Patterico's Pontifications

3/29/2012

The Obamacare Echo Chamber

Filed under: General — Karl @ 12:21 pm

[Posted by Karl]

At the New York Post, John Podhoretz notes liberal shock that the Supreme Court arguments on Obamacare do not point to an obvious progressive triumph:

Jeffrey Toobin of the New Yorker and CNN confidently asserted on Charlie Rose at the beginning of the week that the court would rule 7-2, maybe even 8-1 in favor of ObamaCare. The previous week, he called the anti-ObamaCare arguments “really weak.”

His view was echoed by an equally confident op-ed assertion by the veteran court reporter Linda Greenhouse, who in The New York Times declared the case against ObamaCare “analytically so weak that it dissolves on close inspection.”

It was quite a change, then, to see Toobin emerge almost hysterical from the Supreme Court chamber after two hours of argument on Tuesday and declare the proceedings “a train wreck for the Obama administration.”

Yesterday, after another two hours of argument, he suggested it might even be a “plane wreck.”

Meanwhile, at another New York-based outlet, NYT columnist (and former editorial page editor) Gail Collins emotes:

I can’t believe this might be overturned. How can this law not be constitutional? The other alternatives are forcing taxpayers to cover the cost of the care in emergency rooms for people who don’t want to pay for their insurance, even if they can, or letting human beings just die on the side of the road. I can’t believe fiscal conservatives think either of those options is a good idea.Really, I have my hands over my ears. Not listening.

All the News That’s Fit to Print: “Lalalalalalalalala…”

Yesterday, I noted the libs are likely overreacting, but also noted similar self-delusion from Dahlia Lithwick and Michael Kinsley. Lithwick relied heavily on the aforementioned Linda Greenhouse, whom Ed Whelan shows to be engaged in denial and dismissal herself (along with claiming Nancy Pelosi as a constitutional scholar).   Lithwick also asserted an an “argument” that Obamacare’s constitutionality is “best illustrated by the fact that—until recently—the Obama administration expended almost no energy defending it.”  Whelan correctly notes that this is as factually false as it is bizarre.  The same goes for Kinsley’s claim that that nobody argued the mandate was unconstitutional until after Obamacare passed.  Ramesh Ponnuru notes Kinsley is factually wrong, not to mention making a claim progressives would never make regarding legal bans on abortion or sodomy.

Liberals and liberaltarians are increasingly fond of claiming the right lives in an echo chamber.  It is said — sometimes even on the right — that the right’s successes in the past few decades has made them intellectually lazy, unable to engage and overcome progressive arguments and attacks as they did in the halcyon days of Buckley and Reagan.  However, when it comes to Pres. Obama’s signature achievement, and a major step toward socialized healthcare, the progressives’ experts and top-shelf pundits display the judgment, rhetorical skill and logic of toddlers.  The liberal echo chamber has a long history, exemplified nicely in the apocryphal quote attributed to New Yorker film critic Pauline Kael: “I can’t believe Nixon won. I don’t know anyone who voted for him.”  Having started with John Podhoretz, we come full circle with his account of the real quotation, which may be even worse.

–Karl

159 Responses to “The Obamacare Echo Chamber”

  1. There’s enough spin to form a singularity, if not an out and out worm hole.

    narciso (83bb81)

  2. The other alternatives are forcing taxpayers to cover the cost of the care in emergency rooms for people who don’t want to pay for their insurance, even if they can, or letting human beings just die on the side of the road.

    So much stupid… If you are a human being dying on the side of the road, if someone happens to see you, you will get an ambulance ride to an emergency room where they cannot refuse to help you. Her alternative to “forcing taxpayers cover the cost of the care in emergency rooms” is to force taxpayers to pay for EVERYONE, ER, Dr appointments, pharmacy…

    Like I said, so much stupid.

    Ghost (6f9de7)

  3. “I can’t believe fiscal conservatives think either of those options is a good idea.”

    It’s a good idea, therefore it’s constitutional. That about sums up the depth of their legal argument.

    They should’ve seen it coming.

    foxbat (8b8494)

  4. Hah, Karl. Here it is. Your post on the subject that you mentioned yesterday you were thinking of writing about. And in it you talk about many of the very things I predicted you would talk about! Epistemic closure? Libs? Never!!

    As a little reminder here is how Julian Sanchez defined epistemic closure–(in conservative circles of course):

    One of the more striking features of the contemporary conservative movement is the extent to which it has been moving toward epistemic closure. Reality is defined by a multimedia array of interconnected and cross promoting conservative blogs, radio programs, magazines, and of course, Fox News. Whatever conflicts with that reality can be dismissed out of hand because it comes from the liberal media, and is therefore ipso facto not to be trusted. (How do you know they’re liberal? Well, they disagree with the conservative media!) This epistemic closure can be a source of solidarity and energy, but it also renders the conservative media ecosystem fragile.

    elissa (c072d8)

  5. “letting human beings just die on the side of the road” This comment by Gail Collins is unreal. The only humans I hear about dying out there are the illegals trying to cross the desert near me. Other than that, lots of jackrabbits and an occasional coyote, but no humans.

    PatAZ (3015aa)

  6. There’s enough spin to form a singularity, if not an out and out worm hole.
    Comment by narciso — 3/29/2012 @ 10:48 am

    – And then, collectively, they can all travel through it, emerging into a parallel universe where there is literally pie-in-the-sky and nobody is ever mean to anyone else.

    Icy (0ad44c)

  7. Delayed *Ding!*

    Icy (0ad44c)

  8. An enlightening, entertaining post. I enjoy days like this.

    DRJ (a83b8b)

  9. If the Supreme Court strikes down this bill we’ll be back to the days of back alley abortions in Rape Barns.

    daleyrocks (bf33e9)

  10. #MISCGENATIONBARN !!!!!!!!!!!’nnnnnm

    JD (f07c66)

  11. Over and above the echo chamber effect, which is of course real, Toobin is a bad lawyer, a flaming idiot and not a credible reporter. His recent books on the Supreme Court have been filled with brazen mistakes of fact. He can’t correctly articulate the most basic of constitutional law principles. He is a clown.

    SPQR (26be8b)

  12. Foxbat, it’s worse than you state. What Ms. Collins is saying is that since these two ideas over here are not good, then THIS one must be good, and good ideas are automatically constitutional.

    I count a total of three failed linkages and at least as many logic fails.

    alanstorm (cb237b)

  13. Feelings, nothing more than feelings

    Icy (0ad44c)

  14. ===Toobin is a bad lawyer, a flaming idiot and not a credible reporter==

    But despite that, SPQR, he may have a sincere personal vested interest in the outcome of all this healthcare stuff. (His love child a result that his girlfriend Casey could not afford birth control pills, maybe?)

    elissa (c072d8)

  15. Obamacare’s Pauline Kael moment. Regardless of the final decision, this angst is best enjoyed with a fine glass of Schadenfreude. It’s a tart wine with a very sweet aftertaste.

    T (400783)

  16. Those that thought the concept of limited government was long dead will not take it well if this goes the way I hope it will. Their surprise will soon be replaced by rage. Then I fear a brutal counter-attack on everything constitutional.

    Amphipolis (b120ce)

  17. This surprises not one conservative in the NY Metro Area.

    Bill (af584e)

  18. BTW

    “forcing taxpayers cover the cost of the care in emergency rooms”

    Even this flat out wrong.

    1) Taxpayer dollars do not go to subsidizing pricing in hospitals. In fact, it is private insurers and self pays who do. They are the fools who over pay. Medicare and Medicaid pay 80% or 60% on the dollars that Private Insurers pay.
    2) Medicaid is a huge subsidy by Taxpayers. Obamacare is MORE MEDICAID. So what is the diff imbecile?
    3) Emergency Rooms are required for Hospitals to charge outrageous fees for aspirins et al
    4) Emergency Rooms are the principal gateway to filling hospital rooms. Without an ER, Hospitals are empty.
    4) ERs are too busy b/c they check in way too many people for idiotic pathologies. See point 3 and 4

    This does not even address the bigger issues. This writer is an idiot as are most people who talk healthcare economics (on both sides) and about 80% in the arena to begin with.

    Bill (af584e)

  19. … to being with are imbeciles also.

