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View Diary: Durbin takes Social Security off the table (216 comments)

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  •  He also put other "entitlements" on the table (10+ / 0-)

    He said that specifically.  That means Medicare and Medicaid.  And, of course, there's no way Republicans agree to more revenue, whether through capping deductions, increasing rates, or a combination of the two, without something like the President's "balanced" approach of $2.50 in cuts for every dollar in revenue.

    •  Does that include the ACA "cuts" ? (3+ / 0-)
      Recommended by:
      joe from Lowell, pistolSO, Cedwyn

      If so, that'll be fine.

      Those cuts target providers and suppliers, not patients.

      Show us your tax returns !!!!!!

      by Bush Bites on Sun Nov 25, 2012 at 08:53:21 AM PST

      [ Parent ]

      •  ACA helps reduce the deficit (13+ / 0-)

        over the long term.  To make cuts now would be foolhardy.

        Please stand by. I'm looking for a new sig line.

        by Betty Pinson on Sun Nov 25, 2012 at 09:04:45 AM PST

        [ Parent ]

      •  Like provider cuts don't affect beneficiaries? (8+ / 0-)

        Of course they do.  Doctors who take Medicare patients are getting harder to find.  That's why Congress always has done the "Doc Fix" so as to AVOID significant provider cuts.  

        •  Your cited survey says Medicaid, not Medicare. (3+ / 0-)

          And the reasons for not taking have nothing to do with the payment system and everything to do with how the state runs the program. But notably, in the article you cite, the doctors who don't want to treat the poor on Medicaid say "we would treat them if you gave us more money!"

          LOL. Well, yeah. I suspect you would!

          I wouldn't worry about it though. That argument is quite meh on the merits. Doctors will treat the sick first and make it pencil out later. If they don't, they shouldn't be doctors in the first place.

          •  That's just unrealistic. Ezra Klein (5+ / 0-)
            Recommended by:
            3goldens, divineorder, VClib, askew, chuckvw

            explained exactly how big provider cuts to Medicare will affect beneficiaries and perhaps increase private insurance costs as well.

            •  Yes, it does mean one less BMW in the driveway. (5+ / 0-)

              They'll have to downgrade to a Honda. Somehow I think they'll muddle through.

              But the idea that this means doctors are going to stop treating sick people is preposterous. If they don't want to accept Medicare or Medicaid, they're going to find themselves with a big problem because ObamaCare is going to start curbing what they get from the private insurers as well.

              Doctors have been living pretty damn good in this country, which pays its doctors far far in excess of what doctors make in other countries.

              They're going to have to shut up and take it. Go to Myrtle Beach instead of Cancun.

              •  No, they are going to treat sick people with (7+ / 0-)

                private insurance.  And (did you read Ezra Klien?) private insurance is going to make up the difference, as it has in the past.

                If there were an overabundance of doctors, and they were hurting for business and needed to take whatever walked in the door, you might be right.  But there's already a shortage, and that shortage is only expected to get worse.  That means that doctors are going to be able to CHOOSE which patients they treat.  And any sane doctor is going to choose to treat as many private insurance patients and as few Medicare/Medicaid patients as possible.  Because that's the clear financial incentive.  

                You already have a significant number of doctors who won't accept new Medicaid patients.   That's because they can fill up their practices just fine with people who pay more, through private insurance.  You're about to add a whole bunch more people with private insurance, which pays much, much better.  And if you add to that cuts in what they get for treating Medicare patients, the financial incentive is to make your practice as much private insurance as possible.  If you can fill your days with private insurance patients (say, 2000 hours a year), what's the incentive to work over and above that to take Medicaid or Medicare patients?  Your return on those extra hours is very small.  

                •  That piece was not from Ezra Klein. (8+ / 0-)

                  It is by Sarah Kliff, who is not a policy analyst and is a staff writer who came to the Washington Post from Politico, where she was also a corporate talking points stenographer.

                  And low and behold...who does she quote on how bad this will be for providers?

                  The providers! How coincidental!

