8 ms·

America’s Looming Primary-Care Crisis

94 points by vo2maxer 6y ago

paulcole 6y ago
Well well well, if it isn’t the consequences of 50+ years of terrible policy making. Who could’ve seen this coming except every other country on the planet?
- runawaybottle 6y ago
  You really think 5 months of a pandemic is going to expose this? New York is returning back to normal. The new surges will pass in the same time frame (5 months). The looming primary care crisis will show itself on a much longer time frame. It’s a snake that’s wrapping around, slow acting venom, and we’ll finally see it when it’s not just the ailing boomers that will need continuous care for ubiquitous things like Diabetes, but gen x, y, and z after it. No one’s gonna die, that’s when it’s all going to come to a head. We cannot afford Medicare for all when everybody is fucking sick.
  - controversy 6y ago
    We should be able to afford it when the government takes its rightful place as health dictator. Ban alcohol. Ban tobacco. Ban fatty foods. Ban meat. Ban high fructose corn syrup. If not ban, make it so only rich white people can afford it. Then we can afford things by requiring doctors to either work within the system or they can’t be doctors. That takes care of them going into private care.
    - 1996 6y ago
      Ban, ban, ban, then force people to work for the government? I'm not sure I want to live in the country you are suggesting we make. What about drugs are legalized instead, and the medical sector is deregulated for example by removing residency requirements? If a rating system can let anyone become the equivalent of a cab, we certainly can do the same with doctors educated abroad while also educating more at home.
      - controversy 6y ago
        The republicans had their chance. They fucked it up. They are the Washington Team Named To Be Determines of policy makers. All they did was piss people off. Unfortunately we now have to fall into the lap of big daddy government.
      - runawaybottle 6y ago
        You guys are missing the point. I’m saying the general public is too unhealthy for this not to be extremely costly going forward, whether it’s for profit or non profit. The only thing we solved is making sure you can live with the ailment. We didn’t solve the cost of continuous care. Whoever is born today, will enter the demographic of questionable health in just 40 years. That means in our lifetime we’ll have almost 3 generations with garbage health inundating the healthcare system. Try to flatten that curve.
        baix777 6y ago
        If you look at this from a socioeconomic standpoint, the poor are more obese and exercise less than the better off. Being poor is hard, so the wealth gap of the US looks to be partial cause of this, but the whole cause and effect is hard to determine here.
  - dimensi0nal 6y ago
    Should health insurance, private or public, really pay to deal with people's self-induced health problems from eating too much, smoking, etc?
    - coronadisaster 6y ago
      Maybe the health insurance companies should sue tobacco and fast food companies amoung others?
    - maxerickson 6y ago
      A healthcare system should strive to make the care people need affordable. Your framing is boring, we need to figure out how to make the care as widely available as possible regardless of the payment model.
    - wwweston 6y ago
      Certainly an issue insurers have been thinking about for a while. Funding certain kinds of care with heavy taxes on things like smoking makes a lot sense. Other things like unhealthy eating (or sitting, HN participants, lookin' at you) are so much harder to draw easy lines dividing contributing activity from everyday liberties that it makes less sense. You can work at the margins with something like soda taxes or maybe even incentives around bloodwork but the tradeoffs are less clear along with the dividing lines.
    - paulcole 6y ago
      Yes.
  - wwweston 6y ago
    Your last sentence is logically equivalent to saying that no society can afford to give medical care to everyone, the only choice is who to ration it for, since Medicare-for-all is characteristically no different from any other comprehensive risk pool bridged over an entire population. And under conditions you're describing where the population truly is uniformly ill, every sub-population will look similar to the population at large, so no private insurance pool will do better by excluding some of the population. Sounds like a problem.
- AdrianB1 6y ago
  No idea what you want to say, but in my country the situation is worse for about 100 years. Yes, we have free lack of health care: no resources shared to almost everyone, so we are equal in getting nothing.
  - maxerickson 6y ago
    The US centrally plans the healthcare supply and then doesn't control prices (sort of). We can and should have lots more doctors (and other primary care providers), but we've long restricted that because people have wacky ideas about things like economics and intelligence.
    - fennecfoxen 6y ago
      > people have wacky ideas about things like economics and intelligence. Boy howdy. There are three major parts of the economy which are extensively regulated to achieve political goals: health care and higher education (on the national level with some state involvement) and housing (city-level zoning, with occasional other mandates particularly in places like California). Notice then the three areas where prices have become radically more expensive over the past several decades, fomenting a crisis that threatens our prosperity as a nation: housing prices, higher education prices, health care prices...
