Obamacare is the law of the land


If you think a primary care doctor wouldn’t get the ever-loving crap sued out of them for missing something like a subarachnoid hemorrhage, I suspect you are mistaken. There are probably other conditions that would be better examples of your point, but a primary care doctor that whiffs on that or a stroke or a heart attack is going to be in for some pain, I’d think.


A PCP who misses any obvious emergency does open themselves to lawsuits, but not all emergencies present in the usual obvious ways. The point I was making is less about ED vs PCP lawsuits and more about costs, and the lawsuits do impact costs. ED care is expensive because it has to be, both because it’s an ED where the whole point is to find emergencies and stabilize patients while getting them to the care they need, and because of the very real possibility of malpractice if an ED doc does miss something. All of that, and the points Nesrie brought up about 24/7 availability of specialists, nurses, radiologists, techs, etc, add into the overall cost of an ED visit.

And magnet, things have changed a whole lot since PCPs staffed EDs in the 70s. The ED specialty had barely gotten recognized at that point. No acute ED uses PCPs now if they can avoid it - their training is not sufficient for what is expected of an ED doctor who is seeing the full spectrum of emergent care now. Some rural EDs that don’t see much trauma do still use PCPs, so it’s not completely gone, but no level 1, 2, or even 3 trauma center is likely to use a PCP now. And I’ve never seen a patient sent from the PCP with a list or orders for testing to be done, not that it can’t happen, just that I’ve never experienced that.

To further elaborate on the headache example, I would hope most PCPs would recognize the symptoms of an acute subarachnoid - thunderclap headache, brief loss of consciousness, and the worst headache of a person’s life are taught to every medical student - and send them to the ED for workup. But a more subtle presentation is possible, perhaps only some neck pain or a lateralizing symptom that only a thorough neuro exam would detect. I feel certain that a PCP would be much less likely to be sued than an ED doc who misses that, assuming that good PCP-patient relationship.

I didn’t discuss stroke or heart attacks, because of course every PCP knows the classic symptoms and will send patients to the ED if they are having them. However, an epidural abscess hiding in a sea of low back pain is easy to miss as a PCP. Nausea can be the only presenting symptom of a heart attack, especially in the elderly, and especially for females, and a posterior stroke may only have dizziness as a presenting symptom. Nausea and dizziness are very common causes to see a PCP, so I can easily see both a stroke and a heart attack being missed by a PCP in the 15 minutes they have to assess and treat a patient. And still, the PCP would be much less likely to be sued if they did.

Why do I keep saying that the PCP would be less likely to be sued than the ED doc? Because good studies have shown that the number one reason people sue their doctor is that they didn’t feel cared for. People know that doctors make mistakes, but they are far more likely to give their PCP (that they know, like, and feel good about) the benefit of the doubt than some random ED doc who likely didn’t spend the amount of time listening to them that would have made them feel cared for. It’s about feelings more than it is about poor outcomes. I consider the PCP-patient relationship as the most important part of a PCP’s job, and all bets are off if a PCP hasn’t fostered that relationship - they are doing their patients and themselves a disservice.


I wasn’t sure exactly where you were going/what you had in mind. It’s pretty funny…at least when I was in medical school, the clinical presentations they describe to you are, 99% of the time, the classic symptoms that no one would miss. That’s what I was envisioning. As you say, real life (and real practice) isn’t always so obvious. No harm, no foul. Carry on.



Not sure it can really be considered a real repeal. Afaik, it’s just talking about removing the penalty for the individual mandate.


But removing the individual mandate will break the exchanges in the long haul. Of course, I suspect the blue states would just put in a patch so the only states would really crap the bed would be the red states.


ObamaCare signups surge in early days to set new record - The Hill



I know we signed up already, which is much earlier than last year.

Overall, since my wife doesn’t work anymore so she can take care of the baby, our combined income is very small, so we only have to pay about half the premiums for the plan we selected. A little over $200 a month for the two of us, overall $2700 for 2018, and if something happens and we have to go to the hospital/doctor for something, co-pay and deductible combined means we’ll pay $4600 out of pocket for the incident. So, not too bad.

I’m confused on why we got so much help on the premiums still. I thought they ended the cost-sharing subsidies and that was what helped us out on the premiums? I guess that was something else?

And my 6 month old is still covered by Missouri Healthnet (covers newborn children), which I think gets its funding from the CHIP, the Children’s Health Insurance Program that congress didn’t fund this year, right? So I wonder if that will problem when its time to renew that next year?


The thing they were talking about ending was money that the government pays to the insurance companies to help them lower costs.

The premium subsidies to actual consumers is separately paid by the government.

I believe that the people who are ultimately screwed by removing the subsidies to the insurance companies, are people who make too much money to get any of the subsidies. The result of not paying the insurance companies, is that they will raise premiums. For lower income people, the effect is nil, because the law limits their total costs. The effect is just that the government will end up having to pay more to subsidize them. But if you don’t receive subsidies, then you will just have to pay the increased premium costs.


Ah, thanks for clearing that up for me Timex.

Any thoughts on CHIP? Is there political pressure to renew that, or is it just gone? I thought that passed through a bipartisan effort and wasn’t controversial?


I think that there must be pressure to renew CHIP, but given what a dumpster fire the Trump admin is, on literally a daily basis, it fell off the table of the American consciousness.


I’m really struggling to find an acceptable plan this year. The company we were with pulled out of the area. There are no exchange PPOs left (and even the one we had pretty much had stopped being a ppo in many ways). I’ve found something that will let us keep the doctors we want, though it will be several hundred dollars more than last year. I could go with Kaiser and pay less than last year, but none of their facilities are near us.

The biggest issue is that my son is in school out-of-state, has no insurance available through the school (largely a commuter school), and finding a plan that will cover him is a major problem.

Thinking of trying to find a broker to help, but I already know that a number of major carriers have stopped selling their off exchange offerings as of the new year


Trump and the GOP wants this to fail. They couldn’t pass anything to replace it and couldn’t kill it outright so they want to starve the process.

Is there any reason why your son can’t get his own plan locally?


I imagine he could, I was trying to avoid him having to deal with it. Plus, he will be home part of the time.


Young college student and not in your state, it might be worth him giving it a try. Maybe he can get an PPO plan that also works out of state for a better price than you can find for all of you. I don’t remember how they have it set-up now but I thought it was possible to kind of shop around without too much effort.


I send a new letter to my representative about CHIP every couple of weeks.


Most colleges have some kind of cheap on site health care. It can handle the small stuff.

My daughter is using Covered California’s absolute cheapest plan for insurance. Something like $40 a month. Not the best if you need a doctor but at least she has something.


The House did pass something to reauthorize CHIP, but only tied to some ACA and Medicare restrictions.


Yeah, I was asking my representative to work on a bill for CHIP that wasn’t tied to other horseshit, but I guess she told me to go to hell.