No, you probably can't keep your doctor

[Recursion]

If we can't be honest about this we have no business trying to reform health care.

We have too many specialists and not enough GPs, too many hospitals and not enough multi-physician clinics, and too many providers in lucrative areas and not enough of them in less lucrative areas. If we want universal coverage that means we're going to be changing where providers are, who they see, and what they do. American ideas of continuity of care are pretty much unknown in most of Europe: you go to the clinic or hospital and see the doctor on duty; they have your chart and history available. You don't have "your doctor" to begin with.

In particular, this means that it is a lie to claim people will be able to keep their doctor. Because a lot of people won't. If we actually go to a universal health care system, a lot of practices will have to consolidate, a lot of hospitals will have to close down, a lot of specialists will have to become GPs, and a lot of providers in general will need to move to less wealthy areas.

People know this. This is why Medicare For All polls at about 22%: people are perfectly aware of how disruptive it would be. I think it would be worth it, personally. But there's no point in even trying if we are closing our eyes to how actually disruptive it would be.

[Meadowoak]

1. I've had to change Drs. A number of times, they were all fine.

Doesn't bother me in the least. All of our medical records, test results, medications are now digitized, and with that knowledge at their fingertips, pretty much, one Dr is as good as the next. At least in my experience.

[pnwmom]

2. If you've ever gone through very serious or unusual medical issues, you would know

that one Doctor is NOT as good as the next.

Based on many experiences with family members and doctors, I couldn't disagree more strongly.

Practicing medicine is far more challenging than inputing data in a computer. Humans aren't hardware and doctors aren't coders.

[Recursion]

3. And yet. We can't all get the best doctor.

A whole lot of us (the vast majority, in fact) are going to have to accept perfectly average doctors.

[pnwmom]

4. And that is a reason to support a public option and see how it goes.

Because too many of us will NOT vote for the disruption that a Medicare for all could result in.

(Also, people have different ideas of who is the best doctor. One of the worst doctors I have experienced has lots of people on Yelp giving him rave reviews. They are welcome to keep seeing him -- but I would warn anyone I know away from him.)

[MuseRider]

69. There are lots of average docs that are fine but there are those that are not.

I wish the Medical community policed itself better. Right now we can ban a doc from a state but they can trot over to another state and get a practice without mention of what happened before. THAT right there is a worse Doc that should not be seeing patients and it happens fairly frequently.

We all should be able to pick our doctors. I am a retired RN my husband a retired MD. We used to be able to find out who to go to but now, this far out, we do not know anyone practicing anymore and it is a crap shoot.

The next time I show up in the ER with a major flare up and the vapid little PA tells me that they don't do CBC's anymore because they don't tell them anything useful I will send another note to the CEO and escalate my messaging to people who need to know this. THIS is a bad "doctor".

The next time some MD looks at me, a 65 year old woman in strong shape with a very large background in cardiac care, and says to me "So just where did we hear about PVC's? TV perhaps or a novel?" I will turn that physician in, it was an emergency who the hell cares how someone knows this just do a damned EKG because of age and chest pain and passing out, isn't that enough anymore? That is a bad doctor.

Nobody should have to pick those idiots out. They are either incompetent or nasty and neither of those things belong in the medical field. Sadly not enough people know these things so now we can sometimes pick out a doctor but from what pool of doctors?

I do not know the answer to this. Personally I am for Medicare for All but I do believe we need to go slowly and allow people and the system to adjust. I would gladly do it but I know when someone is incompetent either in knowledge or patient care attitude. It will be a mess at first I am sure. There will be many good things and many bad things while we move to available medical care but we have that now and we pay dearly for it so why not go there and get it over with. Rip the bandage off.

[Hortensis]

71. What DO all those doctors in our towns do if we can't have then?

Who gets to have them if not us? Do they just stop practicing medicine? Move? Let's not be silly.

Of course most of us will both be able to keep our local doctors and any specialists farther away we might have -- if we want. We will also have other choices in case we don't want the old ones.

Anti-ACA Republicans have been able to drive many insurers out of many coverage districts, especially rural. But before they did that, people in most districts had a choice of a number of insurers. I'm in semi-rural Georgia and I remember Kaiser still wouldn't bother with us out here, but that was as before and at that time a pleasingly long list of other companies did.

The coverages and practitioner choices I purchased were far superior to the one, take-it-or-leave-it choice the corporation I'd worked for offered. I no longer had to choose a physician from the list the insurer contracted with and no longer had to have insurer preapproval for specialist visits.

Even out here I had to scan down very long lists of properly licensed physicians to see that our PCP was acceptable to every company I looked at.

[Recursion]

74. Well, a lot of them will have to move, yes

At least as of a couple of years ago there were zero pediatric nephrologists in Mississippi, so at least 2 or 3 pediatric nephrologists will need to move there. In general doctors will need to move from currently overserved areas to currently underserved areas, and since we aren't talking about nationalizing the physicians themselves (yet) that's going to have to be through financial incentives.

[Hortensis]

76. Not because of the ACA or MfA. This is a RW meme presented

from a different angle. We all remember when a few people having to change physicians, most of them because they'd had junk insurance, while millions continued with theirs was turned into an "OBAMA LIED. HE PROMISED YOU'D BE ABLE TO KEEP YOUR OWN DOCTOR." lie.

Of course healthcare reform has been addressing, and has to continue to address all the trends you mention. But if it's not terribly effective now, what do you expect after so many people chose to elect, or enable election of in the case of "Dexit" and nonvoter types, a Republican president, Republican congress, and Republican state governments?

The Republicans promised for over 10 years to destroy government-organized healthcare, for heavens' sake, and are still doing their very best to accomplish that. And only scoundrels blame the ACA for their sabotage.

[CTyankee]

112. My primary care doctor was my doctor before and after Obamacare. He was in the same place.

He had the same hours.

Same, same, same. I loved him and his staff. He retired a couple of years ago and I grieved. My new doc is fine, but not like him.

So all these scare tactics didn't work in the past so I don't think they'll work now. Of course, I don't put anything past these pukes...