      - kcb 6y ago
        You really think that those are the only three things regulated to achieve political goals?
        prawn 6y ago
        At the time of my reading, their comment says "three major parts of the economy which are extensively regulated". I don't think that they're ignoring all others.
      - HarryHirsch 6y ago
        You think that other countries don't have housing, education and healthcare policies?
- refurb 6y ago
  Canada is having a huge shortage of primary care doctors. So much many people don’t have one and have to rely on urgent care.[1] This isn’t a US only issue. [1] https://www.ctvnews.ca/health/despite-more-doctors-many-canadians-don-t-have-a-family-physician-report-1.4611149 https://www.ctvnews.ca/health/despite-more-doctors-many-cana...
  - dantheman 6y ago
    The US purposefully lowered the amount of doctors in the 90s. If anything we should be creating more need schools and creating more doctors.
    - tharne 6y ago
      That's a big claim to make without providing any evidence or even some context.
      - wonder_er 6y ago
        I'm not the OP; when I read OP's comment, I thought "Oh, I think the AMA's been doing this since long before the 90's". Here's the article I read a few years back that made me think this is the case: I know it's mises.org, so hold the pichforks until the end. Even if they're way off base, there's got to be some value to be gleaned: https://mises.org/library/100-years-medical-robbery https://mises.org/library/100-years-medical-robbery
    - controversy 6y ago
      The AMA corrected course on this. The problem is not a lack of schools. The problem is a lack of hospitals to train them in as part of the residency. As long as residency is a thing, we have an insurmountable bottle neck. Evidence to the limitations. https://skeptics.stackexchange.com/questions/4561/does-the-ama-limit-the-number-of-doctors-to-increase-current-doctors-salaries https://skeptics.stackexchange.com/questions/4561/does-the-a...
      - tesmar2 6y ago
- Proven 6y ago
  which "policy making" hasn't turned out to be terrible? why not call it "50 years of statism"? let the state make the policy and before you know crony capitalists and corrupt state employees (in healthcare, insurance and politics) create a mess that results in high costs, poor quality or shortages. why is anyone surprised? the NYT has contributed to this mess by supporting increased role of government in healthcare (and not just in healthcare)
belltaco 6y ago
And then we chase away thousands of foreign doctors serving even rural areas with bs like this. https://money.cnn.com/2018/06/08/news/economy/immigrant-doctors-green-card-backlog/index.html https://money.cnn.com/2018/06/08/news/economy/immigrant-doct...
gdsdfe 6y ago
haven't read the article but it seems that every week there a new looming crisis in America
disabled 6y ago
> Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time. This is more deadly than it appears on the surface. For example, this article on life expectancy is a good read. One should pay close attention to the case of South Korea and how they are focusing on the health of the younger generation, which has the best payoff (By the way, I am both a citizen of the US and Croatia. The biggest difference: Croatia is going the right way, the US is not): https://www.washingtonpost.com/news/to-your-health/wp/2017/02/21/us-life-expectancy-will-soon-be-on-par-with-mexicos-and-croatias/ https://www.washingtonpost.com/news/to-your-health/wp/2017/0... Archived version of link: http://archive.is/3EpBi http://archive.is/3EpBi
hippich 6y ago
Anecdotal data point about primary care: About a year or so ago I subscribed to "direct/concierge primary care practice". I pay $80/month and in exchange getting an access to a primary doctor who takes care of keeping an eye on me, my blood pressure, all my prescriptions (some of which used to require monthly visits to specialists). I am also getting access to really cheap prices on labs, typically 30 min visits same or next day if I wanted (unlimited visits per months), EKG when I wanted to put my mind at peace right there in the office ($25 one time fee), etc. Doctor is available over the phone, text or email. Does not dismiss me when I mention "I've read on internet..." something and actually explains things. Basically, I think it will take care of the most of my health care needs, as well as puts my mind at ease thanks to easy access to the doctor. The doctor also refers me to specialists who's cash-prices were often below my co-pays. For major accidents I still have a traditional health insurance with high out-of-pocket limit bought at the marketplace (self-employed). This practice existed for quite some time and thanks to the subscription-based fees (not episodic described in the article), I expect it to be a long-term sustainable business. It is also owned by the doctor as far as I am aware. They explicitly do not deal with private or public insurances. (Although by recent law changes I can charge monthly fee to HSA account). There are a few practices like that in the area. Can't say if others are similar in experience, but fees - are. So it looks like it is possible to build sustainable business around primary care. But it takes a different approach.
