Obamacare: Will Mandates for Doctors Come Next?

Central planning is replacing individual choice.


John Foust, a Democrat running for the 10th congressional seat in Northern Virginia, is—like Gov. Terry McAuliffe and other state Democrats—gung-ho to expand Medicaid. His wife's position is, shall we say, a bit more nuanced.

Foust has slammed his opponent, Republican Del. Barbara Comstock, for her opposition to expansion. He has spoken of the need to "make health care available to 400,000 Virginians," insisting it is "the right thing to do."

Foust's wife, Dr. Marilyn Jerome, practices with Foxhall OB/GYN in northwest Washington, D.C. Six of its physicians made Washingtonian magazine's list of "Top Docs," and one of them—Nichole Pardo—was featured on the cover. Not too shabby.

The practice is notable for another reason as well: It doesn't accept Medicaid patients.

This draws attention to an under-covered aspect of the debate over Medicaid expansion. While advocates speak of it as "making health care available" to the needy, what it really does is make coverage, rather than care, available to them. A newly enrolled Medicaid patient can get the money to pay a doctor. But can she get the doctor to take it?

On his website, Foust blasts insurance companies that "hiked insurance premiums and gouged consumers. … Insurance companies denied care to those with pre-existing conditions … and refused coverage to those who needed it most. … We cannot go back to the days when insurance companies could arbitrarily … deny coverage." In a commentary on the Foxhall practice's website, Dr. Jerome praises the Affordable Care Act—particularly because now "women cannot be denied insurance" and because the plan's standards mandate coverage for a wide variety of treatments.

Doctors, however, can operate under a much different set of standards. They can deny care all they want. Statewide, roughly one in five physicians will not accept new Medicaid patients—usually because Medicaid pays only two-thirds as much as private insurance does, on average.

The point here isn't to shame physicians or to provoke a marital spat. The incongruity goes to a much broader issue—regarding individual responsibility in a system that is becoming increasingly collectivized.

You might have read recently about the blowback some pharmaceutical companies have been getting for charging stratospheric prices for new wonder drugs, such as Sovaldi—a life-saving treatment for Hepatitis C. Two U.S. senators, Democrat Ron Wyden and Republican Charles Grassley, are demanding the company that makes Sovaldi justify its $84,000 price tag. Similar questions have been raised about Kalydeco, a life-saving treatment for cystic fibrosis that costs more than $300,000 per year.

Prices like that provoke a lot of anger. Many people think it's wrong to charge more than patients can pay. Much of the outrage also comes from insurance-company self-interest. The trade group AHIP (America's Health Insurance Plans) routinely cranks out diatribes against what it considers unjustified prices and profit margins in the pharmaceutical industry.

This is a sore spot for the insurance industry. Under Obamacare's medical-loss-ratio rules, insurers must spend at least 80 percent of premium dollars to pay for treatment (rather than, say, for overhead). Drug companies face no such government-imposed caps. Yet.

Indeed, insurance companies now face a whole raft of mandates governing whom they must insure and what treatments they must cover. The rationale for such requirements is that to deny someone insurance because of a previous medical condition, or to decline to pay for certain categories of medical care, is immoral.

Obamacare also imposes obligations on individuals: Everybody must obtain insurance coverage, or pay a hefty fine (or, as Supreme Court Chief Justice John Roberts calls it 50 percent of the time, a "tax"). This is partly for people's own good, but mostly the requirement exists to make Obamacare work. Without the individual mandate, the rules on insurance companies would bankrupt them, and the whole system would collapse.

Abiding by the individual mandate therefore constitutes what President Obama, in another context, recently called "economic patriotism." He was castigating companies that use overseas mergers to avoid U.S. taxes. "You know," he said, "some people are calling these companies corporate deserters."

Ominous language. Treating private enterprise as a conscript in service to the State is a philosophy with an ugly lineage. In liberal democracies, government is supposed to be the servant—not the master. In health care, however, the relationship is growing increasingly inverted. As a result individuals are forced to buy insurance, and insurance companies are forced to accept them. Now many people want to force drug companies to cut prices. And so on.

Forcing doctors to accept Medicaid patients would be an obvious, logical extension of these trends. If insurance companies can't turn people away, then why should physicians be allowed to? If drug companies can't charge more than people can afford, then why should doctors? So far, no elected officials have yet proposed reining in the limited liberty that doctors still enjoy. But such proposals could very well come, one of these days. Though probably not from John Foust.

NEXT: The Fight Against California's Electric Skateboard Ban

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  1. You can choose:
    To have an abortion.
    To get gay married.
    To smoke weed in two states.


  2. What’s next for doctors is, of course, conscription.

    1. What’s next for doctors is, of course, conscription.

      Or let in foreign doctors. Like England.

    2. Just a fancy word for slavery.

      1. Which is perfectly legal under the 13th Amendment, provided that you either convict doctors of crimes or you simply induct them involuntarily into the armed services (the latter isn’t in the 13th, but the courts have read it in).

        1. Yes, I believe the Supreme Court said (back in WWI)in so many words that conscription into military service was neither involuntary nor servitude. These days they’d probably tell us it’s a tax.

          1. DOCTOR TAX. Of course, if they conscript the doctors, they’ll have to find a way to replace them. Probably just forced interbreeding of conscripted doctors so that we could raise a class of slave doctors.

