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BrianY
09-26-2013, 08:05 PM
Do you oppose obamacare because you're convinced that it won't work ?

Do you oppose it because you're afraid that it WILL work?

If it's the former, can you cite specific things that you believe won't work?

if it's for some other reason, can you say what that reason is?

I ask this because I've seen and heard a lot of opposition to the act, but I don't really know WHY people are opposed to it. I'd really like to know.

and for my liberal friends, PLEASE don't muck it up and post that the republicans hate obama and everything he stands for as the reason. That's not very useful.

htom
09-26-2013, 09:11 PM
From my experience (first hand) and friends and relatives (second hand) with the Federal Government's Indian Health Service,
military medicine, TriCare, and the VA ... I think it takes the worst of federal medicine, corporate medicine, and insurance company medicine, wraps that collected worst in federal and state paperwork, and it is doomed to fail.

I expect that I will be made to change medicines I've used for decades, because there are cheaper "substitutes" (that my doctors don't currently prescribe for me because they think they don't work well in my body.) I think I will be made to change other medicines because the condition I'm being treated for isn't considered treatable for people my age. I think I'm going to be given grief and rate hikes over my weight -- even though a year ago I passed a stress electrocardiogram at a pulse rate considered "acceptable" for someone half my weight and twenty years less than my age.

I have little faith in "government medicine". It may have saved my life a time or two in the past. Now they claim I'm not a vet, but even if I was, I couldn't get into the WIC program because that's now closed until first of October. Opps, maybe it will open after the end of November.

The government does not provide good health care to the Native Americans.
It does not provide good health care to veterans.
It does provide cheap care to those on TriCare. I know of few who think it's "good".

Now, having demonstrated that they can't do these well, they want to prescribe to everyone.

I'd laugh if I wasn't crying.

nautiguy
09-27-2013, 12:29 AM
My experience with federal health care (VA) has been great. I think, HTom, that you are confusing the problems with gaining access to VA care with the care that the hospitals and clinics provide. There is no doubt that there is a disconnect between military recording keeping and VA assistance which is shameful, but that has nothing to do with the quality of care. Here in San Francisco, the VA medical center uses residents and doctors from UC San Francisco medical Center as well as VA doctors, nurses and techs. Again, the care is excellent. With the quality of the medical establishment in the twin cities, I would be surprised if the care was any less complete than it is here.
If you think you will have an access problem under the ACA, you'll have to decide whether that particular bureaucracy is better or worse than the current insurance company bureaucracy that refuses coverage for preexisting condition, restricts care, has lifetime caps, and insists that you use drugs from their approved list.

htom
09-27-2013, 12:48 AM
It used to be I could choose medical plans that provided for my needs. It was neither easy nor cheap (and I've pre-existing conditions since 1967, thank you, Uncle Sam.) Now I get to choose between plans that meet the government's needs, rather than mine.

VA care can be very good. I know. I said they saved my life. It can be horrible, too. I've paid a pile avoiding having to use it. Had friends and family who did use it. I know some of the horror stories first hand, seeing cousins being poorly treated. Some of that was due to various paperwork problems; that doesn't fix things that could have become non-problems if care had been given in a timely fashion. There's a lot of handwaving about blame in the VA system, and a lot of blame that can be passed around. Much of it comes from conditions for treatment established by politicians. That's part of the reason that I have so little faith in the promises of ACA. Been there, done that, seen the results.

I'm going back to the VA to try to find research they may have done, or might be interested in doing. They have many more epilepsy cases than the Mayo, down the road.

If I can get this study started ... I won't benefit from it. It will take at least a decade to do, and probably a decade to start it. The VA has, can, and will do great medicine. It has always done its best and failed to meet expectations, like someone with ADHD, struggling to maintain its focus because of distractions. Modern ADHD theory is that it's actually a condition caused by failures of executive control in the prefrontal cortex. Rather like politicians trying to write regulations to control medical treatment.

htom
09-27-2013, 12:57 AM
I know about the temporary closing of the WIC program because my wife asked me to sign up for it, so I could use the card at Lowes, Home Depot, etc. I found it was closed until around the first of October, and Tuesday, when I went to give blood, looked to see if they'd opened early, and found the later (maybe after the end of November) target date.

If you can't manage these things for vets, how can you possibly think you're going to be able to manage them for everyone?

(This is the Wounded Identification Card program.)

