? How do you know the entire work history of an individual who visits the ER, much less that of a pediatric patient’s parent. These anecdotes sound more like a narrative formed by your ideology than real observations.

    We all know that some people recieve medical care that they subsequently don’t pay for AND the costs are then passed on to the public in various ways. Some of those people may currently be jobless, but we know some of those people are working poor and middle class without insurance as well as some with insurance. Common sense suggests that some of those people are going to be pretty despicable, just like some rich people are pretty despicable and some doctors are pretty despicable. I’m hardly going to make major healthcare decisions based on anecdotes of despicable doctors*, so why should I form my opinions of how the nation organizes healthcare on anecdotes of despicable patients…from a person on the Internet who seems increasingly unhinged.

  30. mousethatroared says:

    *disregard this asterisk.

  31. BillyJoe says:

    As I’ve said before, I cannot understand the attitude towards patients that SH has expressed on this blog.
    Why not see it as a challenge managing these difficult patients. Or just be happy that you’ve made some small difference in their lives. It must be just easy treating people who do exactly what the doctor commands.
    Maybe there is something wrong with the medical school selection process.

  32. mousethatroared says:

    Lytrigian – If Romney is not in earnest about repealing ObamaCare then why is he saying he will? I think it’s because that is the only way that he will garner the political support that he needs to win the election. He may have an incredibly difficult time maintaining that support if he doesn’t make progress on the Republican platform. I think people view presidents to much as individual decision makers, they are not. They are heavily influenced by their party, donors and in Republicans, FoxNews (who influences the base).

    I think, If Romney doesn’t repeal ObamaCare he is going to take a huge amount of negative pressure from the right and the tea party. There will be also the risk of lack of enthusiasm from the right in mid term elections (that Obama faced from the left during the last mid term). I personally doubt that he would be willing to take the kind of political hit it would require to maintain ObamaCare for something he doesn’t seem to support.

    Of course that just my IMO, I don’t have a crystal ball or anything. :)

  33. David Gorski says:

    You have to actually consider the population you are studying. Sure, I believe that the poorest population probably has the worst outcomes after a surgical procedure. How many of us have had patients that have repeat infections, repeat DKA, repeat MI, repeat practically everything simply because they refuse to be compliant with medication, or because they refuse to take a bath? The mere argument that the poor, or that those on Medicaid, do worse after a procedure or anything else because they have reduced access to healthcare is incredibly naive and short sighted. In fact it makes me question just how much “medicine” someone is practicing who would suggest such a ridiculous position. (David, do you actually do medicine? Or are you all research?) It’s the exact argument that David would argue against under any other circumstance. His argument carries the same weight as any positive homeopathic study – sure, it may correlate, but it doesn’t mean causation.

    Apparently SH thinks that the researchers who did these studies are so dumb that they didn’t try to control for confounders. Oh, wait. They all did. One can argue over whether they controlled for enough confounders or whether they used the appropriate methodology to control for the confounders that they did control for, but to imply that these studies don’t control for obvious confounders, such as socioeconomic status, is just wrong.

    As for whether I do medicine or not, I’m off to the OR in a few minutes. One wonders whether SH actually read this post, rather than, having seen the word “Obamacare” not surrounded by invective leaping to the conclusion without reading further that I’m a hopeless crunchy liberal who wants to Impose A Tyrannical Government Takeover of Health Care on the hapless Galtian heroes like himself. If he had bothered to read, he’d know that I’ve spent pretty much my entire career practicing in cancer centers that have a large percentage of Medicaid and uninsured patients. Currently I practice in the middle of Detroit. I’ll also add that before that a large portion of my training was spent at a county hospital. So, yes, I know about the problems of taking care of the uninsured and underinsured from personal experience. I’m familiar with patients who are poor and have substance abuse problems. I’ve taken care of them for years.

    Finally, if a correlation is strong enough, it can strongly imply causation. For example, do you accept that smoking causes lung cancer in humans? There’s never been a randomized trial to prove it; the data are all from epidemiological studies.

  34. mousethatroared says:

    BillyJoe – I just think that SH is a perfectly good doctor who made the easy mistake of setting up his practice in the 5th ring of Dante’s Inferno…the rent was cheap, you know, and it had a view of the water.

  35. David Gorski says:

    David wrote as nonpolitical a post as is humanly possible and you chose to misinterpret it as political opinion, called it “ridiculous crap” without responding substantively to the content of the post, and now you are calling other commenters “naive morons.”

    After you were warned, you behaved well for a while, but now you are backsliding. You are very close to being banned.

    I don’t really care that much about what SH says about me, particularly since his rants have been so completely data-free and anecdotal. I have a pretty thick skin in online discussions, having developed my skeptical chops on Usenet sparring with Holocaust deniers, quacks, and pseudoscientists who made SH’s current insults seem quaint and tame by comparison. He’d have to start saying I’m a pedophile even to approach that level of vileness. However, I do not like seeing him abuse and insult our other commenters. Our moderation policies are pretty loose here, but once again he’s gone beyond the pale.

    It is also depressing to see a physician who expresses such obvious contempt for his own patients. In any case, SH has been warned a second time. Three strikes, and he’s out.

  36. @MTR –

    And how do you know when ambulances are paid for by an individual? How do you know the entire work history of an individual who visits the ER, much less that of a pediatric patient’s parent. These anecdotes sound more like a narrative formed by your ideology than real observations.

    The only reason that you don’t know the answer to these questions is because you do not know the first thing about an ER visit. Half of these questions are answered by the patient as part of a reasonable H&P (“What do you do for a living?”) and the other is a well known fact. Seriously, do some reading before asking.