        2. No need to induct them into the armed services. The US Public Health Service is part of the uniformed services.


      2. Health care is not a right. Nor is housing, food, internet, or any number of other things socialist nanny/welfare states try to say are fundamental human rights.

        To me, it is a self-evident truth that your rights do not trump mine. If the only way you can afford food, shelter, clothing or health care is to force your fellow citizens to pay for them, then you have essentially decided that it is worth enslaving others to meet your needs.

        Here’s how we can see that health-care is not a right. Imagine that tomorrow every doctor, nurse, P.A., EMT, etc.–every health-care provider–decided to quit their jobs and refused to practice medicine. How then will you exercise your health-care “rights”? Many people will say that doctors will have to be forced to provide care. And those people have just espoused a form of slavery–forced labor is a form of slavery.

        1. I made your argument recently, they said, “So, you just don’t believe in the town square!” Is town square some new prog argument?

          Town Square = Slavery?

  3. “Foust blasts insurance companies that “hiked insurance premiums and gouged consumers. ? Insurance companies denied care to those with pre-existing conditions ? and refused coverage to those who needed it most. ? We cannot go back to the days when insurance companies could arbitrarily ? deny coverage.”

    The point should be made that if they simply prohibited insurance companies from discriminating against patients with preexisting conditions–and got rid of everything else in ObamaCare–it would be an enormous improvement over what we have now.

    Using that one issue to justify all sorts of other problems caused by ObamaCare just doesn’t fly.

    1. Define “discriminate”.

      If you mean “charge an actuarially sound premium” then you can sod off.

      1. I didn’t say it would be a perfect system. I said it would be an improvement.

        Yes, if the dummies in Washington would agree that we should start shooting ourselves in the foot–instead of shooting ourselves in the head over and over again?

        Then I would support that as a transition step towards something sane. Meanwhile, if you’re not willing to improve the system so long as doing so would assuage the concerns of the electorate whose support is necessary to make improvement possible?

        Then you can fuck a duck.

        1. This is exactly what led to the collapse of the insurnace market in New York.

          What they should do is just bar insurance companies from dropping people or jacking up rates after they develop a health problem. Not guarenteed issue, guarenteed RE-issue.
          This should be part of the standard contract anyway, and would be if we didn’t have the retarded employer-based system.

          1. I’m not sure about that.

            Maybe the straw that broke the camel’s back?

            Having worked with New York’s grouper system, I know it was a nightmare.

          2. This idea is better. Rather than forcing people to buy and maintain insurance, it would encourage them to do so. Simply dictating that insurance companies accept people with pre-existing conditions, would not work, absent a mandate for everyone to pay into the system to offset people who sign up after getting sick.

            1. The point is that if mandating that insurers don’t discriminate against people with preexisting conditions is what it takes to get rid of the rest of ObamaCare, then it’s worth it to do so.

              A secondary point is that if mandating that insurer don’t discriminate against people with preexisting conditions is a terrible idea that would seriously and adversely effect our healthcare system?

              Then maybe watching that happen in isolation would be a good thing for the American people to see.

              Meanwhile, all of the other things ObamaCare did was bad for healthcare, too–and I mean all of it. It was all bad with the preexisting condition exclusion–and it will all be bad without it.

              And, furthermore, I maintain that the underpayment of Medicare and Medicaid to providers, which causes providers to turn around and gouge private pay patients to make up for those losses, is of a much higher order of magnitude than preexisting condition exclusions are.

              We’re just used to the enormous market distortions caused by Medicare and Medicaid–because they’ve been in effect for so long. Getting rid of the preexisting condition exclusion is relatively new by comparison, so I guess there’s some kind of cognitive bias at work there? …like the straw that broke the camel’s back.

              But a straw can’t break a camel’s back. it’s the ton of deadbeat Medicare and Medicaid deadbeats that broke the camel’s back–not the straw just because it was the last thing we piled on before everything went to hell.

              1. Can we also create a law where an insurance company has to issue me insurance on my house even if it has already burned down? And force everyone else to buy housing insurance so that my rate is less than the price of replacing the house? And give me the insurance free if my mortgage is upside down?

      2. I think we’d have that if insurance were more free market than not. It would be an obvious niche market, with premiums increased to cover the increased risk.

        1. Yes, adverse selection is a consequence of community rating.

          Let insurers charge people what they want, and they will cover anyone.

          1. And there would be competition among those who offer higher-risk coverage, so rates would likely be far better even for people with pre-existing conditions in a market-based system. And if medical services also return to a market-based system, the cost of charity for those who lack the means (mostly seniors, I suppose) would be mere fractions of what it is today.

      3. Swiss,

        You are retired military, correct? That makes you and your family, including children that are older than 26, are forever Tri-care eligible, correct?

        Assuming I am correct, you’ll understand why your opinion on the subject means nothing.

        1. Argumentum ad hominem, in its truest form.

          1. ^Thinking the same thing.

    2. Ken, mandates to cover people with pre-existing conditions without charging premiums to match is how you trigger a death spiral.

      1. I’m not sure that’s true. I think premiums would rise as a result, but they’d be borne by the system.

        I certainly think they’d be less of a burden on a Medicaid free system than Medicaid is on the system now.

        Oh, and if we’re talking about death spiral under the auspices of ObamaCare? I think that’s going to happen anyway.