    Bill (af584e)

  20. “forcing taxpayers cover the cost of the care in emergency rooms”

    Even this flat out wrong.

    I’m not sure I agree because I know a few states have taxpayer-funded hospitals. In Texas, most of our 254 counties have at least one hospital where the county is responsible for its funding, and it’s these hospitals that are required by law to treat all patients regardless of their ability to pay. So taxpayers make up the difference if there isn’t enough revenue from paying patients to cover the costs. There can be significant shortfalls in some counties, such as in areas with a large illegal immigrant population.

    DRJ (a83b8b)

  21. There’s a wonderful analysis of the MEdicare argument by Althouse, where she demostrateds pretty brutally that the Solicitor General has no frigging clue what makes Anthony Kennedy tick, let alone the conservatives.

    If she’s right, the Medicare expansion would fall even if nothing else does. It is almost as though the Obamaites gamed this without understanding WHY they were getting this pushback.

    Kevin M (bf8ad7)

  22. Patrick, I lost a long post because I accidentally clicked on the live preview. Is there any way that could be disabled. The comment is apparently unrecoverable and I spent some time on it.

    Mike K (d6b02c)

  23. Listening to the arguments and reading some of the commentary, it is increasingly clear that the Left’s disconnect is this:

    They look at the “mandate” objection as a ploy by the Right to attack a bill which it opposes on policy grounds. Mainly because they rate Supreme Court decisions based on outcome, not on law or process.

    It does not dawn on them that the bill is irrelevant to the objection: gutting federalism any further than Wickard did would be opposed by most on the Right, regardless of the case.

    Kevin M (bf8ad7)

  24. #21: Medicaid, not MEdicare.

    Kevin M (bf8ad7)

  25. #20: Instead of forcing taxpayers to cover the costs of the uninsured, they are going to force young people to do it.

    Kevin M (bf8ad7)

  26. True, Kevin, and young people not even born yet.

    DRJ (a83b8b)

  27. elissa (4),

    Surprisingly, this is not the post I was thinking of writing — it just neatly dovetails with the overall theme. I may post more along these lines this weekend.

    Karl (6f7ecd)

  28. #1 Comment by narciso — 3/29/2012 @ 10:48 am

    It’s gravity that forms a singularity, not spin. Sorry.

    Machinist (b6f7da)

  29. Will current law provide psychiatric care for members of the Left who will have severe bouts of depression, and related cognitive dissounance disorders,
    from the (hoped for) declaration by SCOTUS of the unconstitutionality of Obamacare?

    And, wouldn’t that moot their (if they were rational – a BIG IF) demands for changes in current law due to large segments of the population not being covered for every little ailment?

    AD-RtR/OS! (b8ab92)

  30. Liberal legal pundits act a lot like (the mythical version of) lemmings–it’s not surprising that the mood swings of Toobin and Greenhouse have dragged the whole idiot horde with them. The hysterics from the mob should a 5-4 decision striking the whole law come down will be a popcorn moment indeed.

    MSE (e1c2c6)

  31. It was obvious to me that the law was in great dedal of trouble from the fact that the Supreme Court scheduled sessions on jurisdiction and severability. But some people only found out from the tenor of the questioning.

    The liberal people watching this were probably going by the lower court decisions, where the majority of judges did not overturn Obamacare, and one who did they regarded as a partisan hack just about. But they were sort of bound by precedent, and they didn’t consider one argument.

    The best argument for overturning Obamacare is that even if the penalty is a tax, it is not a constitutional tax, and that’s probably the way Chief Justice Roberts will go. It is not constitutional because it is neither an income tax (it’s levied even if you don’t have any income) nor is it an excise tax.

    It’s a capitation tax, with exceptions. There will be some work for the Supreme Court writing their opinions.

    They’ll also go into if the penalty is not to be considered as a tax, with an exemption if you have health insurance but as some kind of direct order to get health insurance and whether that can be done under the Commerce clause,.

    They have before them a lot of analysis that there are many other ways of solving the spiral of death problem, and also even that this law actually doesn’t solve it. (The penalty is too low)

    Sammy Finkelman (d22d64)

  32. Comment by PatAZ — 3/29/2012 @ 11:37 am

    The only humans I hear about dying out there are the illegals trying to cross the desert near me. Other than that, lots of jackrabbits and an occasional coyote, but no humans.

    The illegals are humans, endowed by their Creator with the self-evident un-alienable right to the pursuit of happiness, which they are exercising.

    Sammy Finkelman (d22d64)

  33. ““forcing taxpayers cover the cost of the care in emergency rooms”

    Even this flat out wrong.”

    Bill – I’m with DRJ at #20. You are flat out wrong about the above being flat out wrong, although not perhaps for the reasons you think. I don’t know whether that puts you in the imbecile category you described.

    daleyrocks (bf33e9)

  34. #20, Uh yeah but I think forest and trees apply on that one.

    Bill (af584e)

  35. #33, The rules apply to all ER. All ER have the problem. They all make it up by over charging the private sector.

    If you guys wish to focus on the few and far in between go right ahead.

    Bill (af584e)

  36. Gimme a “T” for Texas!

    Texas man yells ‘Go Cowboys!’ before execution…

    http://www.elpasotimes.com/newupdated/ci_20281077/texas-man-yells-go-cowboys-before-execution

    Colonel Haiku (03f86b)

  37. “#20, Uh yeah but I think forest and trees apply on that one.”

    Bill – Massachusetts passed a law to assess its citizens for uncompensated care. I don’t believe the law was repealed with Romneycare, but I’m willing to be corrected.

    daleyrocks (bf33e9)

  38. Kagan’s comments about the government offering you boatloads of money and not seeing anything wrong with that, anything coercive, indicates a cocoon to me. A cocoon of crazy!

    Where in the Sam Hill do they think the money is coming from? From coercing generations of taxpayers!

    Patricia (e1d89d)

  39. Oh, O/T. I had to comment on the LA Times today characterizing the hysteria against the couple that Spike Lee victimized as “privacy rights versus social activism.”

    Good grief.

    This is the kind of thing that makes them totally intellectually dishonest. So hounding a couple of people possibly to death is now “social activism”?

    Patricia (e1d89d)

  40. #37. Again, the big problem of ER and Taxpayer funding ER is a diversion and is flat out wrong, a ruse and so small as to be unimportant.

    In addition, ER is a basic requirement for Hospitals to actually charge as much as they do for services which one would assume be much cheaper.

    CBCw/Diff = $400 at Hospital
    Quest Labs = $2.50 Cost to an MD Office doing it for the same cash pay. MD might charge $20.

    The amount of tax payer money going to fund rural ER, etc and other entry points for those uninsured is very small. Medicare and Medicaid don’t count as they pay even less then Private Carriers so who is subsidizing who???

    The Hospitals and ER Groups have used this as a marketing ploy which over time grew in such a way as to justify re-engineering the Health Care system via Obamacare. An abomination. A false hood. An issue some use on the RIGHT to bash illegal immigration too.

    It is a complex system. ER’s, in any private or Public Hosptial, is a major money maker and at worst a minimal loss leader.

    Bill (af584e)

  41. If you really want to see lots of taxpayer funded boondoogles got after FQHC’s.

    This is where the major money is in terms of subsidy by Taxpayer.

    FQHC are these bloated “free” clinics that are not hospitals that are paid a premium by Medicaid, have sliding fee schedules for self-pays and get gobs and gobs of money from CMS.

    999:1 ratio likely FQHC to ER …..

    Bill (af584e)

  42. It’s a capitation tax, with exceptions. There will be some work for the Supreme Court writing their opinions.

    Paul Clement was pretty clear on this point. He demonstrated that an excise tax on NOT buying something was the same as a head tax.

    Kevin M (bf8ad7)

  43. Bill, I think that Quest Labs charges more for cash pay. The $2.50 is to AETNA and such.

    Kevin M (bf8ad7)

  44. Bill,

    Maybe this is not common nation-wide, but many hospitals lose money on their ERs, especially government-funded hospitals in Texas. Some are assessing fees to be seen for non-emergencies because the taxpayers got tired of making up the difference at the non-profit taxpayer-funded hospitals:

    The non-profit Midland Memorial Hospital in Texas implemented a $150 ER fee in 2009, as part of an exercise in cost-control, according to a Kaiser Health News story. Kaiser says the hospital had lost $14 million in 2008, in part because of millions of dollars in ER bills left unpaid.