- tristor 6y ago
  I’d be interested in enrolling in a similar service. How do you find out about these services in your area?
  - DoreenMichele 6y ago
    Your best bet to find a direct primary care physician is to do an online search including “direct primary care” and the name of your state. https://www.nextavenue.org/direct-primary-care-time-with-doctor/#:~:text=Online%20directories%20of%20providers%20exist%2C%20but%20their%20quality,have%20a%20good%20handle%20on%20your%20personal%20finances https://www.nextavenue.org/direct-primary-care-time-with-doc....
sangfroid_bio 6y ago
Here's the previous thread on this: https://news.ycombinator.com/item?id=23881342 https://news.ycombinator.com/item?id=23881342
pengaru 6y ago
My understanding is that a major cause of America's burgeoning healthcare burden is the food environment. The argument I've heard smarter, better informed people than me make is: If healthcare were nationalized, it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies. When the government subsidizes farming corn on a massive scale, and all these corn-derived products make people obese and give them diabetes, it becomes counter to the government's own goals if its charter includes providing affordable healthcare to all. If we don't stop subsidizing liquid sugar, it'll continue finding its way into everything possible. What kills me is people proposing taxing products w/added sugar... talk about the American way; spend people's tax dollars on subsidies producing the sugar, then tax them again for consuming the thing you made cheap with their taxes! smh
- DoreenMichele 6y ago
  My understanding is that a major cause of America's burgeoning healthcare burden is the food environment. That's only one factor. Another is car dependence and lack of pedestrian-friendly built environments. There is a lot of research on just how much harm it does us to sit all day, every day. We sit in a car to make a long commute to work. We sit our desks. We sit in the car again. And hitting the gym occasionally doesn't fully compensate for living like that. Urban planners used to configure cities to help promote physical health and we don't do enough of that anymore. It's nigh impossible to escape a sick outcome when trapped in a sick system that makes healthy choices largely out of reach for most people.
  - qserasera 6y ago
    Our metabolism increase from walking 5-15 minutes every day is significant. With individual car transportation there is little want or little ability to do so. Many schedules do not allow for daily 60 minute exercise routines at the gym which take 10-15 min to get there by car. Every day US citizens waste hours life with transportation. I do believe in cars but I also believe we need to reshape how we live. If the US government allows our time to be wasted repeatedly by a variety of lobbies building infrastructure for a variety of interests it shows how little our leadership values the time of our citizens. I almost find it more egregious that government wants to waste the time of our citizens than wanting to eventually kill ourselves with emissions. The US currently has an oversupply of labour and I suggest the US does something with it to reshape infrastructure to be less energy reliant. The world should look into outfit and create houses with manditory natural cooling/heating, increase density in cities and towns to reduce habitat distruction and sprawl, reduce emissions of high GWP chemicals, and create a global political situation to reduce reliance on a failing economic system that incentivizes people to hide pandemics.
spaetzleesser 6y ago
There is just way more money in being a specialist. I don’t really understand why specialists like radiologists or anesthesiologists make >500k by default While primary doctors make much less. In Germany the medical associations set reimbursements rates per specialty. I assume it’s similar in the US. Simple solution: balance reimbursements towards primary care. But I assume there is a powerful lobby with deep pockets that will fight such a change.
- Nasrudith 6y ago
  The assumptions are incorrect. Medical associations may influence supplies to some degree but they don't set the price. Supply, demand, and what the market may bear do. There are also really several different healthcare systems. The government can set say VA rates and medicare to some degree. The sort of balancing done is encouraging more family doctors. Radiology and anesthesiology are also two "cash cows" of procedures. All of internal medicine wants radiology for tests and needs anesthesiologists if surgical remedies are required. Primary care pays less because it requires less additional training than the specialties. Although some specialties aren't higher - Children's Oncology for instance.
  - spaetzleesser 6y ago
    I was thinking about this: https://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val... "Supply, demand, and what the market may bear do." I agree about "what the market may bear". Normal supply and demand market ideas really don't apply to a lot of medical areas.
- naveen99 6y ago
  Medicare had been cutting radiology reimbursements for a while, to the point radiology had almost a 100 unfilled residency spots in the us a few years ago. Radiologists are being paid the bottom of market clearing rates. You pay them much less than what they make now, and you will have a severe shortage quickly.
  - 6y ago