                  •  How about the Medicare chief actuary? (2+ / 0-)
                    Recommended by:
                    VClib, OleHippieChick

                    See here for a video of him testifying before Congress.  

                    And Here:  "Medicare’s chief actuary has warned repeatedly that Obama’s cuts to the future growth of payments to hospitals are too deep to be absorbed without adverse consequences."

                    According to the Medicare chief actuary, significant provider cuts will impact what providers serve Medicare patients, just as it already affects what providers will see Medicaid patients.  He's on video saying precisely that.  

                    •  Apples and Oranges. (3+ / 0-)

                      What he is talking about is a sharp drop off in the reimbursement rate as result of failing to pass the doc fix. N obody is proposing that. Nobody has ever proposed a sharp 30% cut. That is the reason they keep doing these doc fixes.

                      The point is not to keep doc fixing, but have gradual path downward. That is why the proposals center around phasing out fee for service and going to a Mayo Clinic model.

                      Yes that does mean certain doctors offices will close. But it wont be a catastrophe and it will be gradual and most doctors will find a way to cope.

                      Dont apply the same anaysis to two different things.

                      •  bbb - in some areas, including mine (2+ / 0-)
                        Recommended by:
                        OleHippieChick, chuckvw

                        it is getting difficult to find a primary care physician who will accept a new Medicare patient at the current reimbursement rate and it is nearly impossible to find any who will take a new Medicaid patient. There is already a shortage of primary care physicians in the US so the notion that more will stop serving Medicare or Medicaid patients isn't reassuring.

                        "let's talk about that"

                        by VClib on Sun Nov 25, 2012 at 12:17:35 PM PST

                        [ Parent ]

                •  You keep switching between Medicare and (9+ / 0-)

                  Medicaid so often I'm not sure where this argument is going.

                  Who expresses concern over the physician shortage? Why the doctors of the AMA of course! lol Feeding talking points and quotes to a stenographer.

                  Look, the issue of doctor shortage has nothing to do with doctors not being paid enough money. God knows doctors are not poor by any stretch of the imagination. Even crap doctors make six figures.

                  The reason we have doctor shortage is because of the high cost of a medical education. And if we fix THAT problem, we will have an abundance of doctors and that will be that.

                  Another problem we have is doctors shouldn't be making business decisions of this sort anyway. What insurance to take. If they can't keep up a practice, then they should get a job. Which is how it works everywhere else in the world.

                  Doctors should wake up in the morning and think only about healing the sick and getting paid pretty damn good (but not excessively) for doing it. Any doctor who doesn't want to do that shouldn't be one.

                  Our health system should keep decisions about how and which insurance pays far from doctors.

                  •  The reason is that Medicaid is now (3+ / 0-)
                    Recommended by:
                    nextstep, Al Fondy, VClib

                    stingier than Medicare in provider reimbursements.  As a result, you have the shortage of doctors willing to accept Medicaid patients.  If you cut provider reimbursements for Medicare so that they are closer to Medicaid reimbursements, it's not illogical to assume that providers will treat them the same -- especially given the fact that the number of potential patients with private insurance will INCREASE with the ACA.  

                    Of COURSE doctors make business decisions.  All professionals do.  I'm a lawyer and I'm also a small business owner -- a professional practice is a business.  My firm takes some pro bono matters, as part of our professional obligations.  But, aside from that, if we can fill our hours with good clients who pay our standard billing rates, why on earth would we take clients who will pay only, say, only half our rates?  That would be just stupid.  I've worked a lifetime to build up my practice so that my services would be more valuable to people -- that's the whole point.  

                    And if doctors who didn't take Medicaid (or potentially Medicare if provider reimbursements were cut) couldn't find other patients, you might have a point.  But you are concurrently going to INCREASE the number of patients with private insurance, which pays much better.  If you were a doctor, and you had 2000 hours of your time a year to fill, which would you fill those hours with?  A doctor would be insane to do anything other than what is best for his/her business.  