    I don’t know how it works in the other 48 states but this is true in Texas and it’s true in Florida, too.

    DRJ (a83b8b)

  45. I would think that any law that went beyond Gonzales v. Raich (or even Wickard v. Filburn, as people have pointed out in threads past) in its utilization of the Commerce Clause would automatically be a cause for concern for people on both sides of the aisle. And I don’t understand why more liberals aren’t pissed off at the idea of being forced by law to patronize major corporations.

    Leviticus (870be5)

  46. DRJ,

    LOL. You keep buying that nonsense. They will keep selling.

    I luv me non-profits in health care. They always have ridiculously well compensated senior management claiming poverty. Always well over staffed with mid-level management ready to raise the banner for inefficiency, errrr more money for critical services. Kaiser included.

    It is all a lie repeated ad nauseum by MD who don’t know business or don’t care, do-gooders who don’t know accounting nor management and administrative people making amazing livings crying poverty.

    Do you want me to tell you the story a Hospital controlled 40 unit Urgent Care system which was losing tens of millions …. while over staffing the centers by factors of 3:1 in order to provide lots of employment to hospital staff. Then saying it was because of the uninsured and how they needed more cash to fund the operations …. LOL!!!!!! Centers which in private control would hemorage cash.

    Hospitals are like Electric Utilities. The bigger the are (needed or not) the more money they get. So you grow to absurd sizes for purpose of creating excuses to raise money. ER is a great place to start for largesse b/c it is the loss leader for a hospital. Nearly 70% of all hospital beds get filled via the ER. No ER, no hospital, no hospital no big salaries for hospital staff.

    Don’t believe it. It is a lie. A vicious cycle.

    Kevin,

    Uh, yeah, sort of but a self pay can request the price also and will receive it at times. Point is the big lie in medicine is that Self Pay (Uninsured are unprofitable) are this burden. They are, by far, the most profitable patients. A cash pay generates 50% gross margins whereas an insured 10-15%. No billing, no A/R financing. Thing of beauty.

    Bill (af584e)

  47. DRJ, drive I-95 in Florida. Every other $5,000 per month billboard is advertising ER Services at Hospitals and how short the wait time is.

    Baptist in Dade is opening Urgent Care left right and center ….. to fill up the hospital. They “lose” money hand over fist until you realize they rip off patient by over utilizing hospital controlled diagnostic capacity (MRI, etc).

    Again, you are consume dog food under the guise of truth.

    Bill (af584e)

  48. And businesses losing all the money with all these horrid uninsured patients will not take out billboards to fill up the ER with more of the same patients.

    LOL. Wake up folks. No industry in the US is so poorly run, so filled with fraud, so large and so corrupt as the health care system.

    I know. I am a Senior Executive in the field.

    Bill (af584e)

  49. Bill is kind of a jerk.

    JD (318f81)

  50. JD,

    Name calling. Nice. Very erudite.

    Bill (af584e)

  51. Maybe this is not common nation-wide, but many hospitals lose money on their ERs, especially government-funded hospitals in Texas. Some are assessing fees to be seen for non-emergencies because the taxpayers got tired of making up the difference at the non-profit taxpayer-funded hospitals:

    Traditionally, when I was a pup, the hospital ER was a loss leader, just as OB was. That, of course, was when hospitals and doctors could make up for it with paying patients.

    I can remember presenting a fascinating case of a bullet embolus to our chief of surgery at USC. He waas uninterested and annoyed that I had taken his time even though USC was a huge trauma center. He was an old-fashioned chief who supported himself with his downtown private practice and donated his time to the medical school. Trauma was the concern of residents, most of whom knew far more about trauma than their faculty.

    Trauma has gotten far more interesting. Why ? Private practice is less rewarding and trauma is now the cash cow for many groups. They get salaries from the hospitals. We used to do it for nothing because we could afford to.

    I wish I could have collected $100 an hour for the hours that I spent operating on illegals and criminals. When medical practice is less rewarding, who will spend the time on trauma and indigent care ?

    Mike K (d6b02c)

  52. Hospitals are now buying Physician Practices like their hair is on fire. Why?

    Hospitals advertise quite a bit now — especially ER services. Why?

    Hospitals are like Federal Agencies — always crying poverty, always over staffed, always doing lots of unimportant nonsense, always investing in more and more capacity, and always growing budget$$$$$$.

    Bill (af584e)

  53. Again, you are consume dog food under the guise of truth.

    DRJ,

    LOL. You keep buying that nonsense. They will keep selling.

    LOL. Wake up folks.

    This does not even address the bigger issues. This writer is an idiot as are most people who talk healthcare economics (on both sides) and about 80% in the arena to begin with.

    Comment by Bill — 3/29/2012 @ 1:35 pm

    … to being with are imbeciles also.

    Comment by Bill — 3/29/2012 @ 1:36 pm

    This surprises not one conservative in the NY Metro Area.

    DRJ, drive I-95 in Florida.

    Name calling. Nice. Very erudite.

    Carry on …

    JD (318f81)

  54. Mike K,

    Do you agree that while the pricing you received for operating on illegals and criminals was offset by the pricing you received by operating on self-pay and privately insured patients?

    That is to say, did you explicitly understand that in order to do A, you needed to do B? You have no choice. The key was overall how much you made??

    Bill (af584e)

  55. JD,

    Those are not insults last I checked.

    But you may have very thin skin.

    God speed.

    Bill (af584e)

  56. Hospitals give away services to some people so they can charge $490 for a CBC to the vast majority of others.

    Bill (af584e)

  57. That is to say not insults of you or any other poster. I did insult the writer.

    Bill (af584e)

  58. Whatevs. You are not acquitting yourself well. Telling someonemthat is almost universally respected that she is incapable of discerning the difference between dog food and the truth, calling peole that do not share your view imbeciles, idiots, etc … Yet you get all butthurt when I note you are a jerk, then accuse me of having thin skin. Your nonsense is predictable, and played out many times before. Carry on.

    JD (318f81)

  59. Bill, you said god speed so you may have left the thread. But if you are still here just what the hell is it that you are advocating? I “get” the frustration, the barely veiled anger and the sense that you feel an argument is going on. I read the one liners. But what is the fix or the solution you seek? What is the point you want to leave us with?

    elissa (c072d8)

  60. JD

    Fact is you (vast majority) don’t know the difference on this issue between the truth and dog food. Quoting articles which are predictably partisan, agenda driven is also played out.

    Look at what they do commercially and how they behave, not what they say or write or advocate. Healthcare professionals have been raised on the tit of crying poverty and are rewarded handsomely for it.

    ER’s are the profit driver in hospitals. ER brings in patients. ER fills beds. ER creates tons of diagnostics. ER provide cases to internists and hospitalists. No ER, no hospital. Period. So you need to service a few illegals? BFD. Only people who complain about it are ER Staffing Groups who still gross $300-$350 per hour per MD. The Hospital itself nets another $300 for all it’s technical services. So they “forgave” $25-30 per hour of for illegals. So what. They just made a ton of cash.

    You just want to sell chicken breast? Still gotta produce chicken butts and beaks. You need to feed the whole chicken, not just its breast. So you make the best out of the other parts of chicken – beaks, butts and necks — even if Chicken Breast are the big money maker.

    You are not well informed on how the system works and how money is generated in it. There is a reason we spend the most in the world on health care and that money goes into someone’s pocket.

    But you don’t know. Most MD don’t know. Many Health Care Admins don’t understand it. It really is very complicated and intricate with one part of the system feeding the other.

    Invisible hand indeed.

    Bill (af584e)

  61. #59, yada yada yada .. What is the point you want to leave us with?

    ER make lots of money. There is no crisis in the ER with uninsured. It is a convenient argument for special interest groups to line their pockets

    Bill (af584e)

  62. And, Bill, the answer is——?

    elissa (c072d8)

  63. I like when folks who post their view points here constantly on every thread with a level of certainty only afforded by that same collection of posters, get annoyed when a differing thought is presented that upsets one of the members of that collective.

    Ironic how the point of this article above is to attack / mock the echo chamber on one issue but when you attack the echo chamber on another issue, folks get upset.