94 points by vo2maxer 6y ago

Well well well, if it isn’t the consequences of 50+ years of terrible policy making. Who could’ve seen this coming except every other country on the planet?

runawaybottle 6y ago
You really think 5 months of a pandemic is going to expose this? New York is returning back to normal. The new surges will pass in the same time frame (5 months). The looming primary care crisis will show itself on a much longer time frame. It’s a snake that’s wrapping around, slow acting venom, and we’ll finally see it when it’s not just the ailing boomers that will need continuous care for ubiquitous things like Diabetes, but gen x, y, and z after it. No one’s gonna die, that’s when it’s all going to come to a head. We cannot afford Medicare for all when everybody is fucking sick.
- controversy 6y ago
  We should be able to afford it when the government takes its rightful place as health dictator. Ban alcohol. Ban tobacco. Ban fatty foods. Ban meat. Ban high fructose corn syrup. If not ban, make it so only rich white people can afford it. Then we can afford things by requiring doctors to either work within the system or they can’t be doctors. That takes care of them going into private care.
  - 1996 6y ago
    Ban, ban, ban, then force people to work for the government? I'm not sure I want to live in the country you are suggesting we make. What about drugs are legalized instead, and the medical sector is deregulated for example by removing residency requirements? If a rating system can let anyone become the equivalent of a cab, we certainly can do the same with doctors educated abroad while also educating more at home.
    - controversy 6y ago
      The republicans had their chance. They fucked it up. They are the Washington Team Named To Be Determines of policy makers. All they did was piss people off. Unfortunately we now have to fall into the lap of big daddy government.
    - runawaybottle 6y ago
      You guys are missing the point. I’m saying the general public is too unhealthy for this not to be extremely costly going forward, whether it’s for profit or non profit. The only thing we solved is making sure you can live with the ailment. We didn’t solve the cost of continuous care. Whoever is born today, will enter the demographic of questionable health in just 40 years. That means in our lifetime we’ll have almost 3 generations with garbage health inundating the healthcare system. Try to flatten that curve.
      - baix777 6y ago
        If you look at this from a socioeconomic standpoint, the poor are more obese and exercise less than the better off. Being poor is hard, so the wealth gap of the US looks to be partial cause of this, but the whole cause and effect is hard to determine here.
- dimensi0nal 6y ago
  Should health insurance, private or public, really pay to deal with people's self-induced health problems from eating too much, smoking, etc?
  - coronadisaster 6y ago
    Maybe the health insurance companies should sue tobacco and fast food companies amoung others?
  - maxerickson 6y ago
    A healthcare system should strive to make the care people need affordable. Your framing is boring, we need to figure out how to make the care as widely available as possible regardless of the payment model.
  - wwweston 6y ago
    Certainly an issue insurers have been thinking about for a while. Funding certain kinds of care with heavy taxes on things like smoking makes a lot sense. Other things like unhealthy eating (or sitting, HN participants, lookin' at you) are so much harder to draw easy lines dividing contributing activity from everyday liberties that it makes less sense. You can work at the margins with something like soda taxes or maybe even incentives around bloodwork but the tradeoffs are less clear along with the dividing lines.
  - paulcole 6y ago
    Yes.
- wwweston 6y ago
