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As I write this, I'm not really certain how constructive it is to say this, but I know at least that it's the truth, and it's probably a truth that people around here should face at some point.

I hope that Obama will win.  If he does, we are more likely to see Obamacare survive.  If that happens, we will have succeeded in maintaining one of the most expensive, yet least effective health care systems in the world.  If we lose, it will get worse.

I'm in kind of a unique position.  I'm a medical transcriptionist who works from home, processing medical reports all day, while at the same time surviving on about $1000 a month.  I'm also a disabled person who badly needs my medication.  Those three traits combined make me extremely aware of the state of medical care in this country, and when I listen to the political dialogue out there, it becomes very clear to me that most people even at dailykos aren't.

Today, the general practitioner is a position which no doctor wishes to fill, because they are paid less than ever before.  For that reason, we are moving more and more to hospital and emergency room based care than ever before, and Obamacare not only doesn't solve that problem, it actually makes it worse.  The trend of cutting costs essentially gives the message that we think doctors have too much time to see their patients, so we need to force them into seeing even more people in a day.  That of course, means they will spend less time with each patient.

When I process a new medical record, there is something like a 30 percent chance that the person I get speaks English as a second language.  It's a problem for me to understand them, but what is more interesting from a community standpoint is what it says about our health care system.  Specifically, what it says is that increasingly Americans don't want to practice medicine in this country any more, and we have to pull in people educated elsewhere here because they are the only people willing to work for the pay.  Our own doctors want to work as well-paid specialists who only freelance at hospitals.  

I'm constantly told by medical transcriptionists that the records which they see, whether from English speakers are not, are consistently worse as the years go by.  Doctors work faster and cut more corners, and pay less attention to each case they deal with.  We are constantly finding new ways to save a nickle, because Americans aren't willing to pay for health care, and then we lie to ourselves and say that won't result in a higher incidence of doctor mistakes.  Well mistakes are on the rise, and they will get worse under Obamacare specifically because of attempts under that bill to cut costs.

I see people complaining about the attitude the press takes when Romney lies his way through an interview and I can identify with that.  But I wonder if anyone understands just how deep in the hole we really are here?

We've been backed into a corner to the point that we are supporting a plan that will make things only moderately worse, because the alternative is someone who will effectively deny coverage to many millions of people.  We aren't fighting for positive change, we are supporting the part of our two-party system that is relatively sane and won't screw up things too badly.

Sometimes I get a report, and I know the instant I got it that the doctor was barely conscious when he made it.  Sometimes it's because they've been on the floor for days, and are describing a patient's visit that happened a full 24 hours ago.  I wonder if he forgot any details while he was constantly working over that time?

Increasingly, most doctors who see their patients are treating them in the same way they would if they saw them in the Emergency Room.  They can't actually remember their patients details any more, and many of them walk into the room with their chart, ask them a few questions, and come up with a response on the spot.  They don't remember them like individuals or have a coherent idea of what their problems are.  They just respond to what they see on that day, and by the time they see them again they will have forgotten that last appointment.  

Knowing the patient's history is how you catch cancer early; it's how you catch a lot of the hard-to-catch stuff.  That's what doctor's tell me, and some of them have told me that's why they are thinking of quitting.  They are tired of having to push people through their office faster than ever before; they are tired of not being allowed to effectively treat their patients.

And that folks, is one of the main problems of being treated in an Emergency Room, it's one of the reasons why having your own doctor was supposed to be better in the first place.  You wanted a doctor who actually knew you, but even your own doctor probably doesn't really know you any more.

The truth is that the important battles aren't fought come election time, they are fought in the minds of the public over the years.  Today, Americans have only one god, and that is the dollar.  They cut medical costs and insist that it's smart not to regulate anything that's going on because they want a bigger house or a better car.  It never seems to occur to them that when they have a heart attack, they are going to end up seeing the same overworked ER physician that all the poor people see.