                    Yes, it would solve the problem if you suddenly had a huge number of new doctors and doctors needed Medicare/Medicaid patients to fill their hours.  But then, of course, you'd get the "top doctors" taking only private insurance patients, and the "bottom of the barrel" or maybe the brand new doctors (those who, for whatever reasons, can't get enough private insurance patients) taking Medicare/Medicaid patients.  And --more importantly, I haven't seen any steps to provide that huge influx, which (if you started now) would take 10 years to see the results.  

                    Or maybe if you made all of health care a government function, and took it out of the hands of private business, you'd have a point -- doctors would be paid the same, regardless of who they saw.  But that's about as likely now as my wining that $300 million dollar powerball.  

                    As of now, a medical practice is a business.  It's just ludicrous to say doctors shouldn't be concerned about what they are paid for their services.  What business owner is not concerned about that?  

                    This is one of my pet peeves about the "progressive" view. Sometimes, it just doesn't recognize the realities of business.  And yes, a medical practice IS a business.  And saying, "they should just help sick people and not be concerned about what they get paid for it"  is just absurd.  Nobody runs a for-profit business that way.  

                    •  So, you agree the system is structured (3+ / 0-)

                      incorrectly and that the incentives are all wrong. That is exactly why we shouldn't be putting any more money into it.

                      The reason some doctors don't take Medicaid has nothing to do with reimbursement rates per se. It has to do with incentives. And you are correct: if you can can just take private clients and have no medicare or medicaid patients, then certainly... you have ever incentive to do so.

                      But my point is most people who have medicaid or medicare will get seen by a doctor if they are sick and the doctors will make it pencil out. Now why? Because you've got to be one sick fuck of a doctor not to treat someone who is ill because you arent getting enough scratch out of the deal. And if you are that kind of doctor, people should know that.

                      If we impose, they'll find a way to prosper. And still, people still get their Medicaid services and so will people in Medicare once it gets stingier.

                      The last folks we should be worried about here is doctors.

                      •  They will likely be seen by an emergency room (2+ / 0-)
                        Recommended by:
                        greenbell, VClib

                        if they are really sick.   But as a matter of regular practice, doctors can and will limit how many Medicare patients they see if reimbursements to providers are significantly cut.  They are already doing that with Medicaid, which has reimbursements that are now lower than Medicare.  If you cut Medicare reimbursements, why won't the same thing that is happening in Medicaid happen to Medicare?  In a regular practice, a doctor cannot see every possible patient that wants to see him or her.  There aren't enough hours in a day.  There aren't enough doctors.   See my link to the statements of the Chief Medicare Actuary above, who says exactly that.  

                        I'm not worried about the doctors.  They will fill their practices with all those millions of people who now have private insurance and be just fine.  My concern is for my elderly parents not being able to find a nearby doctor that takes Medicare -- just as people (depending on what state you are in) are already having trouble finding doctors nearby who will accept Medicaid.

                      •  The people I worry about (3+ / 0-)
                        Recommended by:
                        greenbell, cslewis, HCKAD

                        are those who will be unable to find primary care using either Medicare or Medicaid without supplemental - for profit - insurance. Many will be unable to afford the latter.

                        This is the tragedy behind ballyhooing a "health care reform" program that is actually a price support program for private insurance.

                        Even before the cuts that are coming... Because we must all feel the pain... And when it gets bad enough we'll go to the emergency room!

                        Those who do not move, do not notice their chains. Rosa Luxemburg

                        by chuckvw on Sun Nov 25, 2012 at 02:38:02 PM PST

                        [ Parent ]

                      •  bbb - physicians don't see people who are ill (0+ / 0-)

                        if they are not already a patient. Physicians can exclude Medicare and Medicaid patients and never see them, regardless of the patients need for healthcare. The exception is the emergency room. That is the only place where treatment is mandatory.

                        "let's talk about that"

                        by VClib on Sun Nov 25, 2012 at 05:31:12 PM PST

                        [ Parent ]

                •  I don't know about your insurance (0+ / 0-)

                  company, but mine doesn't pay much of anything to doctors. Pretty much in line with what the government (and its subcontracted insurers) pay. That's why people with no insurance have to pay more, and that little problem is endemic. Doctors might find themselves doing better on the bottom line if their renumeration was fair across the board for all their patients.