[Hortensis]

113. For them fact-based thinking is a problem to be "solved."

The most proven technique, of course, is just to tell the same lie over and over and over and over, just as long as RW funding will pay for it.

[pangaia]

6. One doctor is absolutely NOT as good as the next. Trust me on that one.

[Recursion]

45. OK, but somebody has to go to the worse ones

How do we pick?

[hedda_foil]

49. Question

1. Do you actually have insurance that lets you choose any doctor with no restrictions at all? If so what kind is it? What does it cost?

2. The bad doctors have plenty of patients who think they're the best.

[Recursion]

50. Of course I don't. Where would you get that idea?

In fact right now I'm in France where I have zero choice whom I see.

I'm saying Americans' fetish for picking and choosing doctors isn't going to be able to survive meaningful healthcare reform, and that we need to be up-front about that.

[Ms. Toad]

80. It's not a fetish when you have a rare, catastrophic disease

It is the difference betweeen life and death - and a doctor who understands and is willing to work with you on insurance is the difference between financial stability and bankruptcy.

We have both in our family. My daughter has $200,000 in billed expenses every year due to a rare disease, which puts her at significantly increased risk of cancer from her more garden variety illness.

One doctor accidentally missed a transition from hospital approved care to home approved care at the 1 year mark. This resulted in $40,000 in bills rejected by her insurance company. The doctor appealed to insurance to fix part of it, and to the facility billing to waive the rest. The bills were for a new medicine that is not on my daughter's formulary. The doctor convinced the insurance company it was the best treatment for my daughter (given her rare disease one-two punch). That treatment has put her more common illness in complete remisison for 2.5 years - after several years of her prior doctor insisting the symptoms were not bad enough to warrant a change in treatment. (Being out of remission is a separate, added, cancer risk - over just having had the disease in the first place).

In contrast, a second doctor ordered an unauthorized test (fortunately only $900), and refused or was ineffective at arguing with the insurance company, and refused to intervene with the same facility billing system that we know is willing to waive fees for procedures when the doctor screws up. That doctor is now toast - because, although her care is good, with $200,000 in billed medical expenses every year, bankruptcy is very real risk with that doctor.

Finally, just after her diagnosis, my daughter ended up in the ER with potential side effects from a liver biopsy. The ER doctor had no idea what her disease is (even though the basics are evident from its name) and had to google her disease (literally google, not check medical sources). Even after that, which presumably told him it was a cholestatic liver disease (translation: static bile) when we told him that her treating physician wanted a GGT (a way to measure how well the bile is flowing), his response was, "Why would he want that? That's a measure of cholestasis. Duh.

Picking a doctor is not a fetish. It is a matter of life and death, and salvation from financial ruin. Once the system is fixed, it will be less the latter - but we still need to be saved from idiots like the ER doctor.

[Everyman Jackal]

100. Why won't we able to pick our own doctor or at least stop seeing a bad one?

I am in the VA system and I have had doctors I didn't like. I just switched doctors. I have also changed clinics and hospitals when I moved and my new doctors with my permission have had full access to all of my records through the VA healthcare system, not just doctors notes or prescriptions but also all my x-rays, labs and MRIs. When I moved if I didn't need to see a doctor I could order my prescriptions through the same system and they were mailed to me. I know some veterans have had problems usually because they were in an area where the VA needs to do more. I was in the private sector for 28 years and now the VA for 24 years and the VA system is far superior plus for me, it is totally free and they even pay me travel.

[Recursion]

101. OK, well, I'm just talking about the system here in France

It's great. It's affordable and low-hassle. But you don't get to choose what providers you see. You go to your neighborhood health clinic, and see who's on call that day, and then if needed she assigns you a specialist. Yes, there are wait times, but honestly wait times in the US were worse (I once had to wait 6 months in DC to see an ENT; the longest wait I've had in France was like a week). The biggest difference I notice from the US is that there's really no expectation of "choosing" a provider. This is the doctor; she went to med school; she's as good as any other doctor; deal with it.

[Captain Zero]

59. I agree with that, but,

You have to figure it out on your own. The medical associations won't tell you who was the lowest grad in his medical class, or worse, won't tell us who is questionable, but not had their license pulled. Another thing is that the big health providers are already doing this. You don't always see YOUR doctor but someone in the practice who is on-duty.

[tymorial]

15. Digitized doesnt mean easily accessible

There see numerous electronic health records but they are not easily exchangeable between systems. Though there is a national standard that each system must maintain in order to be ONC 2015 certified which allows the exchange of summary health data, its use and practice is pretty much limited due to the challenges of how that data is delivered and received. One system delivers the data to the recipient provider via direct mail secure messaging. Most providers have no idea what their own direct email address is let alone others and there is no good way for them to find out. There are various networks in use at this time, some member secure messaging systems have lookups others do not. Even if a practice does have this available, they may not know how to utilize it let alone have the time.

This doesnt even begin to address the fact that summary data is unlikely to be completely useful and may not contain the necessary information required for continuing care. Even if two providers utilize the same exact EMR, there is no way to take an entire chart and place it in another system. You could print and scan but dlscanned documentation is generally stored as PDF files attached to a chart. The data is not integrated into the infrastructure. It's use is limited to accessing the specific document rather than being able to access core functionality.

If we want to get serious about exchange of health data, we need either a universal system (which would destroy the healthcare it market and place millions out of a job) or a better method for exchange data needs to be developed. Though one exists, it is complicated and time consuming. Providers have more patients than they can manage and simply do not have the time or staff to manage exchanging of health data.

I have intimate knowledge of this both as a provider and a former consultant.

[Meadowoak]

28. How do they do it in other countries? They seem to have better

Success rates, from what I've read.

[tymorial]

44. I dont know the answer to every country that has a national healthcare system

I believe the UK is attempting to create a system where all health data is easily retrievable by providers. I know Canada is pushing for a centralized system.