The real fight is one that's been lost ever since Reagan got elected, and it happens in the hearts and minds of the public, and it effects the way they all vote.  It's what allows 'independents' to ignore Romney's obvious dishonesty, and vote for him anyway because they have this vague idea that if they vote for the millionaire, the economy will get better.  They know that the poor will get screwed, but on some instinctive level they hope they will be able to make enough money off the decision that it won't matter.  So they ignore forced ultrasounds and 'legitimate rapes,' and statements about how evolution is a lie from the pit of hell.  They hold their nose and vote for the Republican, because they don't really watch debates but they are sure they'll get a 5% raise in the next few years if they do.

That kind of thinking hasn't worked out well for the country, and it's only getting worse.  Sometimes I look at the situation, and I wonder if the answer here isn't the same one as when you watch an alcoholic killing himself.  If you try to help him up, he'll get up and go buy another bottle.  Maybe what needs to happen is the alcoholic needs to nearly kill himself, and when he has that moment where he look into the abyss, he'll finally understand what he's been doing to himself.

I'm in a very dark place in my life right now, and when I see this stuff I try to tell myself that it's just my mood blotting everything out.  But no matter how much I tell myself that, I think there is probably some value in pointing out that our health care system is not being saved.  As screwed up as my own life is, I wish I could look around and find something better in the world around me, but that just isn't what I see.  The part of the system I see is breaking down.  I don't know how much more it can take.

Obamacare was the result of a hundred compromises; and yet, even with all that ground lost it's still under sustained attack.  Americans have no values left; it's all about the money.  From the way they act, you might think you could bring your savings with you after a botched operation.  

Sadly, you cannot.

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Comment Preferences

  •  Fascinating report from the medical war zone n/t (5+ / 0-)
  •  The other side is only focused on one issue (2+ / 0-)
    Recommended by:
    Plu, martianexpatriate

    the economy and their taxes. It's no use telling them that Obamacare might help others with no insurance, or our health care system is broke. R/R have also done a good deal in demonizing the ACA- higher taxes, death panels, etc and getting the message out that Romney will repeal part of it.  Most distressing is that people don't seem to understand that ObamaCare is RomneyCare. I tried to tell my friend this and she stated that Romney stated he would repeal it.

    I don't know what to say except that many of the same people who complain about higher premiums, insurance costs and doctor bills are the ones that oppose Obamacare.

    •  Yeah Romney did say that (0+ / 0-)

      Obviously he said it because it's what his base likes to hear.  I don't think there is any point in listening to anything that Romney says at this point.  What he says has no connection with what he is really thinking.

      I don't know what to say except that many of the same people who complain about higher premiums, insurance costs and doctor bills are the ones that oppose Obamacare.
      That's true.  I think at some point though, as terrible as the conflict has been, we are going to need to revisit the issue of health care.  Hopefully in 10 years Democrats will have a better hand and a better bargaining position, but I don't know.

      Ignorance more frequently begets confidence then knowledge. Charles Darwin

      by martianexpatriate on Thu Oct 25, 2012 at 08:06:05 PM PDT

      [ Parent ]

  •  Not true (5+ / 0-)
    For that reason, we are moving more and more to hospital and emergency room based care than ever before, and Obamacare not only doesn't solve that problem, it actually makes it worse.
    NO ONE with insurance goes to an ER over a doctor because, gee, their PCP just doesn't spend enough time with them.

    They go to their PCP, pay a co-pay, and are seen. The fact that MORE people will have insurance means that more people will choose the $30 copay over the $3000 ER bill.

    Sometimes I get a report, and I know the instant I got it that the doctor was barely conscious when he made it.  Sometimes it's because they've been on the floor for days, and are describing a patient's visit that happened a full 24 hours ago.  I wonder if he forgot any details while he was constantly working over that time?
    Again, you're describing a very unfortunate fact about ER care that will be decreased under Obamacare. How in FSM's name do you suppose that by increasing access to insurance, we increase visits to the ER AS A PREFERENCE TO A PCP?