    @David -

    I’m a hopeless crunchy liberal who wants to Impose A Tyrannical Government Takeover of Health Care on the hapless Galtian heroes like yourself.

    At least you admit it. :)

    @David & Harriet:

    It is also depressing to see a physician who expresses such obvious contempt for his own patients. In any case, SH has been warned a second time. Three strikes, and he’s out.

    You have been warned, yet you still continue to use insulting language. After you were warned, you behaved well for a while, but now you are backsliding. You are very close to being banned.

    I don’t care that the only “power” you have is to ban me from a website. I’m sure if I can’t read the next article that David posts telling us that cancer is cured with magical radioactive spoons it will be a tragedy. Additionally, I’ll be more than happy to no longer read a website that unapologetically publishes political posts that are as flimsy and ridiculous as the one you (David) posted. Seriously – keep this garbage off your otherwise decent website.

  37. nwtk2007 says:

    Skepties just frustrated ya’ll.

    The world of the ghetto is a strange place and for those not in it, or working around it, a very foreign place indeed. Oh, everyone has their stories of the ridiculus things they’ve seen in related circumstance, but unless dealing with it, you really have no clue.

    That’s all ole Skeptical is saying, really. Do you really want him outa here, going to just some yippy, skippy, happy, pappy meaningless discussion?

    This is a big time topic; very, very relevant to today’s America. Its a growing problem, the things Skeptical has touched on. It is the very thing that Churches in their phoney, ivory towers of self righteousness run from when they build their cathedrals to themselves, proclaiming to help the poor and the indigent….yes, in the nicest neighborhoods. Such rot.

    Its a dirty place in the ghetto. Drugs, mental illness, just utter grossness abounds. What can required health insurance do for that? What will it do for that? Is it fair? Is it right for doctors to be frustrated by the naive notions of passersby? ( I wish I could spell)

    Don’t go Shane!

  38. mousethatroared says:

    The only reason that you don’t know the answer to these questions is because you do not know the first thing about an ER visit. Half of these questions are answered by the patient as part of a reasonable H&P (“What do you do for a living?”) and the other is a well known fact. Seriously, do some reading before asking.

    I have two children and I’ve never been to the ER? Incorrect. No I’ve been to the ER five times for myself or the kids and I’ve never filled out a full employment history. The typical question is “occupation” I sincerely doubt that many people are putting “I’ve never had a job in my life” in that slot.

    As to “well known facts”? Like the well known “fact” that vaccines are full of toxins and doctors are all just pharma shills? Your anecdote is directly contracted by the well known fact of the welfare to work laws. Which you probably don’t know about, because their presence contradicts the narrative you have built.

  39. weing says:

    SH is exhibiting symptoms of burnout. He is a hospitalist. That means he is a glorified resident. As residents, I am sure we can all remember the patients that he is talking about. What kept me sane, was knowing that in private practice I would not have to see those patients. He has no choice. That is his job. Good luck, buddy. From an asshole internist.

  40. Janet says:

    Dr. Gorski, I’m glad you mentioned SH’s contempt for his patients. I was going to, but thought it might be going too far. This incident makes me a little sad because I have corresponded with SH through his now defunct blog and found him to be very different that what has turned up here the last couple of months. I know approximately where he practices and it must be challenging, but sadly, he seems to be an ideologue first and a doctor second, yet accuses the rest of us of politicizing the discussion.

  41. If it’s any consolation :) I agree with Skeptical!

    My personal ‘healthcare’ is vitamins vs. vaccine, less carcinogens and more vitamins to curve cancer rates. I choose to have catastrophic because I don’t run to the doctor’s for every sniffle. But, now my premiums went up 5 times since Obamacare passed, and I’m being forced to pay for others and for something I don’t even want or believe in for myself. The whole idea is immoral bordering fascist state. It’s at a point perhaps to seriously consider leaving, sorry to say if it’s not repealed. I love America…or what it was meant to be. This socialist system is failing in Greece..failing in other countries, no matter how rose colored it’s presented no country is able to sustain it for long without forced intervention and control of how much who gets what. Those on the left, would YOU like GWB deciding what healthcare you get? No? Then you understand why those on the right wouldn’t want BO to decide what healthcare we get. And 2400 pages is deciding what healthcare we get. You’re giving your life over to whoever is in control. This isn’t freedom any longer, it’s tyranny if it’s allowed to continue.

  42. nwtk2007 says:

    Actually Janet, I think SH is implying ignorance of that which he speaks rather than politicization.

    It seems that both doctors and teachers, when frustrated aren’t allowed to vent a bit and let some of that frustration be heard by others who might have similar experiences and also bring to light very real problems in both healthcare and education. They get labeled as jaded, or in this case, accused of having contempt for patients.

    Education is truly messed up by such reactions to teachers concerns and I suspect that many problems in healthcare will be perpetuated by the very same response.

    The frustrations of doctors and teachers alike need to be heard and considered, not taken personally by those who are really not the target of the frustrations. Education in America, especially middle school and high school education is now defunked and pretty much beyond repair because of it. I suspect healthcare is well on its way to such defunkment.

  43. weing says:

    How about changing your name to Sisyphus, SH?

  44. mousethatroared says:

    Actually, I find it a huge consolation that RH agrees with SH.

    weing – Is this typical of the burn-out you see with hospitalists? My mom worked at Community Mental Health and Crisis Center in a tough area in Flint as a counselor, while raising five kids. I never heard her talk about any of the folks she worked with the way SH does. Which is not to say everyone who works in tough situations needs to be a saint, but I don’t think burn-out that results in these kinds of attitudes is inevitable.

    It just makes me wonder what sort of oversight there is of hospitalists or other staff that have high pressure positions.