The use of medical records (electronic or otherwise) is not and has never been a requirement for universal coverage. The OPs argument that keeping your provider is unrealistic is most certainly true. Under our current system providers negotiate reimbursement rates and fee schedules with each payer, commercial or public. Medicare and Medicaid pay far less than commercial payers. Quite frankly, the payments received by commercial payers help subsidize medicare and Medicaid patients. No hospital or physician practice could stay afloat on medicare alone. The costs are too high.

The only way our current system stays intact without consolidation of providers and hospitals stay open is if we take a single payer option which pays at rates equal to what commercial payers currently pay. I'm not sure that would be a viable solution financially.

[Recursion]

46. Nobody's really solved the records problem yet

France's electronic records system literally came online last month, so we have no idea if it's going to work or not.

[Brainfodder]

5. Insurance through jobs can change often & totally change who you have access to.

So, yeah, it's complicated.

COBRA and just catastrophic coverage can have absurd premiums, almost like they've planned it that way.

[Freddie]

130. COBRA is what your employer was paying for you

I’m a retired payroll & benefits admin. People would have a conniption when they learned that COBRA for a family (excellent plan) is $2100/month. That’s what we (employer) was paying on your behalf all this time. Thankfully since the ACA there’s a lot less people doing COBRA.

[Brainfodder]

144. Yup!

...and once income is 0, they want you to magically pay that huge monthly?

Like a kick to the ...

[Voltaire2]

7. Bullshit.

The only thing that has to happen under MFA is that the billions in profits extracted by the private insurance industry will disappear.

[Recursion]

8. ROTFLMAO

Yes, it's a tempting fantasy, and it's complete bullshit. Insurance overhead and profit is about 4% of our total spending.

Germany, Switzerland, the Netherlands, and France all also have private for-profit insurance, and they also pay about 4% of their total spending for its overhead.

The problem is our doctors make twice as much as the OECD average. Outpatient providers are the biggest single category of health care spending we have, and it dwarfs what other countries pay.

We need our doctors to make less money while seeing more people. And that means we can't pretend everybody's going to get to keep their current doctor.

[Voltaire2]

9. So we need to lower doctor costs under

the current system. How are we going to do that?

The only thing that has to happen under MFA is that the billions in profits extracted by the private insurance system will disappear.

[Recursion]

11. No, you're vastly overestimating how much insurance profit there is

It's miniscule. The problem is provider profit. We have too many hospitals and too many of them are for-profit. Most doctors' practices are for-profit and there are too many standalone specialist practices and not enough combined GP practices.

Removing insurance profit doesn't get us there, or even a tenth of the way there. It would lower our health care spending from 19% of GDP to about 17.5% of GDP. The providers themselves would still be unaffordable.

[Voltaire2]

12. Doctor costs have to be lowered.

That is your claim. Ok. How are you doing that under the current system?

[Recursion]

17. I'm not saying "keep the current system". I'm saying "you can't keep your doctor"

I'm saying we need to radically change how much and for what doctors are paid, and that means we need to stop pretending everybody is going to be able to keep their current doctor.

[Voltaire2]

23. So that has nothing much to do with MFA.

Glad we got that cleared up.

My doctors sent letter out last fall announcing that, having failed to reach a contract with my crappy ass private health insurer they would no longer be in their ‘network’.

People lose their doctors under the current system. They just have no input at all into the decisions going into how that happens.

So can we just drop this particular fud attack on MFA?

[Recursion]

37. Yes, it does. If we go to only-Medicare most practices have to close

Because most practices can't survive on just the Medicare reimbursement rate; people with private insurance are currently subsidizing that. If we go to Medicare-only then doctors are going to have to drastically reorganize how, where, and what they practice, which means dropping patients and taking different ones.

[Voltaire2]

107. You've again assumed something not

in evidence. You of course know that MFA is not simply extending the current Medicare system. Well I guess I assume you know that. Both the house and senate bills replace Medicare Medicaid and the private employer based systems with a single universal public insurance system. What rates that system will pay has not been determined.

You still haven’t explained how the current system is going to address the problem of doctor costs. I guess it doesn’t have to, which is odd as you insist that MFA must do this.

[Recursion]

108. Where do you get the idea that the current system addresses this question?

That's a weird assumption. We need to replace the current system because it's broken.

[Voltaire2]

115. If the current system doesn't why do you

insist that MFA must address it, apparently on day 1?

[Recursion]

121. Try reading. MFA *can't* address it, by nature.

I'm saying we need to stop lying about that.

[Voltaire2]

124. MFA can address health care provider costs.

The same way that private insurers do, by negotiating rates.

So again, how is the private system addressing this problem? Why doesn't it have to cut salaries by 50%?

[uponit7771]

29. +1

[Ilsa]

14. You might end up with fewer doctors.

Internists make anywhere from $180k to $250k. Student loans must be repaid from that.

If they can make $125k being an engineer with only five years of college vs ten, plus, start sooner on earning, that might be the practical choice they make.

[Recursion]

16. Here in France physicians start at 30K or so

The highest a doctor can realistically make (except for a few specialties) is €120K, towards the end of their careers; most doctors max out at about €75K

If we had the political will to pay doctors like that in the US, we could have affordable health care too.

[Ilsa]

18. I wouldn't take on the stress for pay that low.

I know nurses who make more than that. Yes, I think some specialties are overpaid, but I don't think my internist is overpaid at $180k.

[uponit7771]

31. There are people who will though and be happy doing it and not running a business with PO

[Recursion]

43. And lots of practices will consolidate

What seems to work in the rest of the world is a clinic with a rotating staff of multiple doctors. When you go you see whichever one is "on" that day.

[MichMan]

87. Nurses will likely have to take pay cuts also

[Recursion]

99. Less likely. US nurses make less than the OECD average

If we simply replicate Western European systems nurses will get a pay raise.

[uponit7771]

30. +1, avg doctor pay in the US is 300,000 a year

[watoos]

36. So you are on single payer health care,

but are against single payer health care in America.

Would you trade your health care for our present system?

[Recursion]

38. What on earth are you talking about?

1. France is not single payer

2. The US needs to adopt a universal healthcare system and that means being honest about the fact that people won't be able to keep their doctor. It's not the end of the damn world.