David W Pratt
09-27-2013, 08:54 AM
I object to the way it was enacted.
A rational approach would have been to appoint a blue ribbon panel to look at the national health plans of other, industrial nations and cherry pick the best features. Then, the proponents could say "we know it will work because we have seen it in action."
Also the fact that Congress has granted themselves waivers seems fishy

John Smith
09-27-2013, 09:41 AM
From my experience (first hand) and friends and relatives (second hand) with the Federal Government's Indian Health Service,
military medicine, TriCare, and the VA ... I think it takes the worst of federal medicine, corporate medicine, and insurance company medicine, wraps that collected worst in federal and state paperwork, and it is doomed to fail.

I expect that I will be made to change medicines I've used for decades, because there are cheaper "substitutes" (that my doctors don't currently prescribe for me because they think they don't work well in my body.) I think I will be made to change other medicines because the condition I'm being treated for isn't considered treatable for people my age. I think I'm going to be given grief and rate hikes over my weight -- even though a year ago I passed a stress electrocardiogram at a pulse rate considered "acceptable" for someone half my weight and twenty years less than my age.

I have little faith in "government medicine". It may have saved my life a time or two in the past. Now they claim I'm not a vet, but even if I was, I couldn't get into the WIC program because that's now closed until first of October. Opps, maybe it will open after the end of November.

The government does not provide good health care to the Native Americans.
It does not provide good health care to veterans.
It does provide cheap care to those on TriCare. I know of few who think it's "good".

Now, having demonstrated that they can't do these well, they want to prescribe to everyone.

I'd laugh if I wasn't crying.

What does any of this have to do with the ACA? All insurance carriers in the ACA are private companies.

John Smith
09-27-2013, 09:43 AM
I object to the way it was enacted.
A rational approach would have been to appoint a blue ribbon panel to look at the national health plans of other, industrial nations and cherry pick the best features. Then, the proponents could say "we know it will work because we have seen it in action."
Also the fact that Congress has granted themselves waivers seems fishy

Can you document Congress granting themselves waivers? Wasn't the "gang of six" the equivalent of a blue ribbon panel?

htom
09-27-2013, 11:19 AM
What does any of this have to do with the ACA? All insurance carriers in the ACA are private companies.

Which part of this
I think it takes the worst of federal medicine, corporate medicine, and insurance company medicine, wraps that collected worst in federal and state paperwork, and it is doomed to fail.


did you not understand?

The primary problem with the American medical system is paying for those who are not caring for patients. There's a clinic that one of my relatives is one of the three owners of; they have more people filling out insurance forms, federal forms, state forms, conducting mandatory inventories, ... than they have doctors, physician assistants, nurses, orderlies, janitors, and their clinic bookkeeper (who deals with company business NOT associated with the insurance claims.) ACA is going to add to the paper pushers. How can this reduce costs?

BrianY
09-27-2013, 11:29 AM
The primary problem with the American medical system is paying for those who are not caring for patients.

I respectfully disagree. The primary problem withthe American medical systems is that some people have health insurance and some don't. If everyone had insurance, the paperwork would be pretty simple - a claim form and some documentation. Of course, each insurer will have its own claim form and process so that complicates thigs a bit. It would be even simpler if we had a single payer system. Then the would be only one claim form. The paperwork mountain you describe exists because there are multiple forms from multiple agencies and insurers that need to be filled out to determine which agency or insurer should pay what percentage of each bill and what exceptions, fee reductions and subsidies the patients qualify for.

John Smith
09-27-2013, 11:42 AM
Which part of this

did you not understand?

The primary problem with the American medical system is paying for those who are not caring for patients. There's a clinic that one of my relatives is one of the three owners of; they have more people filling out insurance forms, federal forms, state forms, conducting mandatory inventories, ... than they have doctors, physician assistants, nurses, orderlies, janitors, and their clinic bookkeeper (who deals with company business NOT associated with the insurance claims.) ACA is going to add to the paper pushers. How can this reduce costs?

Single payer would eliminate a lot of paperwork.

Cost of medical care in the US is an extremely complex issue. If I had no insurance, my bill for my ER visit a couple of months back would have been $9300. Because I had insurance, the maximum they could charge was $167. People who go to that ER without insurance will generate that $9300 bill, which they can't pay, so what do you think happens to it?

AS TO I think it takes the worst of federal medicine, corporate medicine, and insurance company medicine, wraps that collected worst in federal and state paperwork, and it is doomed to fail.