  Your last sentence is logically equivalent to saying that no society can afford to give medical care to everyone, the only choice is who to ration it for, since Medicare-for-all is characteristically no different from any other comprehensive risk pool bridged over an entire population. And under conditions you're describing where the population truly is uniformly ill, every sub-population will look similar to the population at large, so no private insurance pool will do better by excluding some of the population. Sounds like a problem.
AdrianB1 6y ago
No idea what you want to say, but in my country the situation is worse for about 100 years. Yes, we have free lack of health care: no resources shared to almost everyone, so we are equal in getting nothing.
- maxerickson 6y ago
  The US centrally plans the healthcare supply and then doesn't control prices (sort of). We can and should have lots more doctors (and other primary care providers), but we've long restricted that because people have wacky ideas about things like economics and intelligence.
  - fennecfoxen 6y ago
    > people have wacky ideas about things like economics and intelligence. Boy howdy. There are three major parts of the economy which are extensively regulated to achieve political goals: health care and higher education (on the national level with some state involvement) and housing (city-level zoning, with occasional other mandates particularly in places like California). Notice then the three areas where prices have become radically more expensive over the past several decades, fomenting a crisis that threatens our prosperity as a nation: housing prices, higher education prices, health care prices...
    - kcb 6y ago
      You really think that those are the only three things regulated to achieve political goals?
      - prawn 6y ago
        At the time of my reading, their comment says "three major parts of the economy which are extensively regulated". I don't think that they're ignoring all others.
    - HarryHirsch 6y ago
      You think that other countries don't have housing, education and healthcare policies?
refurb 6y ago
Canada is having a huge shortage of primary care doctors. So much many people don’t have one and have to rely on urgent care.[1] This isn’t a US only issue. [1] https://www.ctvnews.ca/health/despite-more-doctors-many-canadians-don-t-have-a-family-physician-report-1.4611149 https://www.ctvnews.ca/health/despite-more-doctors-many-cana...
- dantheman 6y ago
  The US purposefully lowered the amount of doctors in the 90s. If anything we should be creating more need schools and creating more doctors.
  - tharne 6y ago
    That's a big claim to make without providing any evidence or even some context.
    - wonder_er 6y ago
      I'm not the OP; when I read OP's comment, I thought "Oh, I think the AMA's been doing this since long before the 90's". Here's the article I read a few years back that made me think this is the case: I know it's mises.org, so hold the pichforks until the end. Even if they're way off base, there's got to be some value to be gleaned: https://mises.org/library/100-years-medical-robbery https://mises.org/library/100-years-medical-robbery
  - controversy 6y ago
    The AMA corrected course on this. The problem is not a lack of schools. The problem is a lack of hospitals to train them in as part of the residency. As long as residency is a thing, we have an insurmountable bottle neck. Evidence to the limitations. https://skeptics.stackexchange.com/questions/4561/does-the-ama-limit-the-number-of-doctors-to-increase-current-doctors-salaries https://skeptics.stackexchange.com/questions/4561/does-the-a...
    - tesmar2 6y ago
Proven 6y ago
which "policy making" hasn't turned out to be terrible? why not call it "50 years of statism"? let the state make the policy and before you know crony capitalists and corrupt state employees (in healthcare, insurance and politics) create a mess that results in high costs, poor quality or shortages. why is anyone surprised? the NYT has contributed to this mess by supporting increased role of government in healthcare (and not just in healthcare)