[watoos]

58. Universal health care will never fly in the US

Universal health care means that the government owns the hospitals and clinics and sets the costs and prices.

Not one of our Democratic candidates is calling for Universal health care.

Answer my question, would you trade your health care system for what we have now in America?

Why don't you explain what you have in France, it must be a combination of public/private health care.

[Recursion]

62. France has the best healthcare system in the world by most ratings

Of course it's better than the US's.

It's a public/private system where the state fixes prices for providers, assigns them regionally (more or less), provides social insurance that covers about 80% of cost and mandates private insurance for the rest.

Universal health care means that the government owns the hospitals and clinics and sets the costs and prices.

No, universal health care is an outcome; it means everybody has access to care. Socializing providers is only one way to do that.

[Voltaire2]

116. No it doesn't mean the government

owns the hospitals and clinics. Medicare for all just replaces private insurance, Medicaid and Medicare with a single comprehensive public insurance program that covers everyone.

[Recursion]

126. Thank you. People confuse the means and the end.

Universal healthcare is an end; it's an outcome we desire.

Single payer is one means to that end. Multi-payer is another. Nationalized health providers are another. Capitation financing is a fourth. There's about as many solutions as there are countries with universal healthcare; the trick is that we need to find ours.

[Recursion]

19. And anyways we have an engineer shortage too (nt)

[Hoyt]

66. The life of docs ain't that bad nowadays. Residents average salary of $59,000. Docs who join groups

don't work long hours like previous generations did. Being On-call is shared with members of the group. Heck, primary physicians nowadays have hospitalists to take care of hospitalized patient immediate needs in many cases.

There is no job in America that can guarantee $200K - $250K to start. You can make a lot of student loan payments out of that. And, if you really care about medical care, you can go to a health manpower shortage area and get those student loans repaid.

[tblue37]

20. But we let our doctors graduate med school with hundreds of thousands in debt, so they

need to make enough to pay it down. Other countries don't saddle their doctors with that kind of debt.

[Recursion]

22. So we forgive the debt and cut the salaries

That's a one-time payment that lowers health care operating costs for a generation. No-brainer.

[uponit7771]

32. This

[greymattermom]

65. This is exactly why the lower paying specialties

are mostly done by Indian and other immigrant physicians. They don't have huge student loans to pay off.

[Hoyt]

134. One can pay off debt pretty fast making $200+K a year. They can even discharge it by serving in

manpower shortage areas.

[Loki Liesmith]

128. And the millions of jobs in that industry

[Voltaire2]

131. actually not so much.

There will still be a need for the people doing claims processing and it is quite likely that the current big insurance companies would provide those services using the same people.

So it would mostly be the billions in profits.

[tymorial]

10. All quite quite true.

And very well stated.

[Ilsa]

13. If I'm admitted to the hospital,

I get a hospitalist, not my doctor, and it has nothing to do with my insurance.

[leftofcool]

21. Nope, not me. I want the best doctor and best cancer care team

And most people feel this way which is MFA polls so low.

[Voltaire2]

25. Wow your insurance lets you go to any doctor

anywhere and pays for it?

Hmmm. Most policies restrict you to “in network” providers.

MFA would not have “networks”. Any doctor any clinic any hospital.

[uponit7771]

33. Most peoples HC insurance does NOT let them go to any doctor anywhere even the best

[Vinca]

24. If we had "Medicare For All" I think the opposite would be true. If a doctor decides to rely on

patients who can pay cash for all their treatment, he or she will go broke rather quickly. If everyone is covered by a plan, it would make sense that all doctors would accept it.

[Voltaire2]

26. No shit.

[Recursion]

41. Say your current doctor took Medicare For All

What incentive would he have to keep seeing you, rather than any of the other million people in the area?

[Vinca]

86. His incentive would be that I'm his current patient. Why would he dump me for a new patient

who also has Medicare For All? I find the argument that Medicare For All would create too many patients pretty appalling. If the point is to get people who need to see doctors to doctors, the solution is to have more doctors if there are too many patients. How about free medical training for people who want to be General Practitioners as opposed to specialists? The reason there are too few is that medical school costs a small fortune and the big money is in the specialties so doctors tend to gravitate to that so they might be able to pay off their student loans before they die.

[Recursion]

89. Slow down there. It doesn't create "too many patients" in the absolute sense

It creates too many patients for any given person to be confident that they can retain their current provider rather than finding a new one.

That's a huge difference. There are enough doctors to go around, but many of them are in the wrong places right now.

[Vinca]

90. So why would a person's current doctor decide to dump them for a new patient?

Doesn't make sense. The only problem is the influx of new patients who can't find a doctor because practices are full. But that's not a new problem, it's that way now. Our area has been going through a shortage of GPs due to retirements primarily. Both of my doctors retired and I finally had to sign on with a Physician's Assistant. There's an overall doctor shortage in this country when it comes to general practice. Even if you promise someone they can keep their doctor, it doesn't mean the doctor won't move, retire, die or otherwise stop practicing in their area.

[Recursion]

91. There are zero pediatric nephrologists in Mississippi right now

That needs to be fixed.

That will involve incentivizing a pediatric nephrologist away from a lucrative coastal city to move to Mississippi.

His patients will need to find a new doctor.

Now, multiply that by about 10,000.

[Vinca]

98. Okay. I would be surprised if there is one in my state. Usually people are referred to Boston.

I think the problem, primarily, is of a general nature. I have a friend who has recently been diagnosed with a growth inside his spinal cord. It doesn't look good. His local physician isn't prepared to deal with that and referred him to a major medical center in another state for treatment. That's just the way it is. You won't ever find a pediatric nephrologist in every hospital in every state. I think we need to start with basics and make sure if a person is bitten by a deer tick they can see a general practitioner for antibiotics so they don't get Lyme disease.

[Voltaire2]

117. There has to be something wrong with

it, otherwise we couldn’t be against it.

[treestar]

27. More like a middle to upper class problem

Tell them they can keep their doctor; they just have to pay for it. Supplemental policy, for instance.