    Guys, ER make tons of cash for hospitals and MD Groups. Ton$$$$$$$$$$$.

    Bill (af584e)

  64. #62, read 61.

    Bill (af584e)

  65. That is to say, did you explicitly understand that in order to do A, you needed to do B? You have no choice. The key was overall how much you made??

    As I remember it, and it is difficult to recall how things were in a simpler and more innocent time, We thought it would be a good thing for our hospital to be a trauma center. There was an aura of competence that was desirable. My partner and I did not have a high opinion of the local university hospital. We thought we knew a lot more about trauma than they did.

    I know that sounds naive to you, in your anger at medicine, in general. We decided to do it out of a sort of pride in our ability.

    A few years later, at a state emergency medicine committee hearing, Don Trunkey, the first advocate of a trauma system for California, said that only my partner and I could have done it and he didn’t think it could be done. We had a small hospital and two guys who were on their own did better than the university hospital in Orange County, CA. As the years went by and the volume grew, I quit the trauma system. My partner became entranced with the bureaucracy and the power it gave him. We disagreed on that but remained friends.

    I’m sure that you do not understand that. Doing something out of pride does not seem consistent with your values.

    Mike K (d6b02c)

  66. #28 Machinist “It’s gravity that forms a singularity, not spin. Sorry.”

    Actually, as I recall you can do it with spin too.

    Excitable Andrew (49d034)

  67. “How can this law not be constitutional?”

    I suspect that the entire thing is unconstituional per the Tenth Amendment to the United States Constitution. However I’m not going to wade through 2700 pages (or whatever the exact number is) to find out if somewhere in this weighty tome, there’s a tiny little part of it that DOESN’T violate the limitations placed on the power of the federal government by the Constitution.

    Those with more stamina than I, will have to do that.

    Dave Surls (46b08c)

  68. Elissa – the answer is if you do not agree with bill you are a stupid uninformed imbecile and are thin-skinned for complaining that he calls you an uninformed stupid imbecile unable to tell the difference between dog food and the truth which is what bill wraps himself in the truth

    JD (318f81)

  69. Here’s another thing I’m not going to do: Have any respect for the legislative body of a government that passes massive bills, without the legislators having bothered to read, in its entirety, what said bill contains.

    That’s just the way I swing.

    Dave Surls (46b08c)

  70. #65. “Doing something out of pride does not seem consistent with your values.”

    Ah yes, the ad hominem. Your story is very interesting but not the point.

    Point is if you operate a hospital, you need an ER. It is like putting refrigeration in a supermarket. You can’t be a hospital without one. You can’t be a supermarket without on.

    So for all your anger (your words) about the $100 per hour you wanted for seeing illegals and criminals — you also were handsomely paid for the other work you did (the majority of it) to see other patients.

    You likely made $150-$200 per hour, working about 160 hours per month doing 13 shifts per month. That is well over $300,000 per year with the ability to have off 17 days per month.

    Good for all who can do it. Tough assignment. But the money is pretty good. I find it interesting you would complain about the other $30-40K per year you could have made from those unprofitable customers you served …

    “The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

    May I never see in the patient anything but a fellow creature in pain.

    Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

    Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.”

    Bill (af584e)

  71. Thanks JD–see, I foolishly thought he was bravely trying to divulge, from an insider’s perspective, what is wrong with the healthcare system in America– and had some solutions to offer that would fix the problems (but was just not explaining them well.) My bad.

    elissa (c072d8)

  72. JD and Elissa.

    I am dead set against the bill. Your #68 proves my point about ignorance.

    ERs make lots of money and the uninsured crisis is not a crisis is not tantamount to “I support Obamacare.”

    Keep be-clowning yourself (now I insulted you, feel horrible about it).

    Bill (af584e)

  73. I stand corrected, Sammy. My bad.

    PatAZ (3015aa)

  74. #71, Learn to read. I was making a narrow point about ER, Hospital financial health and the narrative falsely spread about uninsured bringing down health care systems.

    If you want to know how to fix it, start with eliminating the incentives for over utilization and over specialisation. The rest cost you about $100,000 per month.

    Bill (af584e)

  75. Mike K,

    Tell me the truth because I don’t want to believe something that isn’t true. Are non-profit hospitals in the Southwest losing taxpayer money on their ERs because of uninsured patients, or is that a myth as Bill suggests?

    DRJ (a83b8b)

  76. Bill,

    A wise man told me that anger always comes from fear. What are you so afraid of?

    DRJ (a83b8b)

  77. If you guys want to feel bad for MDs look no further then your local Pediatrician without Hospital privileges. Especially the inner city ones.
    .
    .
    .
    .
    Hospitals and ER folk$$$$$$ need no pity.

    Bill (af584e)

  78. My diabetes. My wife. A future teenage daughter.

    If you have a specific question, please ask because the fear/anger angle makes no sense to me. Looks like chum thrown in the water to get brainless sharks excited.

    Bill (af584e)

  79. Funny how these commentators avoid the central issue-whether this law falls under the enumerated powers of Congress.

    Michael Ejercito (64388b)

  80. #75. DRJ,

    Do supermarkets measured profitability of their stores based on the their fresh fruit gross margins?

    I don’t know Mike but if he is an MD then he likely has been sold a bag of goods for years on this issue.

    Might there be a few hospitals on border towns where illegal patient mix is 90% and they don’t pay … maybe.

    But there are like 4,000 US Hospitals. Talk to me about the 80% that matter.

    Bill (af584e)

  81. Bill you are mistaken about the profits that are made by the ER. If they were such money makers, hospitals would not be closing their ER’s like they have been all across the country.

    peedoffamerican (ee1de0)

  82. #79 I am not a lawyer but it looks to me like forcing people to buy something they don’t want under the auspices that “in the future” they might need it so as a result the government forces them to “pay it forward” sounds pretty totalitarian to me and something not in keeping with the constitution.

    But what do I know. I guess you need a legal degree from Harvard to understand simple concepts of freedom of choice and freedom of consequence.

    Bill (af584e)

  83. Three in the area where I live have closed their ER’s in the last two years.

    peedoffamerican (ee1de0)

  84. DRJ – Why don’t you know the difference between dog food and the truth?

    JD (318f81)

  85. Hospitals and ER folk$$$$$$ need no pity.

    We’re not talking about the health care providers that work at hospitals. We’re talking about whether taxpayers have to pay the difference when hospital revenues don’t cover expenses.

    DRJ (a83b8b)

  86. #81, Really? That is a new one.

    Usually Hospitals close b/c they are not busy enough to support massive over capacity in staff and plan.

    Not b/c an ER, which operates in about 5% of the Hospital square footage, serves a few mexican’ts

    I know of Hospitals that have closed only to reopen their ER later b/c it is profitable and the community begged for them (the ER) reopened.

    ER is the one part of the hospital which given the nature of demand is very local, fairly forecastable and does not require a ton of marketing.

    It is all that elective surgery and diagnoctics which are easily routed by the outpatient community to larger, more technically sophisticated hospitals this starving the other hospitals of important business.

    Bill (af584e)

  87. JD,

    Honestly, all I’m trying to say is that hospitals in different parts of the country are funded in different ways and some of them have more problems with uninsured care than others. Perhaps the fact that Texas has such a high rate of uninsureds explains why Bill and I are having this disconnect, but I’m willing to acknowledge that other parts of the country may not have this problem.

    I don’t mind Bill’s insults. He’s obviously mad and afraid of something but it doesn’t hurt me that he’s being cross. It reflects poorly on him, not me.

    DRJ (a83b8b)

  88. #85 “We’re not talking about the health care providers that work at hospitals. We’re talking about whether taxpayers have to pay the difference when hospital revenues don’t cover expenses.”

    And that happens when you don’t fill up your hospital beds with tons of paying customers. Not b/c a few illegals don’t pay the ER bill.

    Hey any MD in the house, why is it that NEARLY EVERY MEDICARE PATIENT who goes into the ER is held over for over night observation with a slew of diagnostics performed??????? Whereas the 62 year old is not?

    And before you tell me standard of care at least think about it some …..

    Bill (af584e)

  89. #87. Yes, let us run an entire US Healthcare system based on outliers near Texas border towns and LA.

    So angry I am. Brrrrrrrr.