  45. David Gorski says:

    Additionally, I’ll be more than happy to no longer read a website that unapologetically publishes political posts that are as flimsy and ridiculous as the one you (David) posted. Seriously – keep this garbage off your otherwise decent website.

    He says as he flounces away, clutching his pearls so very tightly.

    Give me a break. You haven’t actually—oh, you know—demonstrated that my post is “flimsy and ridiculous.” You’ve simply asserted that it is without making a single substantive criticism or citing a single bit of evidence to counter its content and evidence. All you’ve done is to make unsupported assertions, heap abuse and insults on other commenters, and whine. You’ll have to do better than that if you expect me to take you seriously anymore.

    Speaking of “seriously,” though: Seriously, dude. What the hell happened? You used to be pretty reasonable around here, but you’ve turned into either a troll or truly obnoxious character. Something’s happened.

  46. lilady says:

    Well I’m just a registered nurse and retired from a large County public health department and SH might not appreciate my experiences working in public health clinics.

    I worked, and I still reside in a County, which has diverse populations and our seven satellite clinics were sited in some dicey areas. We cared for people who were uninsured, underinsured, on Medicaid and who were undocumented immigrants. A small number of our patients were drug addicts and some were HIV positive. I felt then and still feel that we provided a medical home for these patients. Many of the patients came to us for aftercare after they had been treated in our County hospital. No one was ever turned away.

    Going back to Dr. Gorski’s studies that included people who were uninsured; isn’t it a good thing, that our County hospital and County public health clinics provided preventive health care and ongoing health care for pregnant women, young babies and older people, who were uninsured? Isn’t it far better to provide immunizations and to treat emerging health problems, in their early stages, instead of hospitalizing people for advanced cancers, diabetes, and cardiac problems?

    Scott, provided us with a small history of health care insurance in the United States…

    “A large part of the resistance, I think, is because people are used to health insurance being associated with their job rather than thinking of it as a more general concept. The historical accident of employers trying to get around wage controls during WWII has become The Way Things Are Done.”

    To add to his history; the United States was at a different time then. It was mainly the trade unions that provided health care as part of the benefits package during WW II and post war. Health care insurance was cheap then, because our medical technology was in a (relatively) primitive state. We didn’t have medicines to control hypertension; FDR received the very best care and his blood pressure was in stroke territory for years, before he died from a CVA. The medical insurance companies didn’t make huge profits, didn’t pay bonuses to their executives and were not publicly traded on stock exchanges, where their stockholders expected dividends:

    http://en.wikipedia.org/wiki/Blue_Cross_Blue_Shield_Association

    “Blue Cross is a name used by an association of health insurance plans throughout the United States. Its predecessor was developed by Justin Ford Kimball in 1929, while he was vice-president of Baylor University’s health care facilities in Dallas, Texas.[5] The first plan guaranteed teachers 21 days of hospital care for $6 a year, and was later extended to other employee groups in Dallas, and then nationally.[5] The American Hospital Association (AHA) adopted the Blue Cross symbol in 1939 as the emblem for plans meeting certain standards. In 1960 the AHA commission was superseded by the Blue Cross Association. Affiliation with the AHA was severed in 1972.

    The Blue Shield concept was developed at the beginning of the 20th century by employers in lumber and mining camps of the Pacific Northwest to provide medical care by paying monthly fees to medical service bureaus composed of groups of physicians.[6] The first official Blue Shield Plan was founded in California in 1939. In 1948 the symbol was informally adopted by nine plans called the Associated Medical Care Plan, and was later renamed the National Association of Blue Shield Plans.

    In 1982 Blue Shield merged with The Blue Cross Association to form the Blue Cross and Blue Shield Association.[7]

    Prior to the Tax Reform Act of 1986, organizations administering Blue Cross Blue Shield were tax exempt under 501(c)(4) as social welfare plans. However, the Tax Reform Act of 1986 revoked that exemption because the plans sold commercial-type insurance. They became 501(m) organizations, subject to federal taxation but entitled to “special tax benefits”[8] under IRC 833.[9] In 1994, the Blue Cross Blue Shield Association changed to allow its licensees to be for-profit corporations.[4] Some plans[specify] are still considered not-for-profit at the state level.”

    Here’s Wellpoint, which is just one of many the Blue Cross/Blue Shield affiliates that are now “for-profit” corporations.

    http://en.wikipedia.org/wiki/WellPoint

    In defense of my peer group who are Medicare recipients. We are not all *GOGS* (Greedy Old Geezers). The majority of intelligent, informed older people realize that our Medicare Part A, is being paid for by Payroll taxes paid by most employees, employers, and people who are self-employed, and through the Medicare Trust Fund and Income Taxes. Before we retired, we funded the Medicare payroll taxes from our salaries. We are not the seniors on Medicare who held up signs “Keep Government Out Of My Health Care”. We are not the GOGS whose Medicare coverage is assured, who will tolerate the undermining of Medicare coverage for those under age 55.

    We are not the GOGS who b*tch and moan when our Part B month premiums are raised or when we pay income taxes on 85 % of our Social Security checks. Tax all of our Social Security checks, raise the premiums for part B, raise the income tax rates to balance the federal budget…we will be happy to kick in more money to balance the budget and so that we don’t mortgage our childrens’ futures.

    (Sorry, Dr. Gorski…for introducing some politics into this discussion)

  47. lillady..just wondering..to ‘balance the budget’ you do know 4 trillion $ is already mortgaged to your children’s future the last 4 years alone to ‘balance’? And, that’s not even beginning to pay for social healthcare. Can your children’s future be mortgaged any more?