[Meadowoak]

34. Exactly.

[uponit7771]

35. +1, sounds like a fair proposal. The poor don't have a choice of "keeping" anything

[Recursion]

39. Some people will luck out, sure

There will be people whose doctors stay in practice, in their current location and specialty, and who will take supplementary insurance.

Not all that many probably.

And if your doctor does start taking Medicare (and that's the whole idea, right?) then he may not have time to see you because he'll have a much bigger patient pool now.

[treestar]

40. More likely to be a she now

I was able to keep the practice, but my particular doctor retired, and since then the doctors keep changing - all young and female, and sometimes a nurse practitioner instead. Apparently, NPs can write prescriptions that are routine.

[Recursion]

42. I believe it's NPs that are going to save us

That's a good sign, and we need to have a lot more medical work done by NPs and PAs.

[Bettie]

64. Our clinic never has a doctor in

they have a NP and a PA. That is all. Ever.

And generally, we don't see the same person twice, but we're all pretty healthy, so other than an occasional injury or random illness, we seldom go in.

[shanti]

114. And foreign-born

My Kaiser GP is a Filipino woman.

[Loki Liesmith]

129. Oh that's gonna win votes for sure

[treestar]

136. It could, because that type of person

likes to feel superior. They can have a private plan on top of the universal plan, and they will boast about it.

[democratisphere]

47. So you won't be able to keep your doctor.

Poor baby. What about the people that don't even have any doctor?! Some Americans are so damn spoiled. Single payer for all and call it whatever you will. Private wall street option be damned.

[Recursion]

48. That's more like it

That's a better pitch than "you can keep your doctor"

[WhiskeyGrinder]

51. Those of us in rural areas are familiar with the lack of providers the system is already trying to

manage. Any talk about healthcare reform needs to be honest about where we're going even if nothing changes -- a desperate need for providers at all levels and in all specialties, a crisis in pay, and a reexamination of the scope of work performed by NPs and PAs. The way we pay for healthcare is an issue but IMO can't be addressed unless we also talk about how providers give care as well. In that context, the discussion about not keeping your doctor can be less dire and more realistic.

[Recursion]

53. I think that's a great point

And contrasting where we're headed if we don't change to where we will need to go is something we need to do.

[WhiskeyGrinder]

60. Something like, "You can't keep your doctor. But it turns out, most of the time you don't need one."

I think the promise of telemedicine could also be realized, but that would take a massive investment in digital infrastructure, and the will behind that varies by state and region.

[hunter]

82. My parents live in a rural area with a severe shortage of primary care physicians.

They rarely see the same doctor.

Doctors come and go, often arriving with romantic illusions of a rural lifestyle that are quickly dispelled by the overwhelming demands of the job and very frequently social isolation.

[Recursion]

92. There it is. I blame "Northern Exposure"

It's *hard* to keep physicians in rural areas. Most of them bolt given the first chance. That means we need some significant financial incentives to retain them. That's the first order problem.

The second order problem is that we then need rural areas to come up with that money, rather than keep on being subsidized by the 80% of us who live in urban areas.

[rickford66]

52. There's plenty of people, well qualified to become Doctors in this country.

There has to be a system to assist them in getting the education. Government programs with a promise of several years of service in needed areas would go a long way to achieve some type of Universal coverage.

[WhiskeyGrinder]

54. Those programs are already in place. And we don't need more doctors; we need more midlevel

practitioners.

[Recursion]

55. More NPs, RNs, LPNs, PAs, etc.

We're at about the "right" number of doctors, but some of them will need to stop being specialists and be GPs.

[WhiskeyGrinder]

63. Yep. Our doctor-to-patient ratio is okay, but our specialist-to-doctor ratio is out of whack.

[Dirty Socialist]

68. More medical lab technicians are needed too

It used to be you needed a 3.7 GPA to get into a medical lab technician program. Now, colleges are going to high schools begging kids to become medical lab techs.

[Recursion]

70. My cousin is a phlebotomy tech. She literally started as a cleaner.

The head of the clinic talked to her, got her in the community college classes she needed to go to, and she was hired after two semesters.

[Jake Stern]

111. I specifically ask for the PA at the clinic I go to.

The doctor comes in for 5 minutes and never see him again but the PA will stay as long as needed to get to the bottom of what's going on.

[rickford66]

57. Well, train them for that.

[Recursion]

56. It would. Now convince the AMA to increase the med school class quota

They don't like the idea because they know it will drive doctors' salaries down.

[WhiskeyGrinder]

61. This.

[yonder]

67. Slightly off topic: This is a very good

and healthy thread with many thoughtful comments.

Thanks to the OP.

[ecstatic]

72. A lot of people have private group insurance, don't have a PCP,

and don't keep up with annual visits, so it won't matter either way. In my case, I've pretty much turned my current OB/GYN, who I met last year, into my PCP. I really like her, and this is the first time I've ever had a doctor I really liked. Again, only happened within the past year.

My attempts to have a PCP just haven't worked out for various reasons, usually related to promptness and/or professionalism of the doctor or his/her office staff.

[MineralMan]

73. 15 years ago, when I moved to the Twin Cities in Minnesota

I had to change my health insurance. I also had to find a new primary care physician. I made the choice to find my primary care doctor at a multi-physician clinic that was part of a large chain of healthcare providers and had its own hospitals. That made my health insurance hunting relatively easy, because all of the insurers had that healthcare system, its clinics and hospitals as a preferred provider.

The next time I needed to consult a physician, I made an appointment at the closest clinic in that system. I didn't care for the first doctor I saw, so I asked to see a different doctor for a follow-up visit. I liked that one and designated him as my primary care physician. He's an internist who was educated in Pakistan. He listened to me, asked good questions, and was conservative in his prescribing, always starting with generics.

I've had that doctor as my primary doctor now for 15 years. When I went on Medicare, I discovered that all of the Medicare supplement insurance providers also had that healthcare system as a preferred provider. I kept my doctor. I kept my system, which also has specialty providers in all areas of medicine.

