U.S. Budget Negotiations

[gtyellowjacket]

Yeah that’s basically what I’m saying. And this bill will (1) reduce pay in rural areas, and (b) drive US educated doctors to more urban areas. So it may be happening now, but it’s about to get turbocharged in those areas.

Also, I agree doctors from foreign schools can be very good. I’m just skeptical most MAGAs will share that view.

No argument that this bill might reduce pay in rural areas, but I suspect most American born doctors are in rural environments because they want to be there. They have family nearby or they like the lifestyle, or they started out their career in a rural environment and grew to love the place.

They might see a reduction in pay with the new bill but I doubt it would be enough to drive them to an urban environment. Even if they make less, they're still paid very well. Of course if the hospital shuts down because they're not getting enough Medicaid payments to keep the lights on, the rural doctors might be forced to make a move.

 

[kickazzz2000]

Nobody does!

Really? How can they know that? Are you telling me the current hospital in question KNOWS how many patients they will be losing, how much that will cost them and how much they'll get and they KNOW it won't be enough? If that's your claim, explain how they could possibly know all of that HOURS after the bill passed?

Stop changing the subject.

As someone who does healthcare pro formas for a living

Might want to sit this one out. You sound really really dumb.

 

[lawtig02]

Where are these foreign doctors coming from? Ain't no army of Indian doctors who will come to save us. Australia and New Zealand put up travel advisories against even visiting America. Why the hell would trained medical professionals sign up for endless harassment, paperwork, no political freedom, constant threat of being hurled into an unmarked van?

Well, the average physician pay in India appears to be a little less than $35k. Maybe they go to other western countries instead but I suspect people would put up with a lot of bureaucracy to get a substantially higher salary.

 

[gtyellowjacket]

You can only claim them against gambling wins. It is a basket item.

Suppose you sit down at a slot machine and win $1,200.

Later in the day, you lose $1,200 on the slot machine.

For the day, your winnings are exactly zero.

Under your theory, you would need to pay taxes on $1,200 of “income” because you don’t think you should be allowed to deduct gambling losses.

It depends on the gambling. If you buy $1,200 worth of scratch offs, and you win $1,200, the government is going to tax you on the $1,200. As you point out, that's not the way with sports betting and casino games for the most part but it's not unprecedented to not allow you to offset gambling wins with losses.

 

[superrific]

but I suspect most American born doctors are in rural environments because they want to be there.

No. Public interest loan repayment drives huge traffic to rural areas. That's why my wife was working in Missouri. I've seen stats -- slightly dated by now -- that a third to a half of rural physicians are there to get loan repayment assistance.

Loan repayment is an important part of rural health clinic compensation packages. As in, on job listing sites, they list loan repayment along with salary.

Public service loan repayment has been slashed by Trump. Fewer people are going to graduate medical school, and they will graduate with less debt. They aren't moving to rural areas.

 

[Calheel]

It depends on the gambling. If you buy $1,200 worth of scratch offs, and you win $1,200, the government is going to tax you on the $1,200. As you point out, that's not the way with sports betting and casino games for the most part but it's not unprecedented to not allow you to offset gambling wins with losses.

Incorrect. I can’t speak to NC, which apparently has some screwed up gambling laws, but under federal law there is no distinction in the type of gambling wins.

The reality is that you don’t get tax forms for almost all scratchers, so 99.9% of people aren’t reporting that income. But under federal law, all gambling and lottery wins need to be reported as income and all gambling losses are eligible for below-the-line itemized deductions (now limited to 90%)

 

[superrific]

Well, the average physician pay in India appears to be a little less than $35k. Maybe they go to other western countries instead but I suspect people would put up with a lot of bureaucracy to get a substantially higher salary.

The average physician in India is not the population we're talking about. The average physician in India with a realistic possibility of landing a job in the US earns a lot higher than $35K. "Average" salaries in India are meaningless anyway. Large sections of the country are among the poorest places on Earth. Bihar is basically Somalia inside India. You'd have to ask where.

And yes, they will go elsewhere. Canada, for instance.

Plus, we're assuming that the visa process has been unchanged. I doubt that's true. Let's put it this way: there has been a shortage of doctors in the US for a while. If the system was capable of bringing in more foreign medical grads, it would have. Trump isn't making that any easier.

 

[gtyellowjacket]

Incorrect. I can’t speak to NC, which apparently has some screwed up gambling laws, but under federal law there is no distinction in the type of gambling wins.