  48. passionlessDrone says:

    @Dr. Gorski – I quite liked your article.

    @rustichealth – Those on the left, would YOU like GWB deciding what healthcare you get?

    I’d much rather have bureaucrats from the government in charge of healthcare than bureaucrats answering to plutocrats, which is the system we have now. Regarding your ridiculous assertions of an incoming ‘facist state’, has it occurred to you to wonder about some of the countries that actually have a single payer system?

    England. Japan. Thailand. Australia. South Korea. Brazil. Pretty much all of first world Europe.

    All of these places have strong democractic processes in place, and yet none of them have decided to replace their system with one that models America’s system. Why do you think this is? Are they all ‘facists’ in Japan? Is Australia a socialist heaven? Does everyone except the far right wing on the US have it wrong, and for decades the populations of all of these other countries just haven’t decided to vote in a change of their system?

    no matter how rose colored it’s presented no country is able to sustain it for long without forced intervention and control of how much who gets what.

    There are thirty goddamned million Americans with no health insurance, and Dr. Gorski pointed out with great elegance that this is a risk factor for dying. Do you think any of these people are feeling like their healthcare is ‘forced non-intervention’? It isn’t the government that is controlling ‘how much who gets what’, it is our system; one viewed as universally cruel if not inhumane in the rest of the world; especially for a country so rich in resources.

    It’s at a point perhaps to seriously consider leaving, sorry to say if it’s not repealed.

    Here’s a thought experiment for you: to where?. Please, please enlighten us to which country you will retreat to that has a healthcare system that more closely models the for profit model of pre-obamacare US that you hold so dear?

    @skepticalheatlh: see above. You won’t be missed.

    - pD

  49. Harriet Hall says:

    “seriously consider leaving”

    Perhaps RusticHealth would be happier living in Gambia. He would not be taxed there for the health care of others, and even its President discourages pharmaceuticals and offers his own natural cures. Also less pollution, less processed foods, less of all the things Rusty wants to avoid.
    http://www.sciencebasedmedicine.org/index.php/more-hiv-nonsense-in-africa/

  50. elburto says:

    Ah look, it’s Rustic, who keeps healthy by never consuming chemicals. Skeppy’s in good company!

    OK, time to burn some of these straw-Brits who spend three weeks in the Accident and Emergency (A&E) dept. with a severed hand, or two years waiting to have cancer diagnosed.

    It’s utter bollocks.

    Guess what? Americans don’t have a patent on triage. Obviously someone going to A&E at a very busy time, with a bruised knee or a cat scratch, is going to wait longer than someone with a suspected MI or serious injury. However, the maximum wait is capped now at four hours. Sure, if it’s a busy day AND three planes crash into a local housing estate, you might have to wait a little longer, but do not tell me that there’s no wait in American ERs, that’s a flat-out lie.

    We also have nurse-led minor injuries clinics, as well as GP-staffed urgent care centres. They can both deal with injuries, fevers, infections, illnesses worsening etc. The waits are typically very short, and some UC’s let you do phone triage before going there, so that if you do need to go you can see a doctor within minutes of arriving.

    I recently went to my local UC with abdominal pain and inability to urinate, assuming it was my usual kidney infection. Within an hour of arriving there I’d been assessed, taken by ambulance to the nearest acute hospital, and booked into a ward. Stayed there for two weeks thanks to a bowel obstruction, and at no time did I. have to worry about money.

    I was taken home by ambulance, I receive regular district nurse care and my GP has visited on a few occasions. No cost.

    My father-in-law died recently. He was experiencing shortness of breath. My partner called an ambulance, it took him to the local A&E where they assessed him immediately, and admitted him. After one night on the ward his doctors were concerned, and admitted him into ITU. He stayed there for three weeks, with two-to-one case around the clock. They tried everything, but he died. He was cared for with dignity and respect the entire time he was there. We did not have to fret about getting approval for procedures or treatments.

    It was his heart that ultimately failed him. You see, there was no NHS when he was a child. He got rheumatic fever, and his parents couldn’t afford a doctor. He sustained cardiac damage as a result of the illness. But, he lived a long and productive life thanks to socialised medicine.

  51. estockly says:

    >>>@Those from the UK: The entire American system is founded on the premise that a powerful central government is not to be trusted, and we erected one only with the greatest of trepidations.

    Not so fast…. That was the premise for the Articles of Confederation. Nearly all power to the states very little power and authority to the central government and it was a colossal failure.

    Our constitution was drafted as a balance between the power of state governments and a central federal government, and through amendments and laws passed over the years, the balance has shifted somewhat to the federal government, but not as much as the right wing imagines.

    ES

  52. passionless..with all the ‘work’ put into HCR..it still leaves out 40 million people! and, who does it benefit? those who either don’t want HC..like young people who self decided understandably they don’t need it..why would they? I didn’t or wouldn’t want it at that age..but we’re paying for them now! even those who choose not to have it..like myself. Why should you pay for my healthcare? buy my vitamins? my organic food? you gonna pay for that for me too? The only people 2 years of big brains in gov came up with are those with uncovered illness, who don’t want to go bankrupt! great!! we’re paying for them to keep their bank books! Anyone else? We already have medicaid for those who really Can’t afford it. What else will you all ‘mortgage’ over to gov bureaucrats to think for you…they’ve already bankrupted the country as it’s going.

  53. David Gorski says:

    We already have medicaid for those who really Can’t afford it.

    You’re really more ignorant about the issue than I thought if you really believe this is enough.

  54. estockly says:

    >>>But, now my premiums went up 5 times since Obamacare passed

    My premiums have gone up every year for as long as I’ve had insurance (20+ years). I have not noticed any Obamacare bump.