That's so all inclusive as to be meaningless. Medicare if government provided health insurance, but you see private doctors. The government sets the rules by which every industry plays. The ACA is simply a change in those rules.

pkrone
09-27-2013, 11:55 AM
What does any of this have to do with the ACA? All insurance carriers in the ACA are private companies.
THIS is this problem. Private health insurance companies will still be the ones calling the shots. That's why this iteration will fail. However, I still think it's a step in the right direction. BTW, during my training, I worked in both the VA and Indian Health Service. Both were disasters. I owed 3 yrs of active duty to the USAF after training and got to experience Tricare. We called it "Trying to Find Care."

TomF
09-27-2013, 12:05 PM
Single payer does indeed eliminate a lot of paperwork. Drastically reducing the need for one group of people pushing paper in physicians' offices and hospitals, and eliminating all but one of the similar groups at the payer's end is an enormous reduction in waste. When the single payer is government, then a fairly major area of private sector inflation to the cost (i.e. profit) is also wiped clean.

Are the concerns, as it appears from Htom's and pkrone's comments, largely about whether the processes can be efficient and effective? Those are real concerns, but are entirely fix-able through solid and efficient process development. We're implementing Lean SixSigma throughout all of the NB Government, including Health, because we want to drive out a bunch of waste through re-engineering our processes. No reason why you guys can't start with a best-of-breed process at the front end.

My impression, though, has been that the concerns driving Congressional Reps were largely about philosophy - whether Obamacare should exist at all - rather than whether this version of health insurance reform seems up to the task. What are the philosophical objections to implementing health insurance reform - either retaining the private sector as the delivery agent (as Obamacare does) or at least partly through taxpayer-funded single payer?

Keith Wilson
09-27-2013, 12:11 PM
The new law requires private insurers to pay out 80% of premiums for actual medical care - and they kicked about that. The equivalent figure for Medicare and Medicaid is around 97%


What are the philosophical objections to implementing health insurance reform . .. Now you're into the dark corners of the human psyche. Are you sure you want to turn over that rock? I'll be partially sarcastic and list a few.
- I've got mine; screw everybody else.
- Taxes are theft.
- The government shouldn't do anything to help people unless they're already well-off, hence deserving. If it tries, it always makes things worse.
- Some people don't deserve help; you can identify them by their lack of money.
- The US health care system is the best in the world. Evidence to the contrary is socialist propaganda.

htom
09-27-2013, 12:40 PM
The USA has some of, if not the very best health care available in the world if you're a patient.

The USA has absolutely the very worst way of paying for health care in the world.

The philosophical problem is that medicine is an art, not a science. You have to treat patients, not diseases. People are not robots that need their oil changed and hinge pins replaced. Science can aid in the treatment of patients by providing information about the known and studied treatments, but it provides little correct guidance as to which treatment is best for which patient. It can confirm that the "best" treatment or "cheapest" treatment is not working for a particular patient, and in that case, a "less best" or "less cheapest" treatment is actually the better treatment for that patient. Having insurance companies or government committees require their abstract evaluations take precedence over that of the considered expert opinion of trained medical professionals is a prescription for bad medical practice.

Lew Barrett
09-27-2013, 01:02 PM
I have been opposed to the results of the ACA here (based on preliminary research into my own situation) but hadn't been opposed to it in the least up until a few weeks ago. I've been reflecting on the possibilities going forward, and with a few (not insignificant, but still quite achievable tweaks), I am coming to the conclusion that the ACA is or very easily could be a step in the right direction.

I still remain opposed to the participation of insurance companies in this plan and very much want to see a move to single payer, but have decided to hold further criticisms and comments until we see how this actually works out for us, and what directions our congress takes in smoothing over a few of the rough spots.

In the meantime, Tea Party opposition to this in the form of holding the payment of US debt as hostage (and all other forms of hostage taking that focuses on the ACA) make me a firm and complete supporter of the program. Obamacare needs tuning in its details no doubt, but without a sensible approach to managing the package, and without the least bit of consideration as to the short term impacts of sequestering, refusals to pay for what has been already purchased and the like, I'll return to my prior position of complete support for this as it stands with the understanding that compromise to create a truly equitable product is not possible in this environment so we are forced to take what we can get if we have any kind of social conscience at all.