    Finally, you're writing all of this from the perspective of a medical transcriptionist, which I don't condemn at all.

    But do you realize that all the things you claim have been made worse by Obamacare are actually things that have been ADDRESSED by Obamacare- but you're not going to see that until 2014, when the major provisions kick in.


    P.S. I am not a crackpot.

    by BoiseBlue on Thu Oct 25, 2012 at 06:58:38 PM PDT

    •  The problem is that fewer and fewer people are (4+ / 0-)

      becoming GPs or going into Family Practice. That's because as the diarist says, they earn less. As it's harder to find a GP, people will go to the ER.

      There is more money to be made in specialties for the number of hours the work.

      If payment to doctors is squeezed, as is happening under Medicare, fewer doctors will accept Medicare/Medicaid patients.

      I'm in a very large metro area and am having trouble finding an Internist in my neighborhood who accepts new Medicare patients.

      When payments are restricted, so are services.

      It’s the Supreme Court, stupid! Followed by: It's always the Supreme Court! Progressives will win only when we convince a majority that they, too, are Progressive.

      by auapplemac on Thu Oct 25, 2012 at 07:12:16 PM PDT

      [ Parent ]

    •  When you have a heart attack (4+ / 0-)

      you are most likely going to an emergency room, and you probably won't see your doctor of choice there.  It's not a matter of choosing one over your doctor, it's simply how it usually works out.  That's all I mean.  What that specifically means is that no matter rich you are, the decision to not worry about universal healthcare can have a very real effect on your life, just as it would if you get into a car accident and find yourself at the hospital at 2 a.m.

      Don't get me wrong, I'm glad that Obamacare is making it through, and it will help things for some people.  However, new changes in Medicare are in fact not addressing chronic complaints of the amount of money a general doctor is paid when they see someone on Medicare, and some specific parts of it can be described as making it worse.

      I know why that is of course, and so do you; it's because the money just isn't in the budget at this point.

      Ignorance more frequently begets confidence then knowledge. Charles Darwin

      by martianexpatriate on Thu Oct 25, 2012 at 07:18:48 PM PDT

      [ Parent ]

      •  Of course you go to the emergency room for (4+ / 0-)

        an emergency. I'm not disputing that- and I'm not arguing against single payer. I support single payer and believe that it's the only rational way to go.

        My dispute is that you lay out a list of ills that you claim have only been made worse by the ACA. They were not made worse.

        Covering pre-existing conditions, getting more people on insurance, getting rid of the lifetime cap, etc, are all things that help people be more proactive about their health and avoid the ER.

        I absolutely support a single payer system. I am also realistic enough to notice that it's not going to happen anytime soon. Look how hard it was to get a half-measure pushed through.

        But the things that you highlight in your diary as problems that the ACA has only made worse are just wrong. They are not being made worse by Obamacare, they've been addressed my Obamacare.

        P.S. I am not a crackpot.

        by BoiseBlue on Thu Oct 25, 2012 at 07:40:53 PM PDT

        [ Parent ]

        •   No, thats really not what I was ever saying. (2+ / 0-)
          Recommended by:
          Sunspots, cynndara

          I'm not saying it was made worse by the ACA.  I'm saying that the ACA went into place to give more people medical coverage, but it utterly failed to deal with the issue of the pay of general practitioners, and that is an issue which we are eventually going to have to deal with.

          And don't kid yourself... they have not been addressed by Obamacare, not at all.  General practitioners are exceedingly dissatisfied, and the ability to retain doctors in that position is a problem which has been developing for years and is growing worse.  The doctors who are practicing now certainly don't feel that it's been addressed.  Go talk to some general practitioners sometime and see if they feel it's been addressed.

          Giving everyone coverage is a fine thing, but if you can't get enough doctors to take part in the medical system, that's a  whole other problem.