        A nice death spiral might be exactly what ObamaCare needs. In fact, if the SC rules against credits for people on the federal exchanges, isn’t a death spiral exactly what we’re hoping for?

        A death spiral just means that Congress will be forced to renegotiate into a more sustainable solution sooner–and isn’t it better when ponzi scams and other frauds blow up sooner rather than later?

        1. I’m not sure that’s true.

          It is. Community rating plus no medical underwriting gets you a death spiral.

          Why do you think they tried to impose the individual mandate in OCare? Because they were imposing community rating and no medical underwriting. If you have no financial risk for not buying insurance when you aren’t sick, then you won’t. That means that the pool of insured people gets sicker, pushing rates up, and you are tipping into a death spiral.

          When you say higher premiums would be borne by “the system”, you mean by the people paying the premiums. And that’s part of a death spiral, not an answer to the death spiral.

          1. “Why do you think they tried to impose the individual mandate in OCare?”

            The primary purpose of the individual mandate (despite what the Administration said) was to help alleviate the losses providers, insurers, and private pay patients suffer from caring for Medicare and Medicaid patients.

            Covering for preexisting conditions is much smaller than that by several orders of magnitude.

            I know it’s a problem, but if we can’t get rid of all the other shit that’s wrong with ObamaCare without keeping that one part of it–because that’s what the voting sheeple want–then that’s what we have to keep in order to get rid of the rest of ObamaCare.

            And I’m dead serious when I say that if that did cause a crisis, and we had to get rid of that, eventually, in order to stop the healthcare system from imploding, then by all means, once we get rid of the rest of ObamaCare, we should…not let that crisis go to waste.

    3. The insurance companies could cover people with pre existing conditions (which can include non fatal conditions like diabetes, or something) BUT charge them more.

      But that won’t fly with socialized medicine crowd.

      What the left really want is healthcare that they don’t have to pay for. Whatever model they want to adapt from elsewhere will cost them a ton of money. Canada has less than 30 mil people, which tells me most people don’t want to pay 5,6 dollars for a gallon of gas and endure a frozen wasteland just so their ass is covered if they’re hit by a bus.

  4. When you squeeze a balloon, it just pops out somewhere else.

    Once they start mandating, it’s mandates all the way down.

    Utopia can only exist by force because reality always gets in the way.

  5. It should also be noted that, contrary to what you may have heard, the primary purpose of ObamaCare was to save Medicare and Medicaid. The system is broken because the government only reimburses providers for a fraction of the cost of treating Medicare and Medicaid patients, so providers have to gouge insurance companies and private pay patients to make up the difference.

    ObamaCare sought to overcome that problem by forcing healthy people who don’t consume healthcare to pay into the system and alleviate some of that pressure on the insurance industry and private pay patients, but Obama, in classic form, also insisted on using ObamaCare to expand Medicaid–thereby exacerbating the original problem that supposedly required ObamaCare as a solution in the first place.

    If they built state owned and operated clinics and ERs to offer care to the poor for free–and financed it all, 100%, rather than letting Medicaid get away with paying an average 12.5 cents on the dollar billed or Medicare paying 25 cents on the dollar billed–it would be an enormous improvement, as well.

    And the primary beneficiaries of such a system would be the working poor, who are paying out of pocket and being forced to cover, not only their own costs, but to compensate for the unpaid costs of Medicaid and Medicare patients, too. What kind of idiot would try to solve that problem by expanding Medicaid?!

    1. If they built state owned and operated clinics and ERs to offer care to the poor for free

      Send them to the VA.

      1. At least the VA isn’t destroying the market for healthcare.

        Medicaid and Medicare are destroying the market.

        If the government paid for 100% of Medicare and Medicaid costs, the cost of Medicare and Medicaid to the taxpayers might go up 500% to 800%.

        People just have no idea.

        People imagine that because they’re on a government program and don’t have to pay for their hospital bill, that means the government does. It doesn’t! The government sets the prices at whatever they want, tell the providers to eat the rest, refuse to accredit providers that don’t have Medicare and Medicaid contracts.

        If those uncovered costs on the government programs were paid for by the government, the market distortion would disappear. My medication wouldn’t cost $1,600 a month. It would cost $240 a month–like it does in Canada and Mexico, where they don’t have Medicaid (or Medicare), that forces providers to provide far below cost.

        1. I see your unintended consequences and raise you one good intentions.

          1. Unfortunately, we have to take the market price of ideas into consideration.

            When I look for a development project, the first thing I do is study the local market. What’s the market selling/leasing price? Will it justify how much it costs me to build? If it won’t, the project isn’t going to be done and the land just sits there.

            Unfortunately, the market price for ideas in the electorate is such that you can’t build a healthcare system that doesn’t account for taking care of the poor. If we don’t address that market’s concerns, they will not buy what we’re selling.

            In the meantime, we need a market that functions without the gigantic distortion that is Medicaid. Until the market is free of Medicaid, it can’t provide increasingly higher and higher quality care at decreasing lower and lower prices–like it does with flat panel TVs.

            Once the market starts functioning properly, more and more poor people will want to leave government clinics behind; in the meantime, the electorate we have will not let us set up a real private market for healthcare so long as we don’t also offer some way of providing healthcare to the poor…

            I’m merely proposing a way to do that that also allows for a free market, which is a whole lot better than what we have now. There needs to be a private option, but right now, you can’t go to a hospital that isn’t bearing the cost of freeloaders by way of Medicare and Medicaid.