    Bill (af584e)

  90. #66,”Actually, as I recall you can do it with spin too.”
    Comment by Excitable Andrew — 3/29/2012 @ 7:06 pm

    I’m very interested, can you suggest how? It seems counter intuitive but much does so I am open. Thanks.

    My apologies to narciso if I stepped in it.

    Machinist (b6f7da)

  91. DRJ – I cannot help but mock. I am weak ;-)

    JD (318f81)

  92. Bill,

    If 50% of the people who come to your ER are uninsured (and don’t pay their bills) and they’re the same people who fill up 50% of the hospital beds (and don’t pay their bills), is it fair to say the ER is part of the problem?

    DRJ (a83b8b)

  93. Learn reading comprehension Bill. I did not say the hospitals closed. I said the hospitals had to close their ER’s due to losses that they were incurring.

    peedoffamerican (ee1de0)

  94. #83 where dat be? you must have low population density or one hospital that so shiny and new that everyone wants to go there.

    The days of small charity based hospitals run by the nuns is long over. That was not b/c Mexicans can’t pay — it was because they were small, under funded and much bigger, nicer hospitals were built.

    Great news for consumers if you ask me.

    Bill (af584e)

  95. Bill,
    A few years ago it was considered a crisis that so many hospitals in the LA area were closing their ERs so people were taking too long to get to an ER as ambulances were rerouted. Was this all a big lie? Were there ample ER spaces wanting customers to fill their hospital beds and the news reports were false?

    I was in CA then but not down there so I only saw this on print and TV news.

    Machinist (b6f7da)

  96. ==I am not a lawyer but it looks to me like forcing people to buy something they don’t want under the auspices that “in the future” they might need it so as a result the government forces them to “pay it forward” sounds pretty totalitarian to me and something not in keeping with the constitution.

    But what do I know. I guess you need a legal degree from Harvard to understand simple concepts of freedom of choice and freedom of consequence==

    LOL. OK, now I really am confuzzled with respect to your approach on this thread. Are you under the impression that the majority of people whom you have been insulting and arguing with don’t fully share and agree with this statement you made @ 7:39 about the individual mandate?

    elissa (c072d8)

  97. #93 A hospital without an ER? Wonder how the Joint Commission will view their membership.

    Dr any thoughts on that?

    Bill (af584e)

  98. #96. No. I was providing a response. I hear lots of Harvard Lawyers tell me otherwise on TV.

    Bill (af584e)

  99. “If you have a specific question, please ask because the fear/anger angle makes no sense to me.”

    Bill – Why would I ask you any questions? Your answers have already proven untrustworthy.

    Your initial assertion on the thread that taxpayers don’t fund uncompensated care was flat out wrong was flat out wrong. For somebody who claims to be a senior executive in the industry, that is not a very credibility enhancing point.

    I see mostly bald assertions on your part, no links or data, again, not very credibility enhancing, unless you think dog food related comments add value.

    Bill, why did the Univ. of Chicago put Michelle Obama in charge of a patient shifting effort to get people out of its emergency room and back to neighborhood doctors?

    Was EMTALA passed partly in reaction to patient dumping? Is that practice still going on, Bill?

    Seems like a senior executive in the field should be able to put his hands on some data right quick about the costs of uncompensated care and such.

    daleyrocks (bf33e9)

  100. #95 I have no doubt some ERs got killed with “too much demand.”

    My point is a) they likely made a tons of money from the ER itself and b) they fed (subsidized) the rest of the hospital by filling up those beds. I am sure the Hospitalists made a killing.

    Here is a great ER joke …. how can you tell if the internist will want a patient for over night observation? …. you look at their insurance coverage!!!!!

    Bill (af584e)

  101. Bill, I always value insights shared by people with inside knowledge or perspectives. There are many such here from different fields. I am not arguing with what you say but your arrogant and rude approach certainly diminishes your credibility and your persuasiveness. While I appreciate your attempts to share, why bother and then use an approach that reduces the effects? It seems counter productive.

    Machinist (b6f7da)

  102. The days of small charity based hospitals run by the nuns is long over.

    Other than the military hospitals, one of the largest hospital systems in South Texas is Christus Santa Rosa that was founded by nuns and is still run by the Catholic Church.

    DRJ (a83b8b)

  103. “#87. Yes, let us run an entire US Healthcare system based on outliers near Texas border towns and LA.”

    Bill – You forgot Massachusetts and New Jersey even funds part of its uncompensated care with tax revenues. A senior executive in the field should know these things.

    daleyrocks (bf33e9)

  104. #100,
    I’m sorry but you lost me. Why would a hospital close it’s ER because it was making too much money? How did the hospital stay in business without this profit center filling the beds?

    Machinist (b6f7da)

  105. Daley,

    Is Medicaid to you tax payer funding for uncompensated ER care?

    So why do Hospitals want to divert patients out of ER back to outpatient MDs???

    Bill (af584e)

  106. “Other than the military hospitals, one of the largest hospital systems in South Texas is Christus Santa Rosa that is still run by the Catholic Church.”

    DRJ – Prolly just a bunch of overstaffed greedy mackerel snappers pleading poverty who don’t understand the business like Bill if you ask me. Heh

    daleyrocks (bf33e9)

  107. #104, I never said a hospital can’t lose money and have a need to close. I said ERs are usually profitable and are the gateway product (an essential method) to filling up a hospital with profitable patients.

    ++50% of beds in a normal hospital are filled with people who come in via the ER and many of those cases those patients would not be there if not for the ER.

    A Hospital without an ER …. out of the 4,000 US Hospitals how many????????????

    SMH. Tough group.

    Bill (af584e)

  108. Bill:

    Yes, let us run an entire US Healthcare system based on outliers near Texas border towns and LA.

    No, let’s run a system that allows us to deal with your hospital’s problems and with mine.

    So angry I am. Brrrrrrrr.

    Are you angry because you think I support ObamaCare, and you oppose it? I don’t support ObamaCare, but that doesn’t mean I’m going to ignore funding issues like those we have in Texas.

    FWIW I support free-market solutions, but I also understand that state and local taxes will be required to pay for taxpayer-funded hospitals and their ERs as long as hospitals are required to provide care for people who can’t pay.

    DRJ (a83b8b)

  109. “Is Medicaid to you tax payer funding for uncompensated ER care?

    So why do Hospitals want to divert patients out of ER back to outpatient MDs???”

    Bill – I’m asking you the questions since you are the senior executive in the field. Why the heck would a hospital want to shift patients out of its emergency room if it so freaking profitable? What is wrong with this picture?

    daleyrocks (bf33e9)

  110. #106, So just b/c the Catholic Church runs it means there is no chronic over staffing, graft and administrative sloth? OK. Don’t know the outfit but I am not prepared to ignore experience to fit your narrative.

    Bill (af584e)

  111. Bill – We’ve had 16 hospitals close in Illinois since 2000. I’m pretty darn sure it was because they were all too profitable as you continue to assert.

    daleyrocks (bf33e9)

  112. 90. Machinist “I’m very interested, can you suggest how? It seems counter intuitive but much does so I am open. Thanks.”

    I’m sorry, but I really don’t remember at all. It’s been decades since I got my physics degree, extreme relativistic effects was not a big focus, and I’ve been employed as an engineer ever since. Counter-intuitive? Yes. There’s lots of wonderful weirdness–although you are certainly entitled to suspect that this might be weirdness that I am mistaken about.

    pst314 (49d034)

  113. I said ERs are usually profitable and are the gateway product (an essential method) to filling up a hospital with profitable patients.

    In light of your comment above, Bill, how then do you explain ER doctors suing the state because ER’s are on the verge of collapse unless additional funding comes through?

    Emergency room doctors filed a lawsuit today against the state, saying that California’s overstressed emergency healthcare system is on the verge of collapse unless they receive additional funding?

    California has seen 85 hospital closures in the last decade. An additional 55 facilities have shut down emergency rooms. The state now ranks last in the country in access to emergency care and is last in emergency rooms per capita with only seven per 1 million people. The national average is 20 emergency rooms per 1 million people.

    Emergency room physicians say they have been particularly hard hit by the state’s fiscal problems. Unlike other doctors, who can choose not to accept Medi-Cal patients, emergency rooms cannot deny treatment. They provide care for these patients but are reimbursed at rates they say are half the cost of the treatment. California’s reimbursement rate ranks 43rd in the country, state officials said.