When choosing a doctor or clinic system, it's always a good idea to choose one that is large enough to attract preferred provider status with multiple insurance companies. That way, you are less likely to have to change providers if your insurance options change.

While solo practitioners and small group practices have advantages, they can't give you that flexibility. Even in smaller communities, there is likely to be a large multi-specialty network not far away. Even if you have to drive to a nearby larger city for appointments, choosing such a clinical network will simplify your life and maximize your choices when things change.

[Recursion]

75. Absolutely I think the multi-practitioner clinic is needed going forward

I think what we're socially and politically tripping over is that the single-doctor single-office practice is probably not going to be financially sustainable under any sort of universal healthcare system (it's already showing cracks from the ACA).

[MineralMan]

78. In metropolitan areas, such clinics are numerous.

At mine, I can always see my PCP the next day. If I need a same day appointment, I might have to see someone else, but I rarely need a same day appointment.

My wife uses the same clinic, which is a preferred provider for her health insurance. She got something in her eye a few months ago, and called the clinic. "Come right in" they said. She was seen by a Nurse Practitioner, who washed her eye out with saline, but was worried about the possibility of a corneal abrasion. The NP stepped out of the office, and five minutes later led my wife down to the Ophthalmologist at that clinic, who examined her and gave her a prescription for the minor corneal abrasion.

I'm sure the eye doctor had to squeeze her in between appointments, but she got seen quickly. The clinic we use is also an after-hours urgent care clinic, so there's always someone available there in urgent cases. It also has full radiology capabilities, a mammography room and even an outpatient surgery facility for minor surgeries.

But, most importantly, it is part of my medicare supplement's preferred provider network, and my wife's network. Most referrals are handled within the same building. Other things like oncology and other specialties do make you visit another clinic, but most stuff is handled at the clinic we use.

My wife had a total hip replacement. Everything was handled within that healthcare system, with no out-of-network extra costs. The system owns one of the best hospitals in the area, as well.

The advantages are many to hooking up with an overall healthcare system that has multiple facilities.

[ecstatic]

79. Aren't there additional facility fees involved in that approach?

Am I missing something? Maybe my plan sucks? I'm covered at 90% with $1500 deductible. In the past, when I've gone to doctors who are in my insurance network, but part of a larger system or hospital (that's also in my insurance network), I get hit with a ton of additional "facility" fees. For example, I was anemic and my doctor referred me to a hematologist that could set up iron infusion injections. I go to the hematologist--he drew blood, that's it. He had nothing important to say and it was a complete waste of time. But the fees.... OMG... Having the simple blood test done at that location was WAY more expensive than the cost at a solo doc.

[MineralMan]

81. Not if the clinic system also owns the hospital.

Anyway, that's generally the case.

When my wife had her hip replacement, she had already met her annual out of pocket maximum and her deductible. There was no bill whatsoever for the hip replacement. Nothing.

With a hospital within the system, everything can be handled in-system. No out of network hematologist. The system has someone in that specialty and that's who they'll use. Same with anesthesiologists, etc.

The larger the clinic and healthcare system, the less likely you'll end up with some out-of-network services being needed.

It's easy to find such networks in a large metropolitan area, where there are plenty of multi-clinic, multi-specialty networks that also own a full-service hospital. It's more difficult in less populated areas, but there is usually such a system in a nearby city with satellite clinics out in the boonies.

I'm on Medicare, so it's not as big a problem, but I choose my supplemental policy based on its preferred network. I had to change it this past year, but no problem. They all have my clinic system in network. The only thing I had to change was my pharmacy. To get a zero co-pay for my medications, I had to use a pharmacy that was in their preferred category. That was easy. The pharmacy in the supermarket I use is in that category. It's even more convenient now.

It all takes some research, but it's worth doing that research.

[Recursion]

83. MineralMan beat me to it: a broad network avoids that. Think Kaiser

Kaiser kind of pioneered this stuff back in the 1990s and in a lot of ways it's the closest thing to a sane medical experience in the US today.

[Historic NY]

77. 'Dr. Marcus Welby' days are long gone....

you can keep a Dr. but the old guy is either long gone or part of an association of Dr's. The Republicans tried to make hay out of the health care act. I'd like to see what plan they have since they keep telling us of this fantastic, stupendous plan they have. The only plan Republicans and Trump will have will take you of more of your money and give you less. They want you to think otherwise.

[csziggy]

84. When my husband was working so we could both have health insurance we had to change doctors

Almost every time his employer changed insurance providers. We had no choice in the matter, we had to take whatever insurance they offered, the only decision was how much we paid out of pocket or how much the deductible was.

The idea that you can keep your doctor is a fallacy - unless you have always had a private way to pay for your healthcare (private health insurance or paying totally out of pocket) you NEVER had a choice. You could select from a provider list but that was it - and when the provider list changed or the insurance company changed, you might have to change your doctor no matter how much you liked the current one.

If there were one comprehensive medical care system, then people would be more likely to be able to stay with a doctor once they have selected one. For those who want their "own" doctor, they can opt for private insurance or paying out of pocket if they can afford it.

I believe this is as much a myth as the one about having to wait months to see a specialist. I've had a number of health issues over the last twenty years. A few times my GP managed to get me in quickly since he deemed it an emergency. The rest of the time it was months before I could get to see a specialist.

When my heart was giving me problems, it took three months to see a cardiologist, then because the insurance company dragged it's feet it took six months to get the tests he prescribed. Then four months for additional tests. Things only accelerated when on the way to getting my aortic valve replaced they found cancer in a kidney. That kicked everything into high gear - but by the time everything was taken care of, it was over a year after the first heart murmur was heard.

[JCMach1]

85. Insurance already dictates who you can see

[RobinA]

88. I Guess I've Been Lucky

or I live in the land of healthcare giants, but since I began working in 1980, including during two layoffs, I've always had either some form of Blue Cross or Aetna, and the Drs I was using were members of both networks. I can only imagine the stress of having to switch all doctors every couple years. I've had to switch my OB/GYN because my chosen guy moved to Florida - some 15 years ago now, and I STILL haven't found one I particularly like. My PCP went concierge and then his replacement left the practice, so I ended up with another member of that practice I'm not crazy about. I'm just thankful I don't have any real medical problems, because the current norm of musical doctors would probably send me over the edge if I were in cancer treatment or something serious like that.