            1. it can’t provide increasingly higher and higher quality care at decreasing lower and lower prices–like it does with flat panel TVs.

              Cosmetic surgery and Lasik eye surgery keeps getting better and cheaper. I wonder why…

              1. I’m sure Medicare and Medicaid not paying for them has nothing to do with it!

                Because, because…


            2. Maybe not having some magical market effects is a worthwhile price to pay so that old people don’t go without healthcare in large numbers.

              Not that healthcare and gadgets like TVs are comparable on those terms. Unlike gadgets, you don’t get to decide exactly when or whether you’ll need healthcare, and when you do it will likely be expensive. Few can afford major medical expenses out of pocket. Insurance (private or public) is thus necessary for healthcare to be available to anyone but the very wealthy.

              Furthermore you don’t really comparison shop in healthcare. We rely on an assumption of doctors’ expertise and code of ethics to assure the quality of the product, not so much market approaches.

              Which is to say healthcare specifically doesn’t work like a normal market, and that is perhaps why nowhere in the world is there a successful healthcare system based on the free market.

              1. Furthermore you don’t really comparison shop in healthcare.

                Then you’re stupid. I do comparison shop, and it’s ludicrous how much the cost for the same thing can vary from location to location. The only reason for it is because stupid people like you rely on stupid assumptions.
                Now for emergency care, yeah, I can see how comparison shopping wouldn’t work. But most medical care is not emergency care. It’s routine. And there’s no excuse to not make a few calls before having something done. No excuse at all.

                1. Tony:

                  Furthermore you don’t really comparison shop in healthcare. We rely on an assumption of doctors’ expertise and code of ethics to assure the quality of the product, not so much market approaches.

                  That’s such outrageously ignorant bullshit. I don’t know anyone who chooses a doctor without basing that decision on research and reputation.

                  If you think some new doctor moves into town, sets up a completely independent practice, and suddenly gets some approximate, equal share of the local market for whatever he’s practicing, based on his assumed expertise by the customers, then you’re not reality based, and I’m not sure anyone should listen to your screeds about how health care should really work.

                2. Emergency care would be precisely what insurance is for. If your car is totaled and you need a new car, that’s an emergency that you’ve insured the car for. Not for all the oil changes.

                  Likewise, when your house burns down, that’s what the homeowners’ insurance is for, not for hiring somebody to clean out your gutters.

                3. Indeed. You can even comparison shop for ’emergency’ services sometimes. The after-insurance prices at 2 nearby urgent care clinics differ significantly, based on some facility classification difference I don’t care to understand.

              2. Few can afford major medical expenses out of pocket.

                Precisely because economic illiterates like you think that the laws of economics don’t apply to healthcare. Routine care could and would be dirt cheap if not for the market distortions of Medicare/Medicaid, insurance coverage mandates, certificate of need laws, licensing monopolies, etc.

                Furthermore you don’t really comparison shop in healthcare. We rely on an assumption of doctors’ expertise and code of ethics to assure the quality of the product, not so much market approaches.

                Bullshit. I have no idea how cars work, but I can still shop around for them. You can easily find cash-only clinics which post their prices ahead of time.

                1. None of which is the first thing on your mind when you’re having a coronary event.

                  1. To make the analogy work you’d have to suggest that people generally tend to buy TVs only when they missed Game of Thrones and are desperately rushing to avoid spoilers. In healthcare you don’t generally save your pennies till you can afford your lifesaving treatment, then casually stroll to Best Buy and get it.

                    1. The analogy is more like having car insurance in case of an accident, and paying for maintenance out of pocket.

                      Anyone who thinks about it (that excludes Tony) can see how if car maintenance worked like health insurance, a basic oil change would cost several hundred dollars. Why? Because the insurance company is paying for it, not the customer. No need to shop around. Heck, they wouldn’t even post prices at the garage.

                    2. If you are having a coronary event you can walk (er, gurney?) into the closest hospital and get treatment. Nobody was ever denied emergency care! Paying for it is another issue. The fact that the left was conflating the issues as the same thing is what is biting them in the ass. Sold as an answer to both issues, Obamacare makes insurance more available (at gunpoint) to all but routine/non-emergency care not.

                  2. Congratulations; you’ve discovered the point of insurance.

                  3. Maybe if people didn’t consume 18 tons of lard, sit on their asses, and smoke a truck load of tobacco over fifty years, there would be less “coronary events”. I’m not financially responsible for your poor health choices, or your genetics.

              3. “nowhere in the world is there a successful healthcare system based on the free market.”

                That’s because nowhere in the world is there a free market.

                1. Can anybody show me a socialized system that works the way I want it to?

                2. I think US health care in the 1950s worked pretty well. Not perfectly, but pretty well, without Medicare and Medicaid.

              4. Tony:

                Few can afford major medical expenses out of pocket. Insurance (private or public) is thus necessary for healthcare to be available to anyone but the very wealthy.

                Suddenly, everyone needs insurance to get healthcare in general because major medical expenses are too expensive for some people who are not wealthy.

                Gee, when you consider all the qualifiers, it’s a huge non sequitur. Pure awesome.