          Ignorance more frequently begets confidence then knowledge. Charles Darwin

          by martianexpatriate on Thu Oct 25, 2012 at 07:51:06 PM PDT

          [ Parent ]

          •  You said that moving more towards (0+ / 0-)

            ER/hospital care was made worse by the ACA, and I pointed out that's not true.

            As far as the pay of PCPs, I actually do know a bit about this. I recognize that this is a problem. We also have a shortage of nurses. And, yes, the ACA contributed to that.

            With more people able to access health care, more doctors and nurses are needed. Again, that's not in dispute, and I grant you that it wasn't, to my knowledge, addressed by the ACA.

            But your essay focuses solely on ER care, which will go down when people have access to insurance, so that they can take advantage of preventative care.

            Will we need more medical professionals in the future? Absolutely. We need a lot more of everything in the future. We need more teachers, firefighters, construction workers, etc.

            We do that by expanding opportunities for education.

            This is not a simple subject.

            The nurse shortage, for example, is driven more by the lack of nurses willing to teach the courses. They make more working in the trenches, so to speak, than they do teaching a course.

            And since we don't have enough nurses willing to give up the practice of nursing in order to teach other nurses, we have to limit the number of nursing students that are accepted to nursing school.

            I'm not sure how Obamacare could have addressed education issues. I agree with you that it needs to be fixed, but I don't think that it could be written into the bill.

            What I do think can solve the problem is better access to education. You know, stop treating public employees like shit and all that.

            We get that with only one candidate this year.

            Only one.

            The issues are tied, but they can't be solved in one fell swoop. We have to accept that this is a framework we were given to build upon. It wasn't meant to be the ultimate answer.

            P.S. I am not a crackpot.

            by BoiseBlue on Thu Oct 25, 2012 at 08:08:32 PM PDT

            [ Parent ]

            •  You keep seeming to want to tell me what my diary (0+ / 0-)

              was about.  Frankly your conclusions as to the number of candidates we have this year are not different from mine, you can go read my other diaries if you'd like to confirm that.

              There is a fairly direct way to answer the particular problem I'm discussing... which actually is not focused solely on ER care at all.  It has to do with the amount of money doctors are paid for taking care of a medicaid patient.  If you increase it, you would make it possible for a doctor to make money and give patients more time, which I suspect would result in better care.

              I don't think that better access to education is going to have much of a direct influence on what I'm talking about, but I'm certainly not opposed to it.  

              I'm not certain why you reacted this way to my diary.  But frankly, the shortage of doctors is not new information, it's pretty well known, and they tell me that between the cost of college education and malpractice premiums, declining pay is becoming a huge issue, and it is in fact getting worse.

              Ignorance more frequently begets confidence then knowledge. Charles Darwin

              by martianexpatriate on Thu Oct 25, 2012 at 10:17:42 PM PDT

              [ Parent ]

              •  You said several times in your diary (0+ / 0-)

                that Obamacare has made things worse, and the things you highlight are things that Obamacare will actually make better.

                I'm not misreading your diary. You said over and over that X is a problem that Obamacare made worse, when Obamacare specifically addresses X and reduces the problem.

                P.S. I am not a crackpot.

                by BoiseBlue on Fri Oct 26, 2012 at 05:01:15 PM PDT

                [ Parent ]

                •  When people are underpaid, (0+ / 0-)

                  and you can't get sufficient staff to man the system, and you then add 30 million people to the rolls you make things worse.  Medicaid/medicare compensation for doctors is trending downwards by every metric I can identify.

                  I don't believe education is sufficient, you have to actually invest money into the system.

                  I get that you don't agree with me.

                  Ignorance more frequently begets confidence then knowledge. Charles Darwin

                  by martianexpatriate on Sun Oct 28, 2012 at 03:53:59 PM PDT

                  [ Parent ]

  •  thank you for this essay.... (4+ / 0-)

    and I hope things change for the better for you personally.