[DanTex]

93. Medicare for all polls over 50%.

It's only when polls are accompanied by negative information about single payer that the number drops (e.g. your taxes go up, you can't keep your doctor, there will be delays, etc.). And conversely, if polls are accompanied by by positive information (e.g. no copays or deductibles, no premiums, etc.), then the number goes up. But the headline number is above 50%.

And, this hardly supports the contention the people "know" how disruptive single payer will be. It's actually the opposite, people don't know much about it, either positive or negative, which is why the number changes so much depending on what people are told.

SP would definitely be disruptive, which is why I would favor a public option instead, at least initially. But if "keep your doctor" means you get to keep seeing the same GP you are currently seeing, there's no a priori reason why that wouldn't happen with single payer.

[Recursion]

95. OK, but: you can't keep your doctor, under Medicare For All

That's my entire point. We can't tell people that, because it isn't true. A lot of providers will have to move and/or switch specialties.

[DanTex]

96. That depends on a lot of things.

Including who "you" and "your doctor" are. Generally, I think "you can keep your doctor" means that if you currently have a GP, you can keep seeing that same GP. On this question, for most people, I would guess the answer would be "yes".

Yeah, there are scenarios where this wouldn't happen. Say your current doctor doesn't accept medicare. What happens? Does the doctor then require supplemental insurance or out-of-pocket additional payments or even go cash-only (would these be legal?)? Does the doctor's practice cut down on staff or machinery, resulting in the same doctor but not the same overall care? I don't know, but there is a large amount of debate and literature about these kinds of questions, so I don't think it's accurate to just say "you can't keep your doctor".

The general issue with single payer is that care itself is really expensive in the US compared to Europe, and there's no single easy culprit. It's not just salaries or machinery or drug prices or administrative costs, it's everything. Like you said in the OP, if the single payer is going to reimburse at or near medicare rates, then lots of hospitals and clinics will become insolvent or have to significantly restructure.

My guess is that if SP does happen (which it won't anytime soon), rather than the massive disruption and hospital closings, it will just end up costing a lot more than the estimates.

[Voltaire2]

118. You're just making that up.

The only question is why.

[Recursion]

123. It's arithmetic. We don't have enough GPs currently

That means some specialists have to become GPs

We don't have enough doctors in Mississippi, and we have too many in Southern California. That means some of them will have to move from Southern California to Mississippi.

It's absurd to pretend there's a way around this.

[Voltaire2]

125. So we have this current problem of not enough doctors

under the current system. Glad we sorted that out.

The per capita doctor ratio in many developed countries with some sort of universal system is generally better than ours, so again, this has nothing much to do with MFA.

[Recursion]

127. We're slightly above average with doctors per capita

We're 2.3 per mille, and the OECD average is about 2.2. The problem is we have a 2:1 ratio of specialists to generalists, while the OECD manages to keep that ratio at about 1:1.

[Voltaire2]

132. France 3.37, germany 3.4 italy 4.2 ...

The US with its super fabulous private insurance system is way down the list. https://www.nationmaster.com/country-info/stats/Health/Physicians/Per-1%2C000-people

[Recursion]

135. Notice how we're above the UK, Canada, South Korea, etc.?

OECD average is 2.2; we're 2.3 (actually we're up to 2.6 as of last year).

The problem is too many of them are specialists.

[Bayard]

94. We live in a small town in Kentucky

The few local doctors are awful. The little hospital is more of a first-aid station--you never know who you are going to see in the ER, but when I had to go there for a broken arm, and appendicitis, I was fortunate to get the one good doctor both times. An older gentleman. The others don't seem to be real sharp (I once had to wait 4 hours to be told a sudden big cyst on my hand was arthritis. When I went to my regular orthopedist, he laughed). Seem to be young, and their first job out of med school. Probably won't hang around here long, because I can't imagine they're paid much. It would be no big loss if this hospital went away, since you always get referred to another hospital anyway. There's usually only a few patients there when you go in.

So we go to the big network in the nearest small city. GP's, specialists, and a good hospital. 20 miles away. You go in once, and they bring up all your records forevermore. We are quite happy with the doctors.

[ismnotwasm]

97. There are other solutions as well

Advanced practice nurses, Physicians assistants, open up medical school spots, incentives for rural areas, possibly incentives for GPs, because you are right about specialization. Not sure about too many hospitals, when in my city we frequently go on divert because teams just get overloaded, but it’s worth noting that not every hospital can take every kind of patient, they don’t have the trained personal or the diagnostic equipment.

It’s very complicated and I despise reducing universal healthcare to a political slogan

[Doodley]

102. It would be utterly stupid not to adopt a European-style system.

Who doesn't want to live two years longer, have less illnesses, have better health outcomes, have more babies survive, and cut the cost of healthcare in half?

[Recursion]

104. White Americans is who

Like the foretopman on the Pequod when it sank, white American voters will destroy every inch of heaven if it means they are the next to the bottom group in hell.

Why is a European-style health care system politically impossible? Because of the attack ad it will invite: a white factory worker comes home and sees his angelic blonde daughter is sick. He rushes her to his F-150 and speeds away to the doctor's office.

When he arrives, he parks and pulls her out of the cab, carrying her towards the front door. Suddenly, a luxury car parks in a handicapped spot, and a woman of color steps out, and steps into the office in front of him.

We lose 49 states based on that ad alone.

The only way socialized medicine can work is if white people are convinced that nonwhite Americans don't benefit from it.

[RhodeIslandOne]

110. White Americans already believe "welfare" is something "colored" people get.

THEY receive "benefits". And it's never stopped them from voting Republican who are always looking to take it away.

[vsrazdem]

103. I had employer provided insurance and had to switch doctors 2 or 3 times as the plan was changed.

I didn't like it, but unless I wanted to pay out of network prices you live with it. You can never be guaranteed to not have to change doctors by anyone.