                1. If, collectively, we can’t afford healthcare without insurance, then we absolutely couldn’t afford it with insurance (since insurance inherently increases cost, at least by the cost of administration, even if we ignore moral hazard, adverse selection, and other economic problems created by it). The fact of the matter is that healthcare would be cheap and available if people paid routine expenses out of pocket. Insurance should be for sharing the risk of major, unanticipated illness, which is risk-sharing, not prepayment of routine expenses.

                  1. So some of us agree that the unpredictability and high cost of healthcare expenses necessitates an insurance model. So the debate is between whether a private or public scheme works best. And a public scheme works best, if you care about the evidence.

        2. In Canada and Mexico providers earn much less than they do here in the USA. And due to a much simpler “insurance” system, the doctors in these countries doesn’t have to hire specialists in medical billing to get his money. Plus the legal profession in these countries lacks the overwhelming power that it does here. So “malpractice” is only a minor issue there.

          1. I’ve actually gone to Mexico for medical care. They charge very little. My doctor was a Harvard Medical School graduate.


            Mexico has the kind of system I’m talking about, where you have free clinics/emergency rooms for anyone regardless of ability to pay. …and they’re financed 100% by the government.

            But the private hospitals aren’t forced to care for people on government programs–below cost. …and then serve people who aren’t on the government programs, too?!

            And how much of our medical system in the U.S. is made up of Medicaid and Medicare patients? Is it more than half?

            Imagine you were running a store and the government said you had to give half of your merchandise away for between 12.5 cents to 25 cents on the dollar. How much would you have to charge the other half of the customers to make up for those losses?

            Five to eight times as much as it should cost?

            Obama’s solution to this problem wasn’t just to force healthy people who don’t consume much healthcare to pay into the system anyway. His “solution” was to increase the Medicaid rolls by millions!

            Half the problem is forcing the private providers and private insurance markets to absorb the costs of Medicaid. The Mexican model is much smarter than ours.

      2. Let’s go one further and send everyone on Medicaid and Medicare to the VA.

  6. OT: What a coincidence…


    1. Already over in 24/7, but no harm done.

      1. I just noticed. It bears repeating I think 😉

      2. What’s 24/7?

        1. Look in the right column of this page (and all other H+R pages).

  7. Question: Prior to health insurance did everyone who got sick just up and die if they weren’t extremely wealthy?

    1. Prior to health care regulations there simply was no health care at all. No doctors existed until government laid down rules. So yes. Everyone who got sick just died. Until government created health care. Because you didn’t build that.

      Seriously though, before government took over health insurance and set about regulating everything, medical care was reasonably priced. Not only that, but churches and other charities would often pick up the tab when people couldn’t afford care. Or the doctors themselves would give the care for free.

      What really screwed things up was the fee-for-service model, popularized by Medicare and adopted by all health care in the country. Before that a patient would pay to get better. Now they pay for every little procedure that is done, regardless of it actually helps or hinders their health. This encourages quantity, not quality, of care.

      “Everything government touches turns to crap.” – Ringo Starr

      1. That’s what I was trying to get at: Whenever there is a middle man, per se, things cost more. Often much much more.

        Insurance itself makes things more expensive. A lot more expensive.

        1. Yeah, insurance makes things more expensive, but that’s the cost of spreading out the risk.

        2. Not necessarily a whole lot more expensive – and it can be worth it to mitigate the risk of a catastrophic event.

          Best case, it helps things get done if the doers can rationally price in the risk, so they are not deterred by it.

          Assuming a free market in insurance, of course. So, in many cases, never mind… (sigh)

        3. It also allows doctors and hospitals to charge higher prices than what many patients could pay if there were no insurance.

          1. Largely true because of the existing distortions in the health care insurance market, I think.

            And the health care provision market, come to think of it.

        4. I agree that insurance, or any third party pay system, is what drives costs up and creates what I’ve seen described as “perverse incentives”. Doctors are not incented to heal and cure in a cost effective manner. They’re incented to charge high fees and perform unnecessary tests and procedures. Not to mention the administrative costs in dealing with insurance companies and/or the government bureaucracies.

          1. Don’t neglect the effect of legal considerations when doctors order all these tests to cover their asses. If you were paying out of pocket, you’d almost certainly scrutinize the costs more closely.

      2. “Prior to health care regulations there simply was no health care at all. No doctors existed until government laid down rules. So yes. Everyone who got sick just died. Until government created health care. Because you didn’t build that.”

        You forgot to add that on the 7th day, the government granted a tax holiday, in their infinite generosity.

      3. The legal profession hadn’t invented the concept of “malpractice” either back then. Plus, the doctor could do all his own billing. Today that would be next to impossible. Plus the cost of a medical education was a small fraction of today’s. Nor did all the medical technology exist back then. In 1947 my mother spent three weeks in the hospital and her total bill was $300. The “room rate” was $10 a day. They had oxygen, IV, X-ray,although the only antibiotic was penicillin. Nurses weren’t unionized either back then like they are today.

    2. In many cases, yes. Of course the technology wasn’t there either. So much of our health care crises is forged by advancements in procedures. There’s no problem if those advancements were made in a free market, and free market solutions are used to allocate access to the new technology. The problem is the advancements are made outside of a free market system – subsidies for researchers, FDA filtering, etc etc, which then demands non-market allocations.

      The ultimate paradigm shift is that people knew they were going to die, and there wasn’t whole lot to stop it. Blood letting and leeches only got you so far. Care was mostly about pain killers and cool towels to the forehead. Now people think their life is lodged somewhere in the cornucopia horn out of which all good and services tumble (if it weren’t for the evil fellows with the twirly mustaches and monocles).