TomF
09-27-2013, 01:02 PM
...The philosophical problem is that medicine is an art, not a science. ...A whole lot of medicine is a science though - a production process even. Knee and hip replacements, and hernia repairs have been refined into very swift, standardized, repeatable procedures in many clinics which specialize in that line. The data's really clear on this: superior patient outcomes, great value for money, enormous efficiency. I want the person doing my knee replacement who's done 30 or more in the past month, and has his processes down cold. And I probably want it done in a specialized clinic with a crackerjack specialized team.

Pye's famous book "The Art and Nature of Workmanship" argued for the creativity involved in the "workmanship of risk" rather than the "workmanship of certainty." Great art, in craftsmanship, only emerged with risk involved. But the standard of living the West enjoys is built on balancing some luxury goods embodying "workmanship of risk" with the great mass production of "workmanship of certainty" which creates our cars, our cellphones and other IT doo-dads. It also created the type of housing construction enabling the enormous improvement in living standards we have compared with earlier generations. Hobie Cats should never be confused with Coquina, but they've got a whole lot more people out sailing ... though they're not the consummate work of art.

I agree that some medicine should fall into the "workmanship of risk" category - varieties of research, etc. Specialized care for people with specialized needs. But most of us don't need a 17th Generation Hyper-Linked Warp Drive iPod which will cost $5k/per.That may be "better," but really we just want to play our music easily, reliably, safely, and relatively cheaply. The same is true of hip replacements, of therapy for chronic diseases like diabetes. Whenever possible we want certainty, not the riskiness of art - which may be extravagantly successful, or may kill us. Other than the fact that it belongs to me, my knee just isn't that special. A solid, serviceable workmanship of certainty approach is exactly what makes the most sense, if the day ever comes.

Paradoxically, by standardizing treatment whenever possible you're actually focusing on the patient - on the patient's actual needs. Needs for access to effective, safe, efficient, timely, and clinically sustainable care. And you're focusing less on the provider's needs - for convenient processes, for latitude to follow the provider's preferences and creative urges, and (in the case of corporations) for orienting care processes towards developing and protecting profit streams.

Keith Wilson
09-27-2013, 01:21 PM
. . . argued for the creativity involved in the "workmanship of risk" rather than the "workmanship of certainty." Oy! Bloody romantic, he is. You're quite right; if you want to make art, risk is fine - if art doesn't work out nobody dies, or even loses much money. If you want to make something that has to work, you want as little risk (at least after the prototype stage) as possible. One of the things I tell the guys working for me - "What do you call a production machine that works 99%? A disaster." If something in my body goes wrong, I want science, not art, if I can possibly get it.

The physical aspects of medicine are sometimes an art, not a science, only because of our ignorance; i.e. when it involves something in the body we don't understand very well. Hip replacement we understand. The emotional/psychological/spiritual aspects are another matter.

htom
09-27-2013, 03:45 PM
Oy! Bloody romantic, he is. You;re quite right; if you want to make art, risk is fine - if art doesn't work out nobody dies, or even loses much money. If you want to make something that has to work, you want as little risk (at least after the prototype stage) as possible. One of the things I tell the guys working for me - "What do you call a production machine that works 99%? A disaster." If something in my body goes wrong, I want science, not art, if I can possibly get it.

The physical aspects of medicine are sometimes an art, not a science, only because of our ignorance; i.e. when it involves something in the body we don't understand very well. Hip replacement we understand. The emotional/psychological/spiritual aspects are another matter.


A whole lot of medicine is a science though - a production process even. Knee and hip replacements, and hernia repairs have been refined into very swift, standardized, repeatable procedures in many clinics which specialize in that line. The data's really clear on this: superior patient outcomes, great value for money, enormous efficiency. I want the person doing my knee replacement who's done 30 or more in the past month, and has his processes down cold. And I probably want it done in a specialized clinic with a crackerjack specialized team.

You're making my point. Even in the "well understood" knee replacement, it's art, neither engineering nor science. If it was either of those, the surgeon, team, ... would be irrelevant. If it takes skill to get good results, it's not science. Science does not depend on the skill of the scientist.

Science says wash the cut with soap and water, put Neosporin on the bandaid. Engineering makes the bandaid with enough stickiness to hold, not so much it hurts to remove, packages it and sterilizes it for use. And a four year old can do it to his younger sister without even a parent helping (other than to get the supplies.)

I hope ACA works, I really do. I don't think it will. It reminds me of those projects that have buried in the requirements "Using the second even prime number, ...."

TomF
09-27-2013, 04:02 PM
Science says understand the underlying condition accurately, identify the best practice intervention. Engineering says eliminate as much variation from that intervention as possible, identify and reduce the waste in the process of intervening, driving as much value as humanly possible out of it both for the patient and the system in which care is provided.