    If there are continued cuts for payments to Medicare and Medicaid, along with no additional protections against ruinous law suits,  those older doctors with a nest egg, would be foolish not to just quit, exacerbating the shortage and decreasing the quality of care.

    Obamacare is predicated on having the political clout to make some real changes, to ration what is a limited supply of state of the art medicine.  If that can't be done, the whole project will fail, as, as you point out, providers will leave the profession.

    And we are facing more resistant infections, and expectations of longer life and better health.  This is expensive.  We are trying to use the triage model rather than price as the determinant of service, but that takes a strong hand that Obama doesn't have now, and maybe ever.

    But we can hope.

  •  Massacusetts has had RomneyCare for about (2+ / 0-)
    Recommended by:
    martianexpatriate, Sunspots

    5 years now. We only have around 3% uninsured yet we have one of the highest rates of people who use the ER as their primary healthcare stop.

    The data also show that among those who have purchased the mandatory coverage there is a low incidence if copay's for prescription and doctors visits. Implying that they cant afford to use that insurance,  I have private insurance in the state and the wait time for appointments is long.  We have about a 6 month wait for an appointment with an optometrist, etc.

    I would say that the diarist observation and comments are spot on.

  •  One of the main components of Obamacare (3+ / 0-)
    Recommended by:
    martianexpatriate, Sunspots, cynndara

    which everyone seems to have forgotten by now, was "immediately after we get it passed we're going to fix all those things we compromised on to get it passed".

    Underpaying and overworking doctors is not the only problem. Another is the fact that within 15 years it is projected that the cost of insurance will be greater than the median income. Yet another is the fact that increasing numbers of those who have insurance now, and especially those who cannot now afford it but will be paying for premiums anyway, will be going without health care services because they can't afford their deductible or co-pays.

  •  Actually the ACA has provisions that (1+ / 0-)
    Recommended by:
    Clem Yeobright

    extend the reach of our primary care system and increase preventive care: I'm not sure where you got the idea more care would happen in hospitals. NP's and PA's will be utilized more extensively and as a physician I think it will help.
    It's not the reform we wanted but it's better than nothing and once people understand it refining it will become politically easier.

    The founding fathers knew of the mutually corrupting influences of Church and state, wisely sending them to opposite corners.

    by emidesu on Thu Oct 25, 2012 at 08:04:12 PM PDT

    •  Here's one place where I got the idea. (0+ / 0-)

      Have you not heard about the fact that there is a doctor shortage?  I'm kind of surprised that a doctor wouldn't have heard of it.

      I'm all for extending preventative care, but the doctor shortage is real and significant, and has been noted in many news sources for many years.

      Ignorance more frequently begets confidence then knowledge. Charles Darwin

      by martianexpatriate on Sun Oct 28, 2012 at 03:57:38 PM PDT

      [ Parent ]

  •  You are right! (2+ / 0-)
    Recommended by:
    Sunspots, cynndara

    The ACA will make the situation worse. The entire system is broken, from how we train health care professionals to how we pay them to how we use very costly but minimally helpful imaging. But, as a rural FP, I'm all for the ACA, because it will drive the system into the mountain sooner, so that we will be able to grow a phoenix from the ashes. Once we accept the new paradigm that a wealthy country like the US should provide a certain level of affordable healthcare, the old paradigm must die. This includes training, access, pay structure, expectations, insurance. Some can be salvaged, but continuing to try to fix the old structure with fancier duct tape just gives us a quilt of gerry-rigging. I've said for years that healthcare won't improve in this country until there is no more 'money to be made'. Then the folks investing time/money who are looking for a glorious return will go off to some other industry and leave those of us with passion for the science and care to carry on. Sorry for the rant. I feel better now.

  •  Years ago, I went to the local urgent care clinic (0+ / 0-)

    I found out that they had just started doing PCPs as well, and I saw what I thought was a good doctor. I asked him if he acted as a PCP there, and sure enough, he did. I chose him as my PCP.