    >>> I’m being forced to pay for others and for something I don’t even want or believe in for myself.

    You were before Obamacare. Uninsured people who go to emergency rooms are treated at the hospital’s expense and that cost is passed on to the rest of us. A good part of your premiums are already paying for service provided others who can’t afford or simply choose not to by insurance.

    The other issue about costs that no one has mentioned is the inverse relationship insurance has with price/supply/demand.

    For just about any other product sold when demand increases and supply remains steady prices go up. For insurance, because of the very nature of insurance, when demand goes up, more people buy but prices go down because the risks are shared.

    As more people participate in the system some costs may rise but, overall, the price for insurance should drop and the aggregate spending for health care will have less upward pressure when more people are covered and don’t rely on ERs for primary medical care.

    >>>The whole idea is immoral bordering fascist state.

    This whole idea is perfectly consistent with the goal: “Promote the general welfare”

    >>>This socialist system is failing in Greece..failing in other countries

    The crisis in Greece and other countries is due to the free enterprise global banking system.

    There are also more socialized countries that are doing very well, thank you.

    >>>And 2400 pages is deciding what healthcare we get.

    Too many words? Or not enough? How many pages would you prefer. (I think a single page would suffice: “Single payer Medicare for all”)

    ES

  55. mousethatroared says:

    I’m still trying to figure out how a national health care plan that was written and enacted by elected representatives and signed into law by an elected president (who ran on a national health care plan platform) and largely approved by a reasonably conservative Supreme Court can be considered fascist.

    Did I miss the night of the long knifes?

  56. Chris Repetsky says:

    Not everyone who needs healthcare qualifies for Medicaid, nor can they afford insurance. Anecdotal, but I can name countless acquaintances off the top of my head that I have encountered in both my family, friends, and patients I’ve seen.

  57. Harriet..as long as I can grow my own organic food, and buy vitamins..I’m okay. : ) What I find funny is..whenever you come against big over-bearing government, the alternative is living in squalor or anarchy? America wasn’t begun on ‘big overbearing government’..it liberated itself from it actually. We had government, but it was limited..States decided for themselves what they wanted…that’s as it was and should continue to be. And, I have a question ..why are so many unions and other towns, and companies ‘exempt’ from Obamacare..?

    http://www.freerepublic.com/focus/f-chat/2900475/posts

  58. Chris Repetsky says:

    (Damn, Dr. G beat me to it)

  59. elburto says:

    Right, now to new/chronic illness care and waiting times.

    New symptoms reported to a GP that warrant the attention of a specialist are referred on undeR either the two week rule or the six week rule. TWR is for potential cancerous, neurological, cardiac or pulmonary disease. Patients are often seen much sooner. I’ve personally had TWR requests made on my behalf that have resulted in a call from the clinic asking me to attend the next day.

    Under SWR you typically. receive a letter saying “Your GP has requested a referral to [specialty].

    Please go online, and using the details provided (address, userID, password) log into the Choose and Book system. There you can choose which hospital you wish to be treated in, and the most convenient appointment slot.

    You can also call us on [number] or use our minicom (TTS for d/Deaf or HoH users)”

    The waiting time for surgery depends what it is. Obviously something emergent or critical is going to take precedence over a cosmetic procedure or a minor hernia repair.

    As someone with disabilities and chronic illnesses that require ongoing care, I’ve seen the NHS inside out. I even worked for them for a few years. It pisses me off something chronic when people spew secondhand nonsense about waiting days to get treatment for a stroke, or death panels, or whatever the current neocon or libertarian “expose” is. It’s sheer idiocy to do that, and not expect to be rebutted.

    In countries that have the concept of a social contract, where everyone is seen as deserving healthcare, education and a roof over their heads, we’ll always see socialised medicine as a good thing. Nihilistic individualist regimes? Nope. Never gonna get it. You’ll have doctors raging about non-compliance to medication regimens that cost thousands of dollars, while I pay a maximum of £104 a year. You’ll have people ignoring symptoms that could be dealt with cheaply and easily, and instead, turning up to the ER with stage IV cancers and organ failure.

    Oh and Skeppy, one last thing re: the financial crisis. One, the moronic American practice of sub-prime mortgages caused global chaos. Two, the US isn’t exactly sittin’ pretty bucko. Teachers and nurses living in their cars with. their kids, getting food from food banks and soup kitchens. Wow, such prosperity and wealth, and yet… no socialism involved. So that puts a bit of a hole in your smug statement about socialism destroying nations.

  60. Dr. Gorski..I believe it’s a much easier problem simply expanding medicaid, for those who can’t afford it, perhaps pay according to what they can afford in premiums..then to dictate and force everyone else to pay for something they don’t want. How difficult can that be.

  61. elburto says:

    We already have medicaid for those who really Can’t afford it.

    Christ. Do you live under the sea, or in a volcano lair? It’s just, I live across the Atlantic and I know that’s ridiculous.

    You know what’s happening right now with people who can’t afford treatment in the US, but don’t qualify for aid? They’re going to India, Mexico and Colombia. Some Indian hospitals have entire wards devoted to US medical tourists.

    Americans spend. billions every year, flying to India, Turkey, South America etc. for surgery and treatment that is too expensive at home.

  62. mousethatroars..lol “You have to Pass it to Read it!”..Pelosi..heh..wow what does that say?

  63. Americans spend. billions every year, flying to India, Turkey, South America etc. for surgery and treatment that is too expensive at home.

    elburto..problem solved..free people choose to do what they wish with their money.

  64. Narad says:

    You’re really more ignorant about the issue than I thought if you really believe this is enough.