    Another issue is that there is a flight of medical school grads leaving the state because they cannot afford to stay here because of the reduction in reimbursement rates – they can make more elsewhere and pay off their student debt more easily.

    Dana (c6aa60)

  114. Daley,

    Each hospital is different and different at different times.

    1) If the patient is insured and the hospital has empty beds — they will check them in at a very high rate.
    2) If the patient is uninsured they will likely send them outpatient unless the condition presents a possible malpractice liability to the attending. Many time with no treatment, no diagnostics and a referral.
    3) Hospital is full they are very careful to check anyone in.
    4) They love to refer to MD that have outpatient practices who refer to the hospital … why are hospitals running around buying MD practices (for referrals)


    It is all about capacity utilization and yield management. Each department has certain capacity to manage. ERs feeds most of the “profit centers.”

    Bill (af584e)

  115. “Texas man yells ‘Go Cowboys!’ before execution…”

    That’s what I call a die-hard football fan.

    Dave Surls (46b08c)

  116. Bill,

    Here’s an interesting statement about Emergency Room funding:

    Q. How much does it cost U.S. taxpayers to provide health care for illegal immigrants?

    A. Billions of dollars are estimated to be spent each year, although data are scarce on both the costs and use of health care. Transient living conditions, undercounting of migrant workers and desire to avoid contact with government agencies limit the nation’s ability to accurately determine the costs of their medical care.

    In some hospitals, as much as two-thirds of total operating costs are for uncompensated care for illegal aliens. As a result, hundreds of emergency departments have closed. In Los Angeles, for example, 10 hospitals have closed in the past five years because of uncompensated care.

    Congress in 2005 authorized $1 billion in funding over four years to help physicians and hospitals recover costs of providing emergency care to illegal immigrants. This was a critical first step in recognizing the growing funding crisis in the nation’s emergency departments, which affects everyone’s access to emergency care.

    The source of that statement is the American College of Emergency Physicians.

    DRJ (a83b8b)

  117. #111 Who wrote hospitals are profitable?

    All I wrote that has gotten folks in a panty twist is that

    a) tax payers don’t really pay for uncompensated ER care in any meaningful way — private payors do with substantively higher prices and revenue yields.
    b) uncompensated ER care is not bringing down these hospitals, horrible investments in over capacity and over staffing are
    c) a hospital without an ER has much greater difficulty to survive

    You can mis-represent as you wish and pound sand all night but well run hospitals have ERs, see lots of uninsured patients, use the ER as a way of filling bed capacity, have an active referral community whose bread they butter and try to keep out uninsured patient for every thing but the most urgent care

    Bill (af584e)

  118. #112,Comment by pst314 — 3/29/2012 @ 8:26 pm

    No problem. I was certainly not expecting a physics education here and I have not spent a day in college so I am not questioning anything. I am reading an article another fine commenter sent me so hopefully I will find some light. The life and death of stars has become my main science interest on late. Thanks again.

    Machinist (b6f7da)

  119. #116 DRJ,

    100% of Medicaid patients pay 10% of the Posted Price of a Hospital. Total losses according to the hospital from serving Medicaid. 0.

    30% of Self-pay patient pay 100% of the Posted Prices of a Hospital. Total losses according to the hospital for serving uninsured 70%.

    The focus of collection departments is to eliminate A/R — with insured patients once the HCFA/Whatever goes out the door, they write off the ‘un’allowable, collect what is needed from the insurance and then send the insured a bill a fraction of the price. With self pay — they send a giant bill and then have to collect.

    A/R always looks gigantic for self pay, writeoffs always look gigantic, but when what matter is Amount of Money Collected per Patient Visit. Health Care Accountants look at the wrong measures. Their MD friends are even more clueless.

    Bill (af584e)

  120. “I never said a hospital can’t lose money and have a need to close. I said ERs are usually profitable and are the gateway product (an essential method) to filling up a hospital with profitable patients.”

    Bill – You are now making progress. This is the first comment in the thread in which you have recognized there may be a difference between profitable and unprofitable patients rather than looking to high salaries and bloated staff as the determinants of hospital profitability.

    There may be hope for you yet.

    BRAVO!

    daleyrocks (bf33e9)

  121. “How can this law not be constitutional?”–some doofus

    Well, one reason is because the Constitution wasn’t written by Karl Marx.

    Or, Groucho, or any of the other Marx Brothers.

    OTOH, there’s pretty good evidence that’s not true of the laughable pap that exudes from the Walter Duranty Times.

    Dave Surls (46b08c)

  122. Our Average Self Pay Revenue per Patient Visit is $175. Our write-offs $125 per patient visit.

    Our Average Revenue per Medicare Patient visit is mid $70. We write of about $5-10 per patient visit.

    Why the difference? Medicare Allowable Price is low and write-offs are low. Self pay are high and write-offs are high.

    By any metric that matters self pay is better except for write-offs (Collections %) which are irrelevant to our business or any other in medicine.

    Any yes, this accounting thing is tough in Medicine.

    Bill (af584e)

  123. “It is all about capacity utilization and yield management.”

    Bill – Gee, which might explain why some hospitals advertise on billboards to an active health care consuming public in God’s Little Waiting Room. Sheer Genius!

    daleyrocks (bf33e9)

  124. “100% of Medicaid patients pay 10% of the Posted Price of a Hospital. Total losses according to the hospital from serving Medicaid. 0.”

    Bill – Where do your stats come from? In Illinois, hospitals purport to lose money from Medicaid patients on average, probably because they are overstaffed and the people are overpaid or something.

    daleyrocks (bf33e9)

  125. Daley,

    High salaries and bloated staff are a major problem in non-profits. Great example, go to an FQHC Facility. Please. Inform yourselves. Try also get their non-profit filings and beyond salaries focus on third party contractors and who they are. It is beyond corrupt.

    I had an Executive soliciting a grant for rural healthcare brag to me if he wins a large grant that he will use his personal company to provide for profit services to his non-profit entity.

    Please guys. It is beyond disgusting. It happens all the time.

    Bill (af584e)

  126. “try to keep out uninsured patient for every thing but the most urgent care”

    Bill – Womp! There it is.

    daleyrocks (bf33e9)

  127. #124, Daley,

    How is it that a hospital loses money on Medicaid?

    Provide me the Fixed Cost and Variable Cost analysis demonstrating this.

    Last I did it, the variable cost of serving patients in a hospital setting is peanuts. Most hospital costs are fixed.

    Would the hospital like to sell more “oil” for $100 then oil for $50 — sure …. but when your variable cost of oil is $5 ……….

    Bill (af584e)

  128. I work here is done.

    daleyrocks (bf33e9)

  129. #126 Because the hospital is full. If not, check them in too.

    Rather have a 5% chance of collecting 100% of my fees then have an empty bed with collecting 0%.

    Dude, this much much too complex for the average bird.

    This is like yield management system for airlines where each seat is like for a different size customers.

    Stop. This is like a bad dream educating you guys on concept of yield management, true variable cost, true margin analysis, etc. Even your average Standford MBA melts with this…

    Simple way to run a profitable hospital is keep the damn beds full, when full get rid of the low yield customers like Medicaid, always manage staffing levels like a nazi, make sure by all means needed those outpatient MD are referring.

    Bill (af584e)

  130. “How is it that a hospital loses money on Medicaid?

    Provide me the Fixed Cost and Variable Cost analysis demonstrating this.”

    Bill – Why don’t you provide some data first? All we have from you on this thread are your assertions. I pulled my info from an Illinois Hospital Association sponsored group, so it may have a bias. We have no idea where yours comes from.

    daleyrocks (bf33e9)

  131. #129, And a great ER makes this all easier b/c it provides the most efficient way to do the above.

    You can cherry pick patients more efficiently (yields). You can route to parts of hospital as occupancy rates go up or down (capacity utilization and staffing efficiency). You keep lazy docs happy who don’t want to be bothered with sick patients (more referrals for all sorts of other stuff).

    Bill (af584e)

  132. Yes, you have no data just hearsay but I need to prove my point no matters how logical it is. SMH.

    Hospitals are one giant fixed cost when run right. Every patient demographic (no matter how bad their revenue yield is) is 80-90% marginally profitable son long as staffing is done right. Done wrong 50%.