There is always art present in good craft, whether the craft is medicine or writing or making a wooden chair with hand tools. But making high quality services and interventions available to the broadest possible population is far less about art, and far more about process standardization and optimal design. At best, an applied rather than a pure art.

John Smith
09-27-2013, 05:12 PM
THIS is this problem. Private health insurance companies will still be the ones calling the shots. That's why this iteration will fail. However, I still think it's a step in the right direction. BTW, during my training, I worked in both the VA and Indian Health Service. Both were disasters. I owed 3 yrs of active duty to the USAF after training and got to experience Tricare. We called it "Trying to Find Care."

Actually, the government is simply changing the rules under which private insurance companies function.

John Smith
09-27-2013, 05:14 PM
The new law requires private insurers to pay out 80% of premiums for actual medical care - and they kicked about that. The equivalent figure for Medicare and Medicaid is around 97%

Now you're into the dark corners of the human psyche. Are you sure you want to turn over that rock? I'll be partially sarcastic and list a few.
- I've got mine; screw everybody else.
- Taxes are theft.
- The government shouldn't do anything to help people unless they're already well-off, hence deserving. If it tries, it always makes things worse.
- Some people don't deserve help; you can identify them by their lack of money.
- The US health care system is the best in the world. Evidence to the contrary is socialist propaganda.

I believe that's 80% of their total revenue, not just premiums. As I recall, rates went up substantially a while back when insurance companies took a hit in the stock market.

John Smith
09-27-2013, 05:15 PM
The USA has some of, if not the very best health care available in the world if you're a patient.

The USA has absolutely the very worst way of paying for health care in the world.

The philosophical problem is that medicine is an art, not a science. You have to treat patients, not diseases. People are not robots that need their oil changed and hinge pins replaced. Science can aid in the treatment of patients by providing information about the known and studied treatments, but it provides little correct guidance as to which treatment is best for which patient. It can confirm that the "best" treatment or "cheapest" treatment is not working for a particular patient, and in that case, a "less best" or "less cheapest" treatment is actually the better treatment for that patient. Having insurance companies or government committees require their abstract evaluations take precedence over that of the considered expert opinion of trained medical professionals is a prescription for bad medical practice.

What's this got to do with the ACA?

John Smith
09-27-2013, 05:21 PM
You're making my point. Even in the "well understood" knee replacement, it's art, neither engineering nor science. If it was either of those, the surgeon, team, ... would be irrelevant. If it takes skill to get good results, it's not science. Science does not depend on the skill of the scientist.

Science says wash the cut with soap and water, put Neosporin on the bandaid. Engineering makes the bandaid with enough stickiness to hold, not so much it hurts to remove, packages it and sterilizes it for use. And a four year old can do it to his younger sister without even a parent helping (other than to get the supplies.)

I hope ACA works, I really do. I don't think it will. It reminds me of those projects that have buried in the requirements "Using the second even prime number, ...."

I have no doubt it will work a great deal better than what we had before the ACA. Saying that, it is still far short of the single payer system I'd like to see.

Let me talk again about my granddaughter's boyfriend, who suffered a minor concussion in high school football. He can stay on his parent's plan longer than he would have been able to before the ACA. When he outgrows that plan he will not be denied health insurance because of the pre-existing football injury.

I have no doubt that the individual states will have considerable impact on how well it works.

As Obama said today, and I fully agree with him, anyone who wishes to offer improvements to the bill and work through the problems it will undoubtedly have, I'm open to listening.

The GOP has chosen not to take that route.

Keith Wilson
09-27-2013, 09:51 PM
Eh? Sorry, I misplaced my secret decoder ring. Check out the NY exchange (link here (http://info.nystateofhealth.ny.gov/)).

Shang
09-27-2013, 10:52 PM
...I think it takes the worst of federal medicine, corporate medicine, and insurance company medicine, wraps that collected worst in federal and state paperwork, and it is doomed to fail.

No, there is no reason to suppose this. Gawd knows that the Affordable Care Act couldn't be worse than the present system of "private health care administrators," but those are going to be better regulated under the ACA.]

...I expect that I will be made to change medicines I've used for decades, because there are cheaper "substitutes"

No, probably not. But this has been one of the major problems with private "Health Care Providers," they could order you to take generic drugs or pay a premium price for the real thing any time they pleased, to boost their own profits.