    Or if RH actually thinks the statement is even true. Try getting Medicaid as a single male.

  65. Correction: Pelosi: “We have to pass the bill so that you can find out what is in it” lol…what a comfort that is :) “trusted” bureaucrats in control…

    http://www.unitedliberty.org/articles/5233-pelosi-we-have-to-pass-the-bill-so-that-you-can-find-out-what-is-in-it

  66. Harriet Hall says:

    Just an observation: David’s article said there is evidence that insurance saves lives. There has been no disagreement with that premise. All the commenters agree that insurance is a good thing, but they have turned the thread into a political discussion about how best to provide that insurance: exactly what David tried to avoid. Let’s try to stick to science and leave political opinions at the door. There are plenty of other, more appropriate places for those discussions.

  67. lilady says:

    @ rustic health:

    I’m willing to *bet* that you don’t have enough money to pay for hospital care for a major medical emergency. Should we stop treatment and kick you to the curb, once you run through your assets?

    See how long your assets last, if you require care in a long-term facility.

    http://www.completelongtermcare.com/states/

    I’m also willing to *bet* that you have already, or will be, planning to divest yourself of assets and ownership of your home, so that your heirs have an inheritance and you qualify for Medicaid-funded care. (Medicaid has five year “look-back” authority to check for assets in your name).

    I have a real “problem” with people who have personal wealth that they divest themselves of, to “qualify” for Medicaid care. These are the same people who have the ability to purchase, and refuse to pay for, Long Term Care Insurance.

  68. passionlessDrone says:

    @Chris Repetsky:

    Not everyone who needs healthcare qualifies for Medicaid, nor can they afford insurance

    How is this any different than before Obamacare though? It seems like Obamacare is at least trying to address this.

    From Kaiser: [http://www.kaiserhealthnews.org/Stories/2012/March/22/consumer-guide-health-law.aspx?p=1]

    What if I make too much money for Medicaid but still can’t afford to buy insurance?

    You might be eligible for government subsidies to help you pay for private insurance sold in the state-based insurance marketplaces, called exchanges, slated to begin operation in 2014. Exchanges will sell insurance plans to individuals and small businesses.

    These premium subsidies will be available for individuals and families with incomes between 133 percent and 400 percent of the poverty level, or $14,856 to $44,680 for individuals and $30,656 to $92,200 for a family of four (based on current poverty guidelines).

  69. Narad..medicaid can very easily be expanded..as above.

    And, none of this covers illegals, which is the major problem in ER isn’t it? Exactly who does it benefit? very very few…yet will cost more, and control all..(except those who were exempt!)

  70. mousethatroared says:

    @HarrietHall – I’ll respect the editors wishes if you all don’t want political comments, but to be honest it’s not so easy to find a forum that provides such a broad spectrum of intelligent political attitudes. My objections to SH’s comments are not that they are political, but that they are abusive and lacking in content.

    I actually enjoy hearing the informed political opinions of other readers. There are other commentors here, whose politics are quite opposed to my liberal leanings, who make some excellent observations.

    I enjoy hearing the accounts from other parts of the world as well.

    If a bunch of people who are into critical thinking can’t question hyperbole and discuss constructive political solutions to an agreed problem, then who can? We’re doooomed. :)

  71. lillady..I have a problem paying for anyone except myself and my family. Everyone else should have a problem paying for me too. If you have a medical bill..you pay… on time.. That’s what I do..what my parents did. I have catastrophic, but, that’s my business..I shouldn’t have to ‘fess’ up to you what I’m covered or not covered for. But, there..see? want control? Now pay for my vitamins and organic food, since that’s my ‘healthcare’..oh..I don’t see anything in the brainiacs hc bill to cover real health actually..imo :)

  72. David Gorski says:

    Dr. Gorski..I believe it’s a much easier problem simply expanding medicaid

    Careful. You do realize that Medicaid is a government program and expanding it could result in our coming closer to a single payer plan, don’t you?

  73. lilady says:

    Okay, back on topic. Why should little kids be put at risk for vaccine-preventable diseases and for untreated asthma, because their parents are uninsured?

    What about the *silent killers* (elevated blood glucose levels, hypertension and hyperlipidemia) that go undiagnosed and untreated due to lack of insurance? Do we as a society want people to go into major organ failure or lose their eyesight due to undiagnosed and untreated glaucoma, because they lack insurance?

    I have familial hypercholesterolemia, and because I had medical insurance my condition was monitored…but untreatable. I was enrolled in one of the early Lipitor trials by my private physician. When the trial was unblinded, my cholesterol level was 180 mg/dl…down from 400 mg/dl. What would my health status be today, if I didn’t have insurance coverage?

  74. David Gorski says:

    @Harriet

    Although I was trying not to be too political in my post (little swipe at Mitt Romney aside, which I considered justified given that I was about to present evidence to show him to be wrong in this instance), I also realized as I wrote this that it’s impossible to avoid politics completely discussing this particular topic and that the issue would almost certainly be politicized to some degree in the comments. And it was. Given the subject matter, it was almost inevitable, although admittedly I didn’t expect it to happen so fast and so obnoxiously in the very first comment, with SkepticalHealth leaping in with a political rant attacking me. That being said, I do not think we at SBM should shy away from easily politicized issues or inherently political issues. The caveat, of course, is that we SBM bloggers should in our posts stick with positions that are science-based, which is what I tried to do. This is the Science-Based Medicine blog, after all. If that weren’t the case, I might have injected my ideas regarding what should be done about the problem of the uninsured. If I decide to repost this particular post over at my not-so-super-secret other blog, you can be sure that there will be…modifications. I don’t follow the same rules with respect to avoiding being too political over there as I do here at SBM.