      1. And the ironic thing is – people are still going to die…all of them eventually.

        1. Something like 30% of all Medicare costs are spent in the last year of a person’s life.

    3. Let’s talk about Medicare. Before Medicare: 50%-56% of seniors were uninsured. Now virtually all seniors have coverage. (Before Social Security, poverty among the elderly was around 35%; now it is around 9%.)

      Private health insurance evolved from a form of accident insurance during the first half of the 20th century. Medical care was fee-for-service, which means yes if you couldn’t afford, you didn’t get. But then presumably leaches and such were less expensive than modern medical care.

      There would possibly have been no private health insurance industry if FDR had managed to implement a national system when he wanted. Both private and public health insurance were opposed by the AMA, which was ultimately responsible for the failure to get a national system.

      1. You do know that “modern medicine” still uses leeches? It charges a pretty penny for the procedure, too.

      2. God forbid we give the market time to evolve and correct itself.

        1. How many should we needlessly let die while we wait on something that has never happened and that is in all likelihood impossible (the free market delivering near-universal access to affordable healthcare)? Once again, government did it first. So whatever else that means it’s not a point in favor of the market approach.

          1. “What do you mean a charter that limits government? It’s never happened, and it in all likelihood impossible. It will never happen. Ever.”

            Tony, in the year 1214.

            “What do you mean sail across the Atlantic to do trade? It’s never happened, and it in all likelihood impossible. It will never happen. Ever.”

            Tony, in the year 1491.

            “What do you mean a limited government based upon individual liberty? It’s never happened, and it in all likelihood impossible. It will never happen. Ever.”

            Tony, in the year 1775.

            1. So go do it. You’re not gonna let a little thing like government healthcare schemes get in the way of your obviously superior alternative? Surely that’s practically nothing compared to the obstacles faced in those other instances.

              1. Yeah, go do it, man! When men with guns show up because you disregarded the 50,000 pages of regulations in health care, just tell them to go away! I never knew it was so simple.

              2. Not voting for Democrats and Republicans over and over again may help.

                Re-electing the same big government parties that have the same agendas isn’t going to change things.

              3. Tony told us last week that he cares more about the race and sexual orientation of the person who’s making the argument–and little or nothing about the argument itself.

                Why bother even addressing Tony?

            2. “What are you talking about? The Nazis are our friends and Jews have nothing to worry about. Stop reading Faux News you teabaggers!”

              Tony, in the year 1938.

          2. Oh, they don’t need to die, Tony. After all you are completely free and more than welcome to use your own resources to pay for their care. However, you are not free to use the resources of others. Other people weren’t put on this Earth to serve you and/or your designates, or to pay for your “good works.”

            1. Then the same goes for your precious property entitlements. And your right to a fair trial.

              1. Right, and the same goes for free dildos for everyone.

                I mean, government provided healthcare, government provided justice, government provided dildos…they’re all the same, really.

      3. Tony:

        (Before Social Security, poverty among the elderly was around 35%; now it is around 9%.)

        Gee. Since poverty is a measure of income instead of wealth, then an elderly person sitting on a heap of money conservatively invested is in poverty, not counting his social security income.

        And, when an elderly person working until the age of retirement reaches the magic age of social security, where his income is now the working taxpayers problem, he can retire, trading his work income for SS income. At this point, we can now claim that SS is “keeping him out of poverty.” I mean, we can just assume they’re all poor and can’t work, right?

        Pure derp.

        1. Tony:

          (Before Social Security, poverty among the elderly was around 35%; now it is around 9%.)

          So, in other words, the free market was keeping 65% of old people out of poverty.

          So, all the poor and working taxpayers are forking over 12% of their income to hand practically all old people a SS check in order to lift 35% of the elderly out of poverty.

          Pure awesome. I can’t imagine an alternative reality that could possibly be more appropriate.

          1. Yes, 0% in poverty is better than 35%, and it’s paid for by a simple generational transfer program. Almost any alternative is less preferable.

            1. Uh, 9% does not equal 0%.

              SS Takes in about $855 billion in taxes, for about 33 million old people.

              It takes in about $25K/year for each elderly person. Not too bad, right now.

              However, if we assumed that only 35% of them needed it, that would be about $74K/year for elderly person who would be in poverty.

              For a frame of reference, poverty is defined at $11K/year for a single person, $15k/year for a couple (for which, you could multiply the above by 2 for their household benefit).

              Yeah, this is near optimal. Almost any alternative is less preferable.

          2. Before Social Security people generally worked until they couldn’t do it anymore. They also tended to move in with their children. It was common to have three generations in one house. Grandma and grandpa helped out around the house, watched the kids, and so forth.

            The idea of “independent living” by seniors is a consequence of pensions and Social Security. Along with Medicare.

      4. Before Medicare: 50%-56% of seniors were uninsured.

        Insurance is a means to an end. The interesting question is, how many seniors were denied medical care?

        1. Depended upon what the condition was. It must be remembered that there were a lot of things they couldn’t do back then that they can do now today. The two most common causes of death in the middle of the 20th Century was heart attack and stroke. There wasn’t much doctors could “do” about either one back then.

          Medications for high blood pressure and high cholesterol didn’t exist back then either. So these two conditions were much more often the cause of death.