...I think I will be made to change other medicines because the condition I'm being treated for isn't considered treatable for people my age...

Have you been listening to what has been said about "pre-existing conditions? Your insurer can't kick you out any more.

...I think I'm going to be given grief and rate hikes over my weight

Well...you'd be happier and healthier, but that's your business.
Good luck to you!

...I have little faith in "government medicine". It may have saved my life a time or two in the past.

Good for you! And good for "government medicine." You owe them a debt.

...Now they claim I'm not a vet, but even if I was, I couldn't get into the WIC program because that's now closed until first of October...

Comon', htom you know, that the Republicans having been doing everything in their power to delay every aspect of the Affordable Health Care Act.

Come and join us. My health insurance rates are down, my HMO has sent me checks to pay for their increased profits, and today they announced that we no longer have to kick in "co-pays" for some of our medical costs.]

Things are getting better as the AFCA kicks in. DON'T LET the Right Wing screw it up.

htom
09-28-2013, 12:58 AM
As it happens, at the moment I'm in an HMO-like thing, Medica Advantage + Medicare. Around $300 a month for both.

John Smith
09-28-2013, 08:03 AM
No, there is no reason to suppose this. Gawd knows that the Affordable Care Act couldn't be worse than the present system of "private health care administrators," but those are going to be better regulated under the ACA.]

...I expect that I will be made to change medicines I've used for decades, because there are cheaper "substitutes"

No, probably not. But this has been one of the major problems with private "Health Care Providers," they could order you to take generic drugs or pay a premium price for the real thing any time they pleased, to boost their own profits.

...I think I will be made to change other medicines because the condition I'm being treated for isn't considered treatable for people my age...

Have you been listening to what has been said about "pre-existing conditions? Your insurer can't kick you out any more.

...I think I'm going to be given grief and rate hikes over my weight

Well...you'd be happier and healthier, but that's your business.
Good luck to you!

...I have little faith in "government medicine". It may have saved my life a time or two in the past.

Good for you! And good for "government medicine." You owe them a debt.

...Now they claim I'm not a vet, but even if I was, I couldn't get into the WIC program because that's now closed until first of October...

Comon', htom you know, that the Republicans having been doing everything in their power to delay every aspect of the Affordable Health Care Act.

Come and join us. My health insurance rates are down, my HMO has sent me checks to pay for their increased profits, and today they announced that we no longer have to kick in "co-pays" for some of our medical costs.]

Things are getting better as the AFCA kicks in. DON'T LET the Right Wing screw it up.

A lot of hogwash. My Blue Cross demands a generic if it's available unless the doctor specifically requires the non generic. I expect that's been common practice throughout the health insurance industry for years.

Y Bar Ranch
09-28-2013, 08:31 AM
You're making my point. Even in the "well understood" knee replacement, it's art, neither engineering nor science.
As someone who does and has done science and engineering both on a daily basis, I'll tell you straight out they are both arts in the fullest sense. Medicine and engineering of complex systems (e.g., stock market, internet, anything involving humans, an operating system) both try to understand and modify things not fully understood or likely understandable.

Engineering is the art of modelling materials we do not wholly understand, into shapes we cannot precisely analyse so as to withstand forces we cannot properly assess, in such a way that the public has no reason to suspect the extent of our ignorance. Dr. AR Dykes
British Institution of Structural Engineers, 1976

John Smith
09-28-2013, 08:52 AM
As someone who does and has done science and engineering both on a daily basis, I'll tell you straight out they are both arts in the fullest sense. Medicine and engineering of complex systems (e.g., stock market, internet, anything involving humans, an operating system) both try to understand and modify things not fully understood or likely understandable.

Engineering is the art of modelling materials we do not wholly understand, into shapes we cannot precisely analyse so as to withstand forces we cannot properly assess, in such a way that the public has no reason to suspect the extent of our ignorance. Dr. AR Dykes
British Institution of Structural Engineers, 1976

I think a great deal of medicine is trial and error or educating guesses. Doctor looks at your symptoms and looks at probabilities of cause based on his experience and education. He likely has several possible tests he can have the patient take, and makes his choice through an educated guess as to which is most likely to help reach the proper diagnosis.

Shang
09-28-2013, 09:22 AM
As it happens, at the moment I'm in an HMO-like thing, Medica Advantage + Medicare. Around $300 a month for both.