[Recursion]

105. And that's what we need to be pushing

We can't try to keep Harry and Louise in their comfort zone. We have to make them see they're already way outside of it.

[stranger81]

106. I don't have a doctor -- our family's been priced out of the ACA for 3 years now,

and we can only afford to have health insurance for our daughter. Insurance for me, my husband and our daughter (we don't qualify for any subsidies) runs appx $1500/month -- roughly equivalent to our monthly mortgage -- for the cheapest ACA plan in our area with the lowest coverage and sky high deductibles. It's completely unaffordable to us. Without single payer, MFA or some other alternative, my husband and I have no hope of ever having doctors to lose.

[matt819]

109. But this isn't because of Medicare of universal health care

It's because there are fewer and fewer GPs.

When I moved to where I live now, I had a GP at the local hospital. She was great. She left, and I had another GP. And she was great.
She left last year. No more GP. Nurses only. And I haven't had the same one twice, though, to be fair, I've kind of wanted to check them all of them out to see which one I clicked with. I think I've found her. Am I satisfied with the switch to RNs? At first I was irritated. I wanted to see a fucking doctor. How difficult can that be. You're a fucking hospital. Now? I'm sort of getting used to it. They spend more time without giving me the sense that they would like me to leave. The doctors were also generous with their time, but I sorta kinda felt that they would like me to finish up. The nurses are generous with their time, very thoughtful, seem to be very knowledgeable. So I'm okay with the change. I know that if I need specialists, they are available, either at this hospital or the leading hospital in the group, which is about an hour away, and I like the drive.

This isn't a political issue. It's the reality of a change in demographics, med school attendance, declining interest in GP and family medicine, etc.

[KentuckyWoman]

119. I wish people knew how great it is to not have a doctor.

We had Kaiser Permanente for a while years ago. It was the best provider experience we ever had. They are the prototype of what all medical care should be. Not perfect.. nothing is.

If people could just see how amazing it is to be able to get the tests and doctor and decision same day at a low cost....

I can't overstate how good clinic based coordinated medical care is.

[Recursion]

122. Seconding Kaiser here

It's the closest thing to sane medical delivery in the US

[Hoyt]

133. I agree too. I'd have Kaiser now, but they don't offer it where I moved. Had it before and

really liked it. If they finally expand two more counties, I'll sign up again.

Of course, I'm fine with seeing just about any competent doc or Physician Assistant or Nurse Practitioner. I'm fine with leaving the decision of specialists to someone else who monitors quality. I also like doctors who aren't out to maximize their take, those that just want to practice medicine.

[Blue_true]

120. You make a lot of good points.

MFA is going to have a large "startup" cost, but the continuing cost benefits after that period are enormous.

Where I live doctors are beginning to form pseudo HMOs. As that system matures, a number of things like labs and pharmacies will fall under the bigger HMOs.

One of the unfortunate realities of life is that most things concentrate where people and wealth are. That sucks for rural places, so any plan has to figure that out and get practionals of all kinds to those places and keep hospitals open. I think Trump's attack on immigrants hurt rural communities because some of the practitioners that were willing to go to rural places were foreign born doctors who did not have the bigger city orientation of their American counterparts. We can also use technology better, connecting rural doctors to specialists that work in big name hospitals.

[Yavin4]

137. How about Medicare for all and you can buy supplemental insurance to see the Dr of your choice?

Medicare for all would be a default health insurance program for everyone. If you want to control your choice, then you can buy supplemental insurance to cover that.

Most people don't need a specific doctor.

[Voltaire2]

138. There is NOTHING in MFA that prevents you from seeing any doctor.

This whole thread is just nonsense.

[Recursion]

139. Your doctor's practice will probably have to close under MFA

Currently doctors that accept both Medicare and private insurance depend on the subsidy private insurance provides. Most practices would operate at a loss if they took only Medicare. This problem gets particularly acute if we also replace Medicaid with MFA.

If your GP has an individual practice, he will probably have to consolidate it under MFA. That means you can't say with any certainty where his new practice will be and whether or not it will take you as a patient. There isn't something magical about MFA that generates phyisicians; we need the same medical workforce we have now to treat more people than it currently is. If you think its just "those people's" doctors that are going to be effected by that, stop. People with medical care they like are going to need to share the wealth. You'd think I wouldn't have to explain this to Democrats, since we at least believe in that in theory (except apparently where "our" doctors are concerned).

[Recursion]

141. Here's a better physician shortage map

Lots of doctors are going to have to move to those red counties.

[Recursion]

140. Here's a map of counties with a physician shortage

Many doctors are going to have to move from the white and light red counties to the dark red counties. If your doctor is one of them, and you want to keep seeing her, you will have to go to whatever dark red county she moved to. If her new practice will take you as a patient.

Furthermore, about 1/3 of physicians are GPs, but we need about 1/2 of physicians to be GPs, so about a quarter of existing specialists will need to switch to general practice. So if the doctor you want to see is a specialist now, she may not be later.

[kcr]

142. People who believe RW spin don't need to be lecturing on healthcare reform

[Recursion]

143. MFA doesn't manufacture physicians

Those of us who are fortunate need to share with those who are not. I thought Democrats believed in that, but apparently not where doctors are concerned.

"If you like your plan you can keep it" in 2010 was a disaster. We all knew it was not true, but Obama felt compelled to say it anyways. We can't make that mistake again.

Getting medical services to underserved communities means overserved communities have to give some of them up. Whether you like it or not, something much closer to equality is coming.

[elocs]

145. It's hard to have continuity of care with a constant change of doctors.

After being forced to switch clinics because my new insurance does not have in-network doctors at where I had gone for years, I saw my new doctor for my annual physical in January. Five months later I get notified that he no longer carries my insurance. I just got to know him and he just got to know me, my ailments, prescriptions, and issues.
I currently have a new medical issue that requires testing, but no primary care physician until I see a new one next week.
So keeping your own doctor is a big deal because doctors are not interchangeable.