    4. There used to be charity hospitals, and doctors took patients as charity, and families and churches and fraternal organizations pitched in to help individuals.

      1. And life sucked balls for the old and poor. Especially those without access to those things.

        1. Especially those without access to those things.

          If you chose to live 500 miles from civilization, it is not anybody else’s fault that no one is around to support you.

          Otherwise, there is nothing factually accurate about what you wrote, except “life sucked balls for the old and poor” which is simply a subset of “relative to modern standards, life sucked balls for basically everybody”.

  8. Of course people can’t choose, they might choose wrong.

  9. “?Kalydeco, a life-saving treatment for cystic fibrosis that costs more than $300,000 per year.”

    The Cystic Fibrosis Foundation (CFF) & Vertex Corporation developed Kalydeco without federal or state funding. Kalydeco and its follow-on treatments are a libertarian’s dream: voluntarily donated money teamed with entrepreneurial businesses. The cost of Kalydeco should be coming down dramatically over the next few years with no “help” from anyone in the federal government as the base of people that are candidates for treatment with Kalydeco and its follow-on treatments expands.


    1. There are greater than 1200 different identified gene mutations that cause cystic fibrosis. Kalydeco was approved in 2012 for the treatment of one specific gene mutation, G551D. The G551D mutation is present in about 4% of the 32,000 CF patients in the US. Earlier this year Kalydeco was approved for the G178R, S549N, S549R, G551S, G1244E, S1251N, S1255P and G1349D mutations, expanding the reach of the drug to 7-9% of the CF population and dividing the research cost over a great many more individuals. Just a few months ago, a drug combination VX-809 in combination with ivacaftor (ivacaftor & Kalydeco are the same thing; no idea why they are named differently), finished Phase 3 (of 3) testing. The testing of the VX-809 in combination with ivacaftor was considered a success and the paperwork has or will shortly be submitted for FDA approval of this combination for those that have a double F508del mutation. Those that have the double F508del mutation amount to about 70% of the CF population, including my son.

      I know people that have the G551D mutation. I should have said known, for I know one young woman with that gene type that succumbed to CF not long before Kalydeco was approved. The change in the patients taking Kalydeco is simply amazing. They go from having to take 30,000, that is right, 30,000 pills per year to 365 per year.

      1. BTW, 1-in-28 of you reading this are carrying one copy a CF gene mutation, as is your spouse, assuming you have a spouse and are not the typical libertarian living in his mom’s basement. The odds are even greater the more northern European your ancestry is or if your ancestry is Ashkenazic Jewish.

  10. This note appeared on the door to my doctor’s office earlier this year:

    “Unless we can verify the status of your deductible or copayment, payment of the full charges of the office visit will be due at the time of the office visit….NO EXCEPTIONS.

    Dr. XXXX WILL NOT ACCEPT insurance associated with OBAMACARE until our office has been made aware of the methods of claims/payments associated with these policies.

    All refunds of money due to patients will be made immediately after “Explanation of Benefits” are received by the office.

    All of the changes as a result of the “Affordable Care Act” (OBAMACARE) have made this policy necessary. We are sorry if the changes, which are beyond our control, inconvenience you as our patient!”

    Don’t think he cares for OboCare……

  11. No one in the media, including Hinkle, has mentioned this, but my 77 year-old mother, and patient of Foxhall OB/GYN since before my birth 35 years ago, said it to me straight away: Foxhall doesn’t accept Medicare either.

    I’m in the 10th District. Unless Barbara Comstock, the GOP candidate, calls someone macaca, she’ll probably win the race.

  12. Those guys do not seem to have a clue man, None.


  13. Those guys do not seem to have a clue man, None.


  14. And what’s the status of the backend of Healthcare.gov these days? It’s been out of the news for months, but the last I heard, large portions of it still aren’t built.

  15. People who show up in our ER who don’t have a frickin’ penny to spend on health care, apparently can always find the money to keep their car running.

    Funny, that.

    1. You can’t expect a brotha to ride the bus, man. Crown Vic with 28″ rented wheels is a necessity.

    2. A trip to the ER can cost $7000. An ambulance ride in SF is about $1600.

  16. Want to see a doctor shortage happen faster than you can blink? Mandate that they accept Medicaid (soon Medicare; soon after that, Obamacare).

    Then you’ll have to pass a law barring doctors from quitting their profession at the new wages you have subtly but effectively mandated with all this market meddling.

  17. Of course mandates for doctors are next.

    You don’t guarantee that everyone who wants medical treatment gets it regardless of what it costs without maximizing demand.

    Someone has to say no. And if patients are going to say no, and doctors aren’t going to say no, then someone has to make them say no.

    And that applies to getting treatment, performing treatment, charging certain prices, etc.

    Otherwise, costs explode.

    1. It’s actually the worst of both worlds: increased cost and decreased supply.

  18. A couple years ago Rand Paul and Bernie Sanders were debating in a committee hearing about what it means to have a “right” to healthcare. Paul said that any time the government establishes that a person has a “right” to healthcare that they are effectively turning people who work in the healthcare industry into slaves. Of course, Sanders mocked the idea.