belltaco 6y ago

And then we chase away thousands of foreign doctors serving even rural areas with bs like this. https://money.cnn.com/2018/06/08/news/economy/immigrant-doctors-green-card-backlog/index.html https://money.cnn.com/2018/06/08/news/economy/immigrant-doct...

gdsdfe 6y ago

haven't read the article but it seems that every week there a new looming crisis in America

disabled 6y ago

> Payers routinely reimburse health-care providers for specialized procedures at high rates, but primary-care visits—which might include chronic-disease management, routine vaccinations, or smoking and diet counselling—generate lower revenues. This imbalance is due, in large part, to the Relative Value Update Committee (R.U.C.), an extraordinarily powerful group of doctors that advises the federal government on reimbursement rates for physicians. The R.U.C. consists of thirty-one doctors convened by the American Medical Association; it’s structured such that each specialty has an equal say. On the R.U.C., urology, thoracic surgery, and head-and-neck surgery have, individually, about the same representation as all of pediatrics. The Centers for Medicare and Medicaid Services (C.M.S.), which has final authority to set payment rates for Medicare, has in many years accepted the R.U.C.’s recommendations nearly ninety per cent of the time. This is more deadly than it appears on the surface. For example, this article on life expectancy is a good read. One should pay close attention to the case of South Korea and how they are focusing on the health of the younger generation, which has the best payoff (By the way, I am both a citizen of the US and Croatia. The biggest difference: Croatia is going the right way, the US is not): https://www.washingtonpost.com/news/to-your-health/wp/2017/02/21/us-life-expectancy-will-soon-be-on-par-with-mexicos-and-croatias/ https://www.washingtonpost.com/news/to-your-health/wp/2017/0... Archived version of link: http://archive.is/3EpBi http://archive.is/3EpBi

hippich 6y ago

Anecdotal data point about primary care: About a year or so ago I subscribed to "direct/concierge primary care practice". I pay $80/month and in exchange getting an access to a primary doctor who takes care of keeping an eye on me, my blood pressure, all my prescriptions (some of which used to require monthly visits to specialists). I am also getting access to really cheap prices on labs, typically 30 min visits same or next day if I wanted (unlimited visits per months), EKG when I wanted to put my mind at peace right there in the office ($25 one time fee), etc. Doctor is available over the phone, text or email. Does not dismiss me when I mention "I've read on internet..." something and actually explains things. Basically, I think it will take care of the most of my health care needs, as well as puts my mind at ease thanks to easy access to the doctor. The doctor also refers me to specialists who's cash-prices were often below my co-pays. For major accidents I still have a traditional health insurance with high out-of-pocket limit bought at the marketplace (self-employed). This practice existed for quite some time and thanks to the subscription-based fees (not episodic described in the article), I expect it to be a long-term sustainable business. It is also owned by the doctor as far as I am aware. They explicitly do not deal with private or public insurances. (Although by recent law changes I can charge monthly fee to HSA account). There are a few practices like that in the area. Can't say if others are similar in experience, but fees - are. So it looks like it is possible to build sustainable business around primary care. But it takes a different approach.

tristor 6y ago
I’d be interested in enrolling in a similar service. How do you find out about these services in your area?
- DoreenMichele 6y ago
  Your best bet to find a direct primary care physician is to do an online search including “direct primary care” and the name of your state. https://www.nextavenue.org/direct-primary-care-time-with-doctor/#:~:text=Online%20directories%20of%20providers%20exist%2C%20but%20their%20quality,have%20a%20good%20handle%20on%20your%20personal%20finances https://www.nextavenue.org/direct-primary-care-time-with-doc....