                  Let's face it. There are only so many rich people who can pay out of pocket for expensive medicine (and even they often negotiate). Hence only so many plastic surgeons are needed in any given area of rich people to do those lifts, tucks, nose jobs and implants.

              •  You don't get it. In many places Medicaid almost (2+ / 0-)
                Recommended by:
                Calamity Jean, nextstep

                always pays an amount well below the cost of treatment.  As long as the payments stay below the actual costs then doctors will have to limit the number of Medicaid patients they accept otherwise they will go out of business.

                You have watched Faux News, now lose 2d10 SAN.

                by Throw The Bums Out on Sun Nov 25, 2012 at 11:56:41 AM PST

                [ Parent ]

        •  My condolences to the Doctors who cannot make (2+ / 0-)

          a million. Insurance companies are often as willing to fight back as Medicare is and the doctors who don't like it will either have to deal or just gouge the carriage trade.

          The GOP is the party of mammon. They mock what Jesus taught.

          by freelunch on Sun Nov 25, 2012 at 09:59:53 AM PST

          [ Parent ]

          •  A typical fallacy in thinking (3+ / 0-)
            Recommended by:
            VClib, chuckvw, greenbell

            "Well, they will just keep doing what they are doing and make a lot less money" is the typical fallacy in thinking.

            No, they won't.  People change what they are doing if they suddenly are faced with making a lot less money.  There's a big shortage in doctors now who will accept Medicaid patients.  Significantly cut provider reimbursements in Medicare, and you have the same situation in Medicare.  

            If there were an overabundance of doctors, then maybe you could find some -- typically, the ones not in demand -- who are willing to make a lot less money for those years and years of very expensive education.  But there aren't.  There was a doctor shortage before the ACA, and the additional people with insurance coverage after the ACA takes full effect is only expected to exacerbate that shortage.  Which means that most doctors won't have to take Medicare and Medicaid patients  -- or at least very many -- to keep a full schedule.  If a doctor can fill 2000 hours or so a year with private insurance patients, why on earth would he or she work an extra 500 or so to take Medicare/Medicaid patients?  There are very very diminishing returns on those extra hours. The incentives are all against taking Medicare/Medicaid patients.  

            •  Then we will train doctors who will care (9+ / 0-)

              I don't want any doctors to be motivated only by their greed. It does not make them good doctors. We pay doctors far more in the US than anywhere else in the world. Insurers are cutting back on what they will pay just as Medicare and medicaid did. Still the doctors are extremely well paid.

              Yes, there is a shortage of doctors and it can be alleviated by changing immigration laws and by creating more medical schools and increasing the number of seats in the schools that exist now. The doctor shortage is purely a result of artificial limitations on the number of people allowed to be trained as doctors for practice in the United States. The AMA should be the leaders in reform, not the stumbling blocks for it.

              The GOP is the party of mammon. They mock what Jesus taught.

              by freelunch on Sun Nov 25, 2012 at 10:29:45 AM PST

              [ Parent ]

              •  And is that happening? (1+ / 0-)
                Recommended by:

                I haven't seen it.

                •  yes; the ACA has all kinds of incentives (0+ / 0-)

                  for people to go into medicine.  it's also true that nurse practitioners et al can do a lot.  i'm sorry, but one does not need a medical degree to take a throat culture and diagnose strep.

                  those kinds of expansions are going to make a difference, and there are programs for doctors via PPACA as well.

                  Please don't dominate the rap, Jack, if you got nothin' new to say - Grateful Dead

                  by Cedwyn on Sun Nov 25, 2012 at 07:00:13 PM PST

                  [ Parent ]

              •  Training doctors to care won't help because (3+ / 0-)
                Recommended by:
                VClib, coffeetalk, greenbell

                the problem is simple math.  If the Medicaid payments are less than the actual costs of the treatment (and in most cases, that is true) then there is a hard limit on how many Medicaid patients they can accept without going bankrupt and no amount of training will change that fact.