    This article is right. Forcing doctors to accept Medicaid payments is the logical next step for Obamacare. So will forcing doctors to accept all insurance plans offered on the exchange. If healthcare is a “right” why shouldn’t a person be able to choose exactly the doctor they want? What if a person needs a specific, highly technical procedure done and there is only doctor who can perform it doesn’t except Medicaid or an exchange plan a person holds? Shouldn’t that doctor be required to provide his or her services to the person in need? After all, they have a “right” to healthcare.

    If healthcare is a “right”, what is the solution to a general shortage of doctors that lead to very long wait times and this shortage is blamed for more people being sick for longer periods of time? Does that mean the government can implement a type of draft for doctors and other healthcare professionals to meet the demand?

    The more one things about what it means to make healthcare a “right” the more absurd this idea becomes.

    1. It’s easy to be “choosy” when you are part of a legal government enforced monopoly that gives you control over access to medical drugs.

      Prior to the passage of prescription laws in 1938, most people when sick went to their local drugstore and asked the druggist for help. Often the druggist could provide the same medicine that a doctor would prescribe. But the druggist generally didn’t charge for his advice, only for the medicine he provided. This state of affairs kept the cost of health care low, but also meant that doctors didn’t earn that much either…

    2. I have a RIGHT to live in Corona Del Mar. I have a right to have a nice big house. I have a right to take what my neighbor has to buy what I want. This is the sick thinking that progressives believe in.

  19. Don’t know if someone already shot this down: “A newly enrolled Medicaid patient can get the money to pay a doctor. But can she get the doctor to take it?”

    The proper phrasing is: “A newly enrolled Medicaid patient can get what is often a laughably small fraction of the cost involved to pay a doctor. But can she get the doctor to work at a loss?”

    1. How is the “loss” figured? And how much of today’s costs are created by a very complicated system of health insurance?

      Back in the middle of the last century, a doctor generally only had an “office nurse”. Medical malpractice didn’t become a major issue until about 50 years ago. So the concept of “defensive medicine” dates back to that era.

      All of this indicates that the very large increases in the cost of medical care are to a certain extent a consequence of increasing government regulation and our excessive number of lawyers who of course seek to earn a living for themselves through lawsuits.

  20. We could have repealed the prescription laws that give doctors a legal government enforced monopoly over access to medical drugs. There are also a lot of medical issues that do not require a doctorate level of training to deal with. So we can safely say that “government” created the problem in the first place. And that is where the blame should be put.

  21. This is what happens in Canada. Doctor’s salary is regulated. This is probably why my current doctor left Canada and is now practicing in California. He also does not take Medicaid patients. If they are going to tell doctors how much they can make, they should also tell Lawyers how much they can make too. What is good for the goose should be good for the gander.

    1. …”If they are going to tell doctors how much they can make, they should also tell Lawyers how much they can make too. What is good for the goose should be good for the gander.”

      MDs are trained in medical care. Their training is extremely specialized and they have less business commenting on econ than most other professions. Now that they (at least some did) have commented in favor of O-care, they might well be finding what that means to them.
      I’m sure those that did comment in favor presumed they’d just be able to provide care and, well, someone would pick up the check for them: Surprise!

  22. I don’t think they will arbitrarily mandate doctors to always accept medicare. Instead they will start off with just a day – all doctors must only treat medicare patients on Thursday. Then two days. Then three days…

  23. Okay…here is my plan:

    1. Government forms its own health insurance. Bare bones, you can’t sue except for egregious circumstances, therefore charges to doctors are less, generic drugs, wait lists for not life-threatening problems etc. No eyeglasses, no dental care, no breast implants, and you buy your own birth control. Canada in other words.

    2. People on the dole, welfare recipients etc. all go on this. As do government workers, and pensioned government workers. And, all politicians.

    3. Anyone can be on this bare bones insurance program. Anyone. You can pay a fee, that actually covers the cost, and you can be on it. No one is refused, including those with pre-existing diseases. No one gets cadillac care, but they won’t lose their house if they get sick.

    The fees are based on your overall healthiness. If you don’t smoke, you’re normal weight, you obviously exercise regularly etc., your premium is less…because your risk is less. (Not like Canada.)

    4. Anyone also can be on private plans. They can be as full of benefits, or free of benefits as anyone wishes to pay for. Leave it up to the private sphere.

    …more to follow…

  24. 5. Anyone also can be on a plan that merely supplements the government plan. But, that would be left up to the private sphere also.

    6. Take the best and brightest students and for those who wish to become doctors, pay for their med school on the proviso they work for less for ten years after med school in the government plan. If you don’t want to do that, no problem, pay whatever you want in the private sphere and you can go instantly into high priced practice.

    I think this would bring down the price of medical care substantially. Healthy people would pay for this, as their premiums would be pretty cheap. This would force the insurance companies to offer low cost alternatives.

    1. Not bad, but totally unrealistic.
      Won’t pass the first ‘why do you hate the poor?’ propaganda push from the left.

      1. …because they’re smelly and dirty, and don’t dress nicely?

        1. Actually, I forgot one more point:

          7. No one sees a doctor first thing. He or she sees a nurse practitioner. It is ridiculous for a person to show up with a sprained ankle and see someone with the training of a doctor. One doctor would work with 5 nurse practitioners, who would see all minor stuff. Which is as far as I can tell 90% of medical care.

  25. my Aunty Ellie recently got a fantastic red Subaru WRX by work part-time using a lap-top… Read Full Report W?W?W.J?u?m?p??62.C?o???m

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