    Be that as it may, even here I tend to take a somewhat more freewheeling view of the comments, and if our commenters want to get a bit political I don’t necessarily see anything inherently wrong with that, as long as it doesn’t get out of hand. This isn’t Daily Kos, Balloon Juice, or Hot Air (popular political blogs), after all. However, in the spirit of Science-Based Medicine, I would hope that commenters can back up their positions with evidence and…science!

  75. Narad says:

    Do we as a society want people to go into major organ failure or lose their eyesight due to undiagnosed and untreated glaucoma, because they lack insurance?

    At which point they’d also still have a two-year wait before Medicare kicks in under SSI, just by the by.

  76. mousethatroared says:

    RusticHealthy – You need to read up on ObamaCare. If you choose not to buy insurance you will pay a fine (or tax). This offsets the systemic costs of people who decide to gamble and lose. You are not forced to take part in the healthcare system if you don’t wish it.

    http://www.factcheck.org/2012/06/how-much-is-the-obamacare-tax/

    I believe we all benefit from having a healthcare infastructure. I don’t think that Amish people get to pay lower taxes because they don’t use the freeways. Nobody decided to give me a tax discount when we invaded Iraq, just because I thought it was a bad idea. I don’t think that people who decide not to partake in healthcare should get to opt out of paying for the system either.

  77. You all know they can change the $ amounts anyone pays ..anytime they have an inclination to do so right? This isn’t the end..this is the beginning of the problems that come. In the same way they took such “good care” of their ‘stewardship’ of our money in social security? ha, medicare? ha, and most other federal budgetary spending, HA, the same ‘care’ they will have in how much we will be paying for the “healthcare” (not real healthcare to me) they will etch out and allow us to have, and how much we pay for it. What I fear, and see, is, it will be far too late before most people wake up to the fact.

  78. lillady..asthma is helped by vitamins..C, omegas..in my own experience having got off of 2 inhalers and 2 meds including steroids :/…most childhood diseases are vitamin deficiency…causing low immunity.

  79. lilady says:

    @ rustic health:

    “Americans spend. billions every year, flying to India, Turkey, South America etc. for surgery and treatment that is too expensive at home.”

    That’s a crock. The Americans who fly to foreign countries for *surgery* and *treatments* are going to those foreign countries for cheaper cosmetic procedures, that are not covered by private or publicly-funded health care insurance.

    “lillady..I have a problem paying for anyone except myself and my family. Everyone else should have a problem paying for me too. If you have a medical bill..you pay… on time..that’s what I do..what my parents did. I have catastrophic, but, that’s my business..I shouldn’t have to ‘fess’ up to you what I’m covered or not covered for.”

    So you do have catastrophic medical insurance, eh? (Just in case your home-grown organic foods and vitamins don’t protect you). I’m not asking you to “fess up”, but I just “bet” that you wouldn’t refuse Social Security Disability checks and Medicare, should you become permanently disabled. I just “bet” that your parents did not refuse Medicare when they were qualified at age 65.

    “But, there..see? want control? Now pay for my vitamins and organic food, since that’s my ‘healthcare’..oh..I don’t see anything in the brainiacs hc bill to cover real health actually..imo”

    I’ll pay for your vitamins and organic food, when you pony up money to pay for my prescribed OTC calcium/vitamin D tablets and pony up money for my groceries.

  80. mousethatroars..”If you choose not to buy insurance you will pay a fine (or tax). This offsets the systemic costs of people who decide to gamble and lose. You are not forced to take part in the healthcare system if you don’t wish it.”

    why the list of those ‘exempt’ from it then?

    Dr. Gorski..what should be done about uninsured illegals..would like to know what your idea is.

  81. Quill says:

    Rustichealthy wrote “…I have a problem paying for anyone except myself and my family. Everyone else should have a problem paying for me too….”

    So from a psychological and moral point of view, you are a selfish person and believe it would be helpful for everyone else to be just as selfish. That is certainly interesting.

    Science is pretty clear on one thing when it comes to species survival: cooperation is as integral as competition. If we don’t consider other people worth anything or in need of a general social contract to ensure everyone has the basics needed for a healthy life, then what is the point of -any- kind of hospital, clinic or program to provide medical care to anyone? Why are you here on this forum instead of building a sturdy wall around your property?

  82. lilady says:

    @ Narad:

    “Do we as a society want people to go into major organ failure or lose their eyesight due to undiagnosed and untreated glaucoma, because they lack insurance?”

    “At which point they’d also still have a two-year wait before Medicare kicks in under SSI, just by the by.”

    The exception to that two year waiting period for Medicare is for patients who have ESRD (End Stage Renal Disease).

    http://en.wikipedia.org/wiki/End_Stage_Renal_Disease_Program

  83. Quill…We as a society do help the poor. I don’t believe anyone has a problem with that. I’m talking about those who are able to think and do for themselves. I believe in charity giving. Most conservatives do. We give of our own time and money out of free will. Now the gov will be in charge of it all..because no one will have anything left to give to anyone when they’re through with us..as evident with their unlimited spending and ‘giving’ to their crony voters.

  84. Chris Repetsky says:

    passionlessDrone:

    Maybe I didn’t come across as such, but I support Obamacare! My statement about Medicaid was to Rustic, who claimed that Medicaid was available to all those needing healthcare who cannot afford it.

  85. BillyJoe says:

    weing,

    “What kept me sane, was knowing that in private practice I would not have to see those patients.”