    He kept getting pushed to see more and more patients in that clinic, wthshorter and shorter appointments, but he kept taking the time he felt he needed with each patient, and as a result, he was always behind. I quickly learned to bring a book, not that I didn't always have one with me anyway, and just be patient, knowing he'd take the same care with me when my turn came, and he did. I started as a complicated patient and got more complicated, not less. He took over my diabetes care. He saw me through a peruod of trying to find out what was causing me to be in constant pain for years and through different approaches to treating it. He ran regular, extensive labs on me every 6 months and more often if needed; it was he who discovered my quickly rising creatinine early on and sent me to a nephrologist, who diagnosed me with Chronic Kidney Disease. Because of him, I had a year to research dialysis methods and both mentally and ohysically prepare for dialysis.

    He kept getting into strife with the management because he refused to shortchange his patients, and left the practice, moving to become a partner with a GP across the hall. It is now a 3 physician practice with its own building, and he determines how long an appointment each patient needs and schedules him or her for that. He is still my GP and diabetologist. Like many of his patients, when he swirched practices, I switched, too.

    Oh, and he catches up with patients after hours or on the weekend if there is something they need to know right away. That's one doc who found his own way around the ills of the system. He takes Medicaid and Medicare patients. He's outstanding.

    Some docs are overwhelmed by the system and opt out in one or another of many ways: switching fields, retirement, etc. And then there are those like my doctor who refuse to put up with the system and find their own way.

    As long as there are doctors like Dr I. and his colleagues, there is still hope.

    Organ donors save lives! A donor's kidney gave me my life back on 02/18/11; he lives on in me. Please talk with your family about your wish to donate.

    Why are war casualty counts "American troops" and "others" but never "human beings"?

    by Kitsap River on Thu Oct 25, 2012 at 10:26:09 PM PDT

  •  when all doctors go digital as the ACA promotes (0+ / 0-)

    you'll be out of a job.

    Already in the large conglomerates and teaching hospitals, when you see a doctor s/he doesn't walk into the room with your chart, s/he sits down at a computer terminal and brings up your records. Then, while continuing to stare at the terminal, h/she asks you a series of prompted questions. Starts cussing at the terminal because the system won't accept what s/he wants to enter. Digitally orders some tests. Prints out an instruction form. Looks at you maybe twice during the visit.

    Digitalization is supposed to cut costs (in my office it certainly didn't!), promote communication between caregivers, and prevent medication errors. Well, my daughter with the multiple medical issues receives her care at an award-winning urban teaching institution. When she was diagnosed with breast cancer two years ago, in her thirties, she was on a low-dose birth control pill. This was stopped immediately, of course, as it's contraindicated with breast cancer. Damned if it didn't take eleven -- eleven! -- visits, each time being shown a computer-generated list of her medications and asked to update it, which she did, before her contraceptive pill was removed from her list of meds. She was in tears the last time, at the reconstructive surgeon's reception desk, trying to get SOMEONE to notice that if she WERE taking this medication, it would be DANGEROUS. Not only that, but they kept adding allergies she doesn't have and dropping allergies she does have. (I've had the same experience, repeatedly.)

    I believe this is due in part to what you describe: cost-cutting, the loss of excellent doctors (myself included) who refuse to work in this environment, filling the gaps with harrassed third-rate practitioners, and false efficiency measures put in place by administrators and consultants who never treated a patient in their life.

    •  Going digital (0+ / 0-)

      has already lowered my income considerably, but it's unlikely to completely remove the position.  It is possible however that more and more of the jobs related to medical transcription will move to India as many already have.  They are willing to work for less, so they've taken a huge chunk of the market.

      Ignorance more frequently begets confidence then knowledge. Charles Darwin

      by martianexpatriate on Fri Oct 26, 2012 at 08:44:56 AM PDT

      [ Parent ]

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