    Whether or not those revenues cover the expenses are principally correlated to staffing models, their effectiveness in implementing it, and actual square footage of the hospital (a proxy for over head and CEO salary).

    I guess I need to break out the Excel Model, document my data sources and break a few NDAs to do so. Then you will say the data is wrong. Luckily, I don’t do that grunt work anymore so if you want you do it.

    But so long as you buy the nonsense about ERs and illegals that will be used against the cause of a more market based healthcare system.

    Bill (af584e)

  133. No, perhaps this “nonsense” will be used to reform political policies that impact health care and not just health insurance.

    DRJ (a83b8b)

  134. 48. I know. I am a Senior Executive in the field.

    Comment by Bill

    senior in teh field
    he’s just teh señor wences
    and teh totie fields

    Colonel Haiku (2d3391)

  135. Maybe I missed something, but has enumerated powers entered the conversation at this point.

    The Constitution limits powers, it does not grant them, regardless. of how one industry is affected or not.

    Never mind, it has after review.

    Regardless, I would suspect that the majority of the court would be reluctant to expand the commerce clause to include a single-payer system as an overreach of federal powers regardless of the effect on individual cases.

    If they do, then the whole construct of limited power of the federal government is null.

    Sometimes I think that the left’s overall philosophy is the government can control everything we do, except, well, you know, getting it on with the person of your choice.

    How they think the government will stop at that point is beyond me,

    Ag80 (b0b671)

  136. “Yes, you have no data just hearsay but I need to prove my point no matters how logical it is.”

    Bill – Sorry, but you have admitted the exact facts to submarine your entire argument while providing no data, industry, trade association, government or otherwise to support your narrative. You admit there are unprofitable patient groups and it is critical for hospitals to minimize them. If they do not, what happens? Well, let’s not talk about that, right, because it runs counter to the unsupported points you are making.

    Bring a better game next time. People here are not stupid.

    daleyrocks (bf33e9)

  137. Stopping by on way to bed.

    If ObamaCare was simply about how best to improve medical care in the US, it didn’t need to be rushed through as it did with so much hidden, especially with all of the dishonest talking points it was sold with.

    Not sure about the discussion on why all hospitals are making so much money and ER’s are cash cows.
    The cost-shifting stuff of what are the billed charges, what are approved charges by the insurance company, does anybody really know what anything costs, seems to me to be a major trouble maker and confusing point. The one good thing of a “single payer system” as I understand it would be to bring some common sense into the overall picture, instead of a plethora of interests working on their own behalf at the expense of others. But even then, I don’t think that is worth the problems to be encountered.

    MD in Philly (3d3f72)

  138. _______________________________________________

    Hospitals are like Electric Utilities. The bigger the are (needed or not) the more money they get. So you grow to absurd sizes for purpose of creating excuses to raise money.

    Lots of people do think that way, based on their awareness of (or assumptions about) high salaries and huge invoices sitting at the heart of the medical industry. With the stereotypical doctor living large in a fancy house, driving a fancy car, and finding plenty of free time out on the golf course. Or that — as in the case of the Edison Co. or huge conglomerates in the oil business — that the medical industry also has a captive audience and a never-ending supply of ready-made customers.

    If so, then something must be terribly awry. Something must be quite off-kilter when emergency rooms struggle to stay open in places like LA, and when the first tier of the medical industry sounds not much better off than a struggling mom-and-pop store down the street.

    money.cnn.com, January 6, 2012:

    Doctors in America are harboring an embarrassing secret: Many of them are going broke. This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists.

    Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice. So if a cash crunch forces the death of an independent practice, it robs a community of a vital health care resource.

    Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors’ lack of business acumen is also to blame.

    Loans to make payroll: Dr. William Pentz, 47, a cardiologist with a Philadelphia private practice, and his partners had to tap into their personal assets to make payroll for employees last year. “And we still barely made payroll last paycheck,” he said. “Many of us are also skimping on our own pay.”

    Pentz said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue. “Our total revenue was down about 9% last year compared to 2010,” he said.

    Beau Donegan, senior executive with a hospital cancer center in Newport Beach, Calif., is well aware of physicians’ financial woes.

    “Many are too proud to admit that they are on the verge of bankruptcy,” she said…. Donegan knows an oncologist “with a stellar reputation in the community” who hasn’t taken a salary from his private practice in over a year. He owes drug companies $1.6 million, which he wasn’t reimbursed for.

    Dr. Neil Barth is that oncologist. He has been in the top 10% of oncologists in his region, according to U.S. News Top Doctors’ ranking. Still, he is contemplating personal bankruptcy.
    That move could shutter his 31-year-old clinical practice and force 6,000 cancer patients to look for a new doctor.

    Dr. Mike Gorman, a family physician in Logandale, Nev., recently took out an SBA loan to keep his practice running and pay his five employees.

    “It is embarrassing,” he said. “Doctors don’t want to talk about being in debt.” But he’s planning a new strategy to deal with his rising business expenses and falling reimbursements.

    Mark (31bbb6)

  139. “Not sure about the discussion on why all hospitals are making so much money and ER’s are cash cows.”

    MD in Philly – I think the issue was a bunch of imbeciles not agreeing with an unsupported overly broad generalization that was provably untrue due to differing patient demographics in different regions and undermined by the generalizer’s own comments.

    daleyrocks (bf33e9)

  140. Comment by MD in Philly — 3/29/2012 @ 10:44 pm

    If ObamaCare was simply about how best to improve medical care in the US, it didn’t need to be rushed through as it did with so much hidden, especially with all of the dishonest talking points it was sold with.

    Not only was it pushed through with special manuvering (altthough they might say laws don’t really require 60 votes in the Senate) but the provisions were timed to take effect several years later, after several elections. I think a lot of people involved knew the whole thing would fall apart or not work as expected.

    It was really designed to push the date when it would be discovered that the whole scheme didn’t work as far ahead into the future as possible. Whoever designed the details had to know it wouldn’t work (not that they necessarily would have told Obama – indeed that might not be something that he and others would want to hear)

    The penalty for not getting insurance was set quite a bit below the cost of insurance, yet the assumption was made that nobody actually would pay the penalty. To help cover poorer people Medicaid eligibility was expanded, with the federal government initially paying 100% of the
    extra cost – but only the first few years, after which is went down to 90%.

    Because this was 100% over what each individual state was currently doing they threw in a “maintenance of effort” requirement into Medicaid saying that states could not reduce what they covered till that halcyon day arrived when the federal government picked up the difference between whose coverage the states paid for and what they paid for, and the expanded eligibility and the new minimum benefit.

    Sammy Finkelman (5736b6)

  141. Comment by Bill — 3/29/2012 @ 9:05 pm

    I think you’re almost 100% right, except for this:

    Simple way to run a profitable hospital is keep the damn beds full, when full get rid of the low yield customers like Medicaid, always manage staffing levels like a nazi…

    When you find you have too many people working for you, you conduct a “selection” and execute the excess personnel?

    Sammy Finkelman (5736b6)

  142. Point is if you operate a hospital, you need an ER. It is like putting refrigeration in a supermarket. You can’t be a hospital without one. You can’t be a supermarket without on.
    Comment by Bill — 3/29/2012 @ 7:19 pm

    Close to a third of emergency departments closed shop over the past two decades, a new study shows. From 1990 to 2009, the number of hospital emergency departments in non-rural areas in the USA declined by 27%, according to a study in today’s Journal of the American Medical Association. The study found that the number of emergency departments dropped from 2,446 to 1,779 — an average of 89 closings per year.
    Updated 5/18/2011 By Mary Brophy Marcus, USA TODAY

    – Just in case anyone thought that Bill (“Bill” Yelverton?) actually knew what he was talking about.

    Icy (ef96c5)

  143. I realize that anecdotal evidence is practically useless but I want to relate my last experience with the best children’s hospital in Houston. On a Saturday morning 4 years ago, a kid on my son’s baseball team slide into home and broke his arm. I took he and his mom to the ER at Texas Children’s. The halls and waitning rooms were packed with children and we were the only people speaking English were the staff and ourselves. After a really long wait I went up to the desk and said, hey we have insurance can he at least have A sling while we wait. We got right in after that. The entire waiting room was full of people taking advantage of ERs forced to treat irregardless of ability or attempt to pay for services that should be done in Doctors office, ie sinus infections and the like. Really ticked me off. That loophole is bankrupting Houston hospitals so most are opening branches in Houston’s suburbs for survival.