                You have watched Faux News, now lose 2d10 SAN.

                by Throw The Bums Out on Sun Nov 25, 2012 at 12:00:07 PM PST

                [ Parent ]

                •  TTBO - I have several close frieds who are (2+ / 0-)

                  primary care physicians and we talk about practice economics all the time. Given their overhead they lose money, even on a marginal cost basis, on all Medicare patients at current reimbursement rates. They have all stopped taking new Medicare patients. They will keep long term patients who turn 65 and start Medicare, but they won't take new ones. They have long ago stopped taking Medicaid patients where the reimbursement is even lower and the patients are the most expensive to serve.

                  "let's talk about that"

                  by VClib on Sun Nov 25, 2012 at 12:32:31 PM PST

                  [ Parent ]

              •  freelunch - who is going to do that? (1+ / 0-)
                Recommended by:

                I think one of the major failings of our political system is the lack of recognizing that we have a shortage of primary care clinicians. Where is the federal program to do many of the things you suggest, including expanding the number of primary care physicians, PAs, and nurse practitioners? Without it you will see the established medical practices just continue to eliminate Medicare and Medicaid patients. From what I see in my area that has been happening for five years and is accelerating. Any one physician can only treat a fixed number of patients and it makes economic sense for them to pick a patient population that provides the best income stream. There are consultants who run successful businesses just assisting physicians on exactly how to do this.  

                "let's talk about that"

                by VClib on Sun Nov 25, 2012 at 12:28:43 PM PST

                [ Parent ]

                •  Seems like a good subject to start turning screws (2+ / 0-)
                  Recommended by:
                  VClib, Kentucky DeanDemocrat

                  for. Why not have the govt pay for med school in return for a number of years' domestic service. Powerful motivation.

                  I ♥ President Obama. ~ Yes, we did. Again.
                  NOW: Hands off SocSec, Medicare and Medicaid. NO Grand Bargain.
                  Rich pay a bit more. DoD take a bit less. End war on Afghanistan sooner.

                  by OleHippieChick on Sun Nov 25, 2012 at 01:38:50 PM PST

                  [ Parent ]

                  •  OHC - I think the key is to have the gov't (3+ / 0-)
                    Recommended by:
                    pistolSO, OleHippieChick, greenbell

                    fund the expansion of slots in med school and primary care. I think we have plenty of qualified students. Some financial incentive to enter a primary care residency, rather than the higher paying specialties would also need to be a part of it as you suggest.

                    "let's talk about that"

                    by VClib on Sun Nov 25, 2012 at 01:52:46 PM PST

                    [ Parent ]

                    •  Well sure. I always simplify things, (1+ / 0-)
                      Recommended by:

                      and there are parts I'm not thinking of like opening more med school/pc slots.
                      I'm saying do whatever it takes to get this done in prep for the coming denial of service to the old and poor. I'ma drop a note to the President and will include what you said.

                      I ♥ President Obama. ~ Yes, we did. Again.
                      NOW: Hands off SocSec, Medicare and Medicaid. NO Grand Bargain.
                      Rich pay a bit more. DoD take a bit less. End war on Afghanistan sooner.

                      by OleHippieChick on Sun Nov 25, 2012 at 02:37:33 PM PST

                      [ Parent ]

              •  With good qualifications for Med school, (1+ / 0-)
                Recommended by:
                Kentucky DeanDemocrat

                (iow, no fools), perhaps tuition costs could be guaranteed by a number of years' govt service, eg, a practice serving Medicare/Medicaid patients or VA patients in more local micro locations.

                I ♥ President Obama. ~ Yes, we did. Again.
                NOW: Hands off SocSec, Medicare and Medicaid. NO Grand Bargain.
                Rich pay a bit more. DoD take a bit less. End war on Afghanistan sooner.

                by OleHippieChick on Sun Nov 25, 2012 at 01:34:19 PM PST

                [ Parent ]

        •  The only way to significantly cut (6+ / 0-)

          into deficit spending on health care is to nationalize the system - single payer, all clinic and hospital costs covered, doctors receiving adequate and fair salary enough to justify the career choice. Government coverage of education (doctors, nurses, technologists, etc.) in exchange for rotating placement in underserved areas.