Good!
You should make out just fine under the ACA.

htom
09-28-2013, 07:26 PM
I think a great deal of medicine is trial and error or educating guesses. Doctor looks at your symptoms and looks at probabilities of cause based on his experience and education. He likely has several possible tests he can have the patient take, and makes his choice through an educated guess as to which is most likely to help reach the proper diagnosis.

I mentioned an echo cardiac stress test above. I had had sudden huge chest pain, ... five-lead ADF said "Transport immediately." After all of the excitement, the three (!) cardiologists came up with three very different opinions as to what had happened to me. They were all certain that I had not had a heart attack and there was nothing wrong with my heart or lungs or ... -- and that it had not been something "in my head". "Don't worry about your heart. I hope when I'm your age my heart is that good." Those three things were tested for, all were possible but unlikely, they were minor things that couldn't even be treated and didn't affect my health (other than causing that pain.) "Really, we don't know. You seem to be one of those patients that can accept that."

Losing weight would be good, but very very slowly, not something to worry or stress or go on a diet or make big changes for. Walk/jog/run/lift a little more, eat a little more protein, a little less sugar and white food. Be careful to stay above 1800 or 2000 calories a day. A pound a month would be ideal. "Looking at what you ordered for your five meals here, you're eating healthier than I am."

The five-lead thing's warning was goofed up because of my auxiliary nipple, which has a nerve that confused it. This is a known problem that can't be compensated for, because where that nerve (if it exists, you can have the nipple and not the nerve and vice versa) goes is not visible.

oznabrag
09-28-2013, 07:48 PM
I respectfully disagree. The primary problem withthe American medical systems is that some people have health insurance and some don't. If everyone had insurance, the paperwork would be pretty simple - a claim form and some documentation. Of course, each insurer will have its own claim form and process so that complicates thigs a bit. It would be even simpler if we had a single payer system. Then the would be only one claim form. The paperwork mountain you describe exists because there are multiple forms from multiple agencies and insurers that need to be filled out to determine which agency or insurer should pay what percentage of each bill and what exceptions, fee reductions and subsidies the patients qualify for.

I agree with both of you!

Medicare runs at a pitifully small overhead because there are not armies of vultures poised to deny care for all conceivable justifications, and because the paperwok is pretty simple compared to the rest of these ghouls. Yes, Ghouls. You know, the ones who feast on freshly dead human corpses. Otherwise known as Medical Insurance Executives.

The other problem is that everyone is not covered. Having ABSOLUTELY EVERYBODY in the risk pool lowers premiums.

That is why universal, single-payer health insurance is the ONLY sane answer to this riddle.

David G
09-29-2013, 11:00 AM
The local daily has a financial reporter who normally advises about such things as portfolio balancing and mutual fund nuts & bolts. He's a moderately conservative and cautious sort. Normally very careful in his recommendations. He has the following to say about ACA:



http://www.oregonlive.com/finance/index.ssf/2013/09/cover_it_oregon_give_health_ex.html#incart_river



It's finally here. The new health insurance exchange, Cover Oregon (http://coveroregon.com/), our own slice of the cornerstone of federal health reform, opens for browsing Tuesday.

And just as I tell you to turn off CNBC when investing, it's time to turn off MSNBC and Fox News if you're considering a new health plan.


The Oregonian's health reporter, Nick Budnick, wrote eight stories and two helpful graphics on the topic in Section R of today's paper (http://orne.ws/2013-health-marketplace). Spend some time with it. His sources even provide tips on what to consider beyond premiums (http://topics.oregonlive.com/tag/2013%20health%20marketplace%20special%20section/posts.html) when shopping.


Sadly, predictably, the political naysayers are out in force, bent on telling you not to shop.


Generation Opportunity (http://generationopportunity.org/), a conservative group backed by oil tycoons Charles and David Koch, unveiled ads the group has dubbed "Creepy Uncle Sam." One ad (http://www.youtube.com/watch?v=R7cRsfW0Jv8&feature=share&list=PLs2QceHTXzgzzxtFeycNmTbPYWSzOnStV) shows an attractive young woman finding herself getting a surprise pelvic exam by someone in an oversize Uncle Sam suit.


The woman musters a weak scream before the tagline fills the screen: "Don't let government play doctor. ... Opt Out of ObamaCare." We get one last image of Uncle Sam creaking open the blades of a speculum.
Another ad (http://www.youtube.com/watch?v=BsN75nt1aUU&feature=share&list=PLs2QceHTXzgzzxtFeycNmTbPYWSzOnStV) involves a young man, a proctology exam and a blue glove.