    TexasMom2012 (cee89f)

  144. BTW, the worst payer in California isn’t the uninsured. It’s the State of California, which can take as long as a year to pay off on Worker’s Comp and such.

    Kevin M (bf8ad7)

  145. Patrick, why don’t we rename the blog “Bill’s place?”

    “#65. “Doing something out of pride does not seem consistent with your values.”

    Ah yes, the ad hominem. Your story is very interesting but not the point.

    Point is if you operate a hospital, you need an ER.”

    This is not an educated opinion. ERs are cost centers and have been loss leaders for decades, especially in new communities like the area I practiced. The news for this “expert” you have pontificating here is that general hospitals which have ERs are in trouble.

    The current trend is to build specialty hospitals WITHOUT ERs so that paying patients can be cared for in specialty settings. I had my heart surgery at Tucson Heart Hospital last September. I was transferred from St Joseph’s, which does have an ER to the specialty hospital for the surgery.

    The cash cow for hospitals has been outpatient surgery for years. That is why doctors and some hospitals are building surgery centers.

    This fellow bill has strong opinions and plenty of anger but he lacks knowledge.

    Mike K (d6b02c)

  146. If Obumblecare is declared unconstitutional, will Donald Verrilli have to go into hiding?

    After all, since our friends on the left believe it to be so obviously constitutional, the only way the Supremes can find it unconstitutional is if the esteemed Mr Verrilli completely FUBARed his case, right?

    The concerned Dana (3e4784)

  147. I had an interesting experience with a Houston hospital seven or eight years ago that some of the lawyers here may appreciate. On a visit to the city I had a little sports related injury that required me to get eight stitches. I went to one of the Memorial Hermann hospitals, was triaged, and waited a couple of hours bleeding in the emergency room. No big deal. It was full. Once in, the stitches took no time at all, no complaints.

    Afterward, within days, before even receiving an explanation of benefits letter from my insurance carrier, I received a letter from a law firm claiming to frequently represent the hospital on collection matters and threatening me with all sorts of dire consequences if I didn’t pay the bill.

    The fun part was that the letter went on to say that if my injury was sustained on some third party’s property or at work, the law firm would be pleased to explore suing that third party or my employer on my behalf.

    Imagine my confusion. Was the law firm threatening me on behalf of their client, the hospital, or soliciting my business as a new client? I saved the letter and later showed it to my General Counsel at work who thought it was one of the most egregious breeches of legal ethics he had ever seen. I had saved him some time though and researched the signatory of the letter and found out that it was a paralegal rather than a member of the bar. Still a problem for the firm sending it out IMHO, though.

    daleyrocks (bf33e9)

  148. Look, they sent me into a high stakes poker game with a pair of threes, and I tried, tried my best, to fill an inside straight. All I needed was a five, just one lousy five.

    Instead, I got flushed. :(

    Donald B. Verrilli, Jr., Solicitor General of the United States (3e4784)

  149. _____________________________________________

    The entire waiting room was full of people taking advantage of ERs forced to treat

    That dynamic is being sustained by, naturally, lots of the bills being flung over to those who can cough up some money—the taxpayers and customers of health insurance plans. It’s analogous to the way that high amounts of shoplifting and pilferage in the retail industry represent a cost of doing business that ultimately is passed on to the consumer.

    Short of that direct or indirect subsidy, more of the medical industry also is having to adjust itself to being more of a pro-bono (ie, volunteer) type of operation.

    I will say that if the folks managing packed emergency rooms don’t make much of an effort to get even token amounts of money from patients — perhaps because staffers are worried about sounding heartless, or they’re cynical because they believe a check will bounce, or they’re not very fluent in Spanish — then they’re making a bad situation much worse.

    BTW, what other business in America allows a customer to waltz in the front door, receive goods or services, and then walk out without having to pay one nickel?

    Mark (31bbb6)

  150. “This fellow bill has strong opinions and plenty of anger but he lacks knowledge.”

    Mike K – As a senior expert in the field and a cooperating forensic examiner in the Trayvon Martin exection, I am shocked, truly shocked, that you would say such a thing.

    Dr. Marcus Finkelman, MD (bf33e9)

  151. Really, I have my hands over my ears. Not listening.

    …And how is this different from ANY OTHER TIME, BEYOTCH?

    Jus’ askin’…

    IGotBupkis, Three Time Winner of the Silver Sow Award (8e2a3d)

  152. Tell me the truth because I don’t want to believe something that isn’t true. Are non-profit hospitals in the Southwest losing taxpayer money on their ERs because of uninsured patients, or is that a myth as Bill suggests?

    Nonprofit hospitals are kind of a myth as they all have for-profit centers to offset the losses on others. All ERs lose money and the more illegals, the bigger the losses. In general, general (all services including ERs) are in trouble as the trend is for specialty hospitals that avoid the money losing areas.

    Mike K (d6b02c)

  153. Afterward, within days, before even receiving an explanation of benefits letter from my insurance carrier, I received a letter from a law firm claiming to frequently represent the hospital on collection matters and threatening me with all sorts of dire consequences if I didn’t pay the bill.

    The fun part was that the letter went on to say that if my injury was sustained on some third party’s property or at work, the law firm would be pleased to explore suing that third party or my employer on my behalf.

    This is probably an example of an incompetent business office. First, we almost never sued a patient. If we did, our office manager would collect about six months of unpaid accounts, file small claims actions and go to court for a day to represent us. One time a deadbeat threatened to sue us for malpractice because she had a thick scar. The judge said ,”OK, Let’s hear your case.” We were in the small claims system and not superior court ! He allowed her $100 to have a plastic surgeon revise her scar.

    When we ran the trauma center, we were constantly barraged with inquiries from the business office for patient information. They had an employee whose job was to collect that but we always had better information.

    Maybe that hospital has made a deal with that law firm to collect the ID and keep what they can from suits and workers comp.

    Mostly evidence of incompetence.

    Mike K (d6b02c)

  154. Mike K., I see a lot of hospitals that ship out AR’s to collection firms in short order these days.

    SPQR (26be8b)

  155. 143. Incidental care of indigents seems to be the custom all over. MN pays in an extra $50 Million every year to Hospitals for their ER overruns in addition to the run-of-the-mill Medicare and Medicaid mandates.

    Wild child has had us in ERs for various and sundry athletic exploits in central MN and vacationing in WI. See a lot of flu cases with respiratory stress treated in the ER and urgent care clinics.

    gary gulrud (d88477)

  156. “Mostly evidence of incompetence.”

    Mike K – I viewed it as a boilerplate letter for the law firm to unethically cherry pick the most lucrative client after the fact, but that’s just me.

    daleyrocks (bf33e9)

  157. Mike K – Again, I had no problem receiving a scary letter before a bill was due. It was just threatening future consequences. I could just ignore that part.

    My issue was the conflicts. Did the law firm represent the hospital or not. If it represented the hospital in a potentially adverse collection matter against me, how could it solicit me as a client for a third party proceeding?

    If it did not actually represent the hospital, how did obtain the private information it did to communicate directly with me?

    daleyrocks (bf33e9)

  158. My issue was the conflicts. Did the law firm represent the hospital or not. If it represented the hospital in a potentially adverse collection matter against me, how could it solicit me as a client for a third party proceeding?

    If you watch much late night TV, you must wonder when legal ethics became an oxymoron. Technically, this is an illegal practice but the blog is run by lawyers who should know more about this than I do.

    I know it’s sock puppet Friday but I don’t want to do an imitation of “bill” by pontificating on legal issues.

    Mike K (d6b02c)

  159. “I know it’s sock puppet Friday but I don’t want to do an imitation of “bill” by pontificating on legal issues.”

    Mike K – I’m not a lawyer, but I thought you were allowed to pretend to be anything you want to be on the internet, as long as you were willing to suffer the consequences. Bill was not ready for any pushback on his argument.

    With the law firm I was more shocked by the brazenness of the dual purpose letter. Did they want to pursue me for collection or pursue me as a client or both?

    daleyrocks (bf33e9)


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