sangfroid_bio 6y ago

Here's the previous thread on this: https://news.ycombinator.com/item?id=23881342 https://news.ycombinator.com/item?id=23881342

pengaru 6y ago

My understanding is that a major cause of America's burgeoning healthcare burden is the food environment. The argument I've heard smarter, better informed people than me make is: If healthcare were nationalized, it would incentivize the government to help fight the battle against itself in the context of unhealthy agricultural subsidies and policies. When the government subsidizes farming corn on a massive scale, and all these corn-derived products make people obese and give them diabetes, it becomes counter to the government's own goals if its charter includes providing affordable healthcare to all. If we don't stop subsidizing liquid sugar, it'll continue finding its way into everything possible. What kills me is people proposing taxing products w/added sugar... talk about the American way; spend people's tax dollars on subsidies producing the sugar, then tax them again for consuming the thing you made cheap with their taxes! smh

DoreenMichele 6y ago
My understanding is that a major cause of America's burgeoning healthcare burden is the food environment. That's only one factor. Another is car dependence and lack of pedestrian-friendly built environments. There is a lot of research on just how much harm it does us to sit all day, every day. We sit in a car to make a long commute to work. We sit our desks. We sit in the car again. And hitting the gym occasionally doesn't fully compensate for living like that. Urban planners used to configure cities to help promote physical health and we don't do enough of that anymore. It's nigh impossible to escape a sick outcome when trapped in a sick system that makes healthy choices largely out of reach for most people.
- qserasera 6y ago
  Our metabolism increase from walking 5-15 minutes every day is significant. With individual car transportation there is little want or little ability to do so. Many schedules do not allow for daily 60 minute exercise routines at the gym which take 10-15 min to get there by car. Every day US citizens waste hours life with transportation. I do believe in cars but I also believe we need to reshape how we live. If the US government allows our time to be wasted repeatedly by a variety of lobbies building infrastructure for a variety of interests it shows how little our leadership values the time of our citizens. I almost find it more egregious that government wants to waste the time of our citizens than wanting to eventually kill ourselves with emissions. The US currently has an oversupply of labour and I suggest the US does something with it to reshape infrastructure to be less energy reliant. The world should look into outfit and create houses with manditory natural cooling/heating, increase density in cities and towns to reduce habitat distruction and sprawl, reduce emissions of high GWP chemicals, and create a global political situation to reduce reliance on a failing economic system that incentivizes people to hide pandemics.

spaetzleesser 6y ago

There is just way more money in being a specialist. I don’t really understand why specialists like radiologists or anesthesiologists make >500k by default While primary doctors make much less. In Germany the medical associations set reimbursements rates per specialty. I assume it’s similar in the US. Simple solution: balance reimbursements towards primary care. But I assume there is a powerful lobby with deep pockets that will fight such a change.

Nasrudith 6y ago
The assumptions are incorrect. Medical associations may influence supplies to some degree but they don't set the price. Supply, demand, and what the market may bear do. There are also really several different healthcare systems. The government can set say VA rates and medicare to some degree. The sort of balancing done is encouraging more family doctors. Radiology and anesthesiology are also two "cash cows" of procedures. All of internal medicine wants radiology for tests and needs anesthesiologists if surgical remedies are required. Primary care pays less because it requires less additional training than the specialties. Although some specialties aren't higher - Children's Oncology for instance.
- spaetzleesser 6y ago
  I was thinking about this: https://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val... "Supply, demand, and what the market may bear do." I agree about "what the market may bear". Normal supply and demand market ideas really don't apply to a lot of medical areas.
naveen99 6y ago
Medicare had been cutting radiology reimbursements for a while, to the point radiology had almost a 100 unfilled residency spots in the us a few years ago. Radiologists are being paid the bottom of market clearing rates. You pay them much less than what they make now, and you will have a severe shortage quickly.
- 6y ago