It's all pretty cynical and tasteless. But these kind of bad-sportsmanship attacks aren't surprising. They've happened before.



When President Franklin Roosevelt championed Social Security in the 1930s, opponents used loaded words such as "socialism" or "communism" to attack it, said Southern Oregon University history professor Paul Pavlich (http://www.sou.edu/history/faculty/pavlich.html). It was a different time, though. In the wake of the Great Depression and the runup to World War II, "significant parts of the population were not opposed to giving socialism a try," Pavlich said.


After Congress created Medicare in 1965, some physicians started a movement to boycott it by refusing to see Medicare recipients, said Steven Howard (http://www.slu.edu/x53476.xml), assistant professor of health policy at St. Louis University (formerly at Oregon State). That dissipated as private businesses discovered loopholes that created other opportunities.


One of those is today known as Medicare Advantage, in which private insurers deliver Medicare services. Research suggests (https://research.hks.harvard.edu/publications/faculty_name.aspx?PersonId=21) some of those plans now provide patients better care than traditional Medicare.


Today, though, emotions and political leanings are running high and are easily aired.


Last week I wrote a blog post and a story about the health exchange (http://www.oregonlive.com/finance/index.ssf/2013/09/money_reads_honesty_on_health.html#incart_river) and notices of new premium increases (http://www.oregonlive.com/finance/index.ssf/2013/09/notices_of_health_insurance_ch.html#incart_river) that some Oregonians face. A few readers accused me of kicking up opposition against the Affordable Care Act.


Others said I was "pro Obamacare" and tolerating online commenters who, one reader was convinced, just had to be Cover Oregon employees paid to promote the program.


As with investing, emotions are exactly what you don't want clouding your thinking. Not while evaluating insurance.
To be fair, some people, indeed, are going to pay more for their health care (http://www.oregonlive.com/finance/index.ssf/2012/07/plan_now_for_tax_impacts_of_he.html) from now on.


Some will find insurance considerably more affordable on the exchange and, as a result, buy it or leave their employer to start their own venture.


Some will finally get insurance after being denied based on an existing health problem.


So far, it appears, 2014 insurance premiums for individual policies have come in lower (http://www.oregonlive.com/health/index.ssf/2013/05/oregons_low_health_premium_fil.html) than experts feared. But the details of each policy remain hard to come by until Tuesday. Drug co-insurance requirements, deductibles or provider networks all should play a role in your decision.


If you opt out, as the Koch brothers would have you do, most of you will pay a penalty. In 2016 it reaches $695 per adult or up to 2.5 percent of family income.


From an economic standpoint, that might make sense. But insurance is about steeling yourself against the unthinkable: accidents, illnesses, things like stock market dives that we cannot predict.


Only you can judge your appetite for such risk. A Koch brothers/Uncle Sam puppet can't.


And you won't be able to just run out and get insurance if you get a cancer diagnosis or severed leg. You will have to wait for open enrollment, which in future years will begin Oct. 15, or hope that a "qualifying event (https://www.healthcare.gov/glossary/qualifying-life-event/)" comes along, such as a marriage, divorce, birth or a move to another state.


No, political pundits and talking heads know little about your personal needs, your budget, your health. I don't know those specifics either.


Shopping for health insurance on the open market will be a personal, complicated affair. But it's the type of minefield for which you ought to seek a guide.


Insurance agents and brokers are one good option. Their help is free, their commissions wrapped up in the premium you pay.


Staff and volunteers from community organizations around the state will be certified and trained as application assistants to help sign up Oregonians.


CoverOregon.com (http://coveroregon.com/) will have a searchable database of these agents and helpers. Readers in states without exchanges can search for local helpers at localhelp.healthcare.gov.


Cover Oregon also will have a customer service center at 855-268-3767.


It's also an enormous new undertaking. Things won't always go smoothly. We'll have a better sense in a year or two how it's really working.


When it comes down to it, I fear many readers will have to carve out more room in their budgets for health insurance or the penalties. You'll have to pick between insurance for the unpredictable and cable, salon visits or (ironically) a gym membership.


Of course, we've already been dealing with rising rates for years. I think the Affordable Care Act's mandates (http://kff.org/health-reform/fact-sheet/summary-of-new-health-reform-law/) aimed at curbing costs -- more preventive care, for one -- are worth a shot.


Give it some time to work.


Give Cover Oregon a go (http://www.coveroregon.com/) this week.