    Again, I don’t understand this. Why did you go into medicine in the first place? Was your original purpose to set yourself up in such a way that you only have to see clean, well-dressed, well-off, compliant, middle class patients who do exactly what you require of them and who know exactly when they need to see you and won’t bother you when they don’t?
    I suppose you are lucky that there are so many patients for every doctor that you can pick those you like and piss off those you don’t.
    You are also lucky I was not on the medical school selection panel, because I have absolutely no respect for this attitude. Fortunately there are counter examples here such as David Gorski, Harriet Hall, and Steven Novella, otherwise I would have lost respect for your profession.

  86. Quill says:

    rustichealthy, out of my own free will I clicked on your name and went to your site, clicking on one of the many links at random. Found this statement from you:

    “So, now I personally dismiss ‘science-based’ conventional clinical findings as “anecdotal”! (“unscientific”, unimportant and meaningless:) and nothing more!:))”

    Of course that is your choice to do so and if it makes you happy, then huzzah! But why on earth do you bother being here with all these non-anecdotal types who value science over one person’s personal experiences? You are passionate but if you hope to persuade you are not making a very good case for why your opinions should trump experimental, verifiable data.

  87. Narad says:

    We as a society do help the poor.

    Interesting that you would like to both include yourself in and offload this concept to suit whatever you find to be most self-servingly convenient at the time. How did you feel about the ARRA subsidy for COBRA payments?

  88. I think they’re ‘taxing’ charities now! So the money we do give will be taxed and who will be suffering? those whom the money was supposed to be going too!..wow…Giving can only be a voluntary action. And, what’s taken, and spent in gov pol hands, is not ‘voluntary’, nor is it giving, it’s legal thievery putting it nicely. The ‘trust’ you all have, is unfounded. What’s evident once again is irresponsible unlimited spending..then whining that the people should be ‘happy givers’ (because that’s what Congress has the right to do right? Tax) and are not ‘giving’ enough, so more taxing..then more spending..then more whining, then more taxing. This is the vicious cycle we are in now, and all getting away with how “we, your trusted politicians know what to do with your money better than you do”..and it seems most of you here fall for it despite the failing stewardship of ‘programs’ they (pols) installed, made us pay for, now going bankrupt!

  89. lilady says:

    Sorry…I just can’t resist posting this link:

    http://www.youtube.com/watch?v=HhHNH9B4TWE

  90. Quill..when I “experimented” on myself, and found vitamins do work..and actually, when others tried them and they did work for them also, then I believe, there’s something wrong with the ‘science’ claimed by conventional medicine that they don’t work…I’m here to share my own hypothesis and hope some might listen. However, I can only take so much in here admittedly :)

  91. Harriet Hall says:

    OK, if you want politics, I’ll share my opinion. Obamacare is too little, too late, but is better than no Obamacare. In the first presidential debate Romney said he wanted to repeal it but he had no other plan to offer. He said he would get people on both sides of the aisle together to talk and see what they could come up with. I thought we already tried that, and that’s what gave us Obamacare. I’d be quite willing to pay substantially more taxes to support any universal or single-payer system; but every system that has ever been tried has had defects. Any system, single-payer or otherwise, is only as good as the people who are responsible and their ability to recognize and correct defects in the system.

  92. Quill says:

    @lilady: Thanks for the reminder! I assumed those few minutes of that debate were secretly sponsored by The Board of the Soylent Corporation.

  93. Quill says:

    Any system, single-payer or otherwise, is only as good as the people who are responsible and their ability to recognize and correct defects in the system.

    Exactly so and this is where this post comes in, where science becomes the only tool to find those defects and propose effective solutions. If there was a single payer system it is reasonable to assume that much of the money, time and debate that goes into arguing about who will pay for things would shift to what to pay for, what is the better treatment and what are the better outcomes.

    Then again, there could just be even more yelling about everything. ;-)

  94. @Quill, regarding your 4:09PM comment. I think it has been established that .rustichealthy doesn’t believe in magic. On the other hand, she does seem to believe in magical thinking.

  95. estockly says:

    >>> In the first presidential debate Romney said he wanted to repeal it but he had no other plan to offer.

    Yeah, Romney says a lot of things.

    Here’s the deal, Obamacare was passed by both houses of Congress and is the law of the land. A president cannot repeal a law. In order to repeal Obamacare he would have to get bet a repeal bill passed by both houses, and Democratic Senators can use the filibuster and other tactics to prevent a repeal, even if the Republicans get a majority.

    There are things a President could do to water down Obamacare, but not repeal.

    ES

  96. Quill says:

    @François Luong: I’m not sure that has been established. If you consider the definition of magic to be “the power of apparently influencing the course of events by using mysterious or supernatural forces” the rustichealthy’s site is full of just such things and even though there is a version of the Miranda Quack Warning there as well, it seems odd she would post so many things without believing in them.

  97. Chris Repetsky says:

    Especially since she claims she can fix asthma with vitamins. If that’s not magic, I don’t know what is!

  98. mousethatroared says:

    RusticHealthy – So you think we should only have voluntary charity contributions for a social safety net? Have you thought about what would have happened to this nation if the programs that you deride hadn’t been started. I can give you one idea. My father rode trains out west to find a job when he was 12, because the family didn’t have enough money to feed everyone. His brother suffered a permanently crippling ankle injury when he was a child, that wasn’t treated by a doctor, because they had no money for it. Where was the charity? My Mother’s family had only navy beans to eat for an entire winter when she was a child. She always talked about how they were lucky, because they had ‘something’ to eat unlike others. Does it look like charity was making sure that children weren’t malnourished?

    I gotta tell you, my parents and the many other working and out of work poor of the great depression weren’t going to just sit around hoping some rich benefactor would give them a hand out. I can’t think of one industrialized nation that got through the great depression with some stability without establishing a social safety network. Can you point me to one?

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