          Medicine is a fine choice of career on all levels and should be encouraged and rewarded up and down the line. It's public service oriented even for those who get into it for the imagined fortunes they'll make, trick is to get them young enough to accept that while they're professionals who had to pass through years and years of intense training, they're still working class - people who actually work (often hard and for long shifts) for their living. Their pay should cover their and their families' needs and many of their wants.

          APA is going to take some of the pressure off, but a real universal health care system would do some serious damage to deficit increases. Cradle-to-grave health care makes both Medicare and Medicaid superfluous. We might even find that at some point down the road our health care outcomes start looking more like those of a modern first world country.

    •  And most people don't get that it's Medicaid that (14+ / 0-)

      pays the majority of elderly nursing home 'warehousing'.  Won't those 40 and 50 somethings be pissed when they find out that not only do they need to sell off their parents assets (and that most definitely does not mean passing out inheritances 'early' - and that includes furniture and jewelry along with financial/real estate portfolios) and 'dip' into their own financials to pay for their parents care, should they not take the task upon themselves.  Or are they going to let their parents 'rot' all the sooner??

      Now, if they were talking cuts in the way of 'allowing' for negotiating drug prices at the upper levels..... and stuff (durable medical supplies, PET, CAT, MRI hardware) along those lines.. yeah....

      •  Wow. (1+ / 0-)
        Recommended by:

        I understand where you're you're coming from, but as a person that is going through that process of getting my father qualified for Medicaid and trying to preserve whatever I can for my mother, your post seems, shall I say, insensitive?  Really it's more like insulting.

        I'd rather have a bottle in front of me than a frontal lobotomy.

        by beemerr90s on Sun Nov 25, 2012 at 10:01:19 AM PST

        [ Parent ]

        •  Medicaid rules will vary from state to state. I (6+ / 0-)

          was pointing my opinion towards those that voted Republican and/or don't care to find out how Medicaid actually works.  Not towards those that are trying to do right by their parent(s), which it sounds like what you are doing.  

          You wouldn't believe how many people think that either Medicare and/or Medicaid will pay for all nursing home costs and whatever assets the parents have will go to the kids instead of the parents care in old/frail age.  There is an inordinate amount of nursing homes that are not much more than warehouses as the children seldom ever visit.  While it's not unilaterally true that all the kids don't visit, it's not uncommon for children to visit less often after the first couple of years of their parents admittance to the facility (for any number of reasons).

    •  That was before the election. Voters voted to (8+ / 0-)

      increase taxes on the rich. They did NOT agree to horse trade SS and Medicare cuts for it.

      The Class, Terror and Climate Wars are indivisible and the short-term outcome will affect the planet for centuries.

      by Words In Action on Sun Nov 25, 2012 at 10:34:44 AM PST

      [ Parent ]

      •  Well, if they voted for the President (3+ / 0-)
        Recommended by:
        seabos84, VClib, nextstep

        then yes they did, at least for Medicare and Medicaid:

        Obama, if he wins, will assert that voters had a choice — and his vision on taxes, entitlements and the deficit prevailed.

        “If I’ve won, then I believe that’s a mandate for doing it in a balanced way,” Obama said this week in an interview on MSNBC’s “Morning Joe.” “We’ve already made a trillion dollars worth of cuts. We can do some more cuts. We can look at how we deal with the health care costs in particular under Medicare and Medicaid in a serious way. But we are also going to need some revenue.”

        "Balanced approach" is exactly the same rhetoric the President used when he put Medicare and Medicaid on the table in the 2011 negotiations.
      •  They voted and are no longer relevant... (1+ / 0-)
        Recommended by:
        Words In Action

        Those who do not move, do not notice their chains. Rosa Luxemburg

        by chuckvw on Sun Nov 25, 2012 at 02:44:56 PM PST

        [ Parent ]

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