The reality is that you don’t get tax forms for almost all scratchers, so 99.9% of people aren’t reporting that income. But under federal law, all gambling and lottery wins need to be reported as income and all gambling losses are eligible for below-the-line itemized deductions (now limited to 90%)

I didn't know that. I'm not a lottery player but if I win say $20,000 in some North Carolina State lottery and I have receipts for $1,000 worth of tickets, the feds only tax me on $19,000? Does NC work the same way?

 

[Calheel]

I didn't know that. I'm not a lottery player but if I win say $20,000 in some North Carolina State lottery and I have receipts for $1,000 worth of tickets, the feds only tax me on $19,000? Does NC work the same way?

If you itemize.

Except now you would only get a $900 deduction, not $1,000.

Also, you should have proof of losses - either the losing tickets or contemporaneous receipts (something that very few people have).

Per Heelyeah, NC doesn’t let you deduct any gambling losses at all.

 

[lawtig02]

The average physician in India is not the population we're talking about. The average physician in India with a realistic possibility of landing a job in the US earns a lot higher than $35K. "Average" salaries in India are meaningless anyway. Large sections of the country are among the poorest places on Earth. Bihar is basically Somalia inside India. You'd have to ask where.

And yes, they will go elsewhere. Canada, for instance.

Plus, we're assuming that the visa process has been unchanged. I doubt that's true. Let's put it this way: there has been a shortage of doctors in the US for a while. If the system was capable of bringing in more foreign medical grads, it would have. Trump isn't making that any easier.

Ok fair. I know you’ve had experiences that make you far more knowledgeable about India that I am. I’ll amend my comment to this. The most likely outcome is rural MAGAs will lose most of their local healthcare. The next most likely is some will stick around, but will mostly be foreign educated doctors. The third most likely is MAGAs maintain something resembling their current healthcare options. And that third option is extremely unlikely.

 

[superrific]

The most likely outcome is rural MAGAs will lose most of their local healthcare.

Based on what I know, I wouldn't predict "most." That's too specific for me; I'd say "a lot." Maybe most. Maybe a plurality. Enough for life to become way shittier.

But others on this thread know more than me about the details here, and specifically about affected institutions.

 

[heelinhell]

My eye surgeon is from Serbia. She did a perfect job repairing my detached retina. I love her

My spine doctor is Asian and his humane approach and treatment has been a godsend. I love him

The dentist who did a wonderful on my root canal had brown skin and was likely from somewhere in the Middle East. I love him


My primary care physician is from India and my only complaint is that she is too diligent in taking care of me, but I love her


Bottom line is I don't give twowhether I see a 'murican doctor for care. I'm pretty sure they will not surpass my current doctors.

 

[p5mmr9]

H1B Visas are awarded based on a lottery per country with a cap per year per country. India is one of the most competitive countries for H1B visa based on applications and population. And regardless - the doctor shortage we are experiencing here is a global phenomenon. The WHO recently estimated a global shortage of 7 million healthcare workers.

Doctor shortages seem like a smaller issue when viewed against the cost of the system as a whole. Yes - doctor availability affects cost, but the legislation signed into law yesterday will almost certainly cause an increase in the cost curve for everyone's healthcare regardless of doctor supply. The whole point of the medicaid expansion under the ACA was to insure as many people as possible under the premise that insured patients cost the system far less than uninsured. It worked and now that has been significantly negatively impacted. Who cares if we do or don't have doctors if 30% of the population can't afford care anyway?

My guess is this was all a shell game for the big tax cut permanent extension. Republicans know the Democrats will do anything to restore medicaid and SNAP. These issues will be re-addressed at some point...maybe even before the mid-terms. The budget hawks will not vote for an increase in benefits, but there will be enough votes to pass something with Democratic Party help. No one has the will to address the actual budget issues.

 

[ZenMode]

My mother retired from being a medical administrator in one of the poorest counties in NC and she could tell you on any given moment at any given time what percentage of their deliveries were Medicaid and what the outstanding balance was from the State of NC on those claims. Routinely, those kinds of hospitals and clinics have to borrow funds for ongoing operations with future due Medicaid payments as collateral. Everyone in medicine knows those numbers about their facility or practice. This is EPSECIALLY true in rural counties.

I can assure you that if the practice she ran found out their Medicaid reimbursements were going to be cut by even 10-15%, they would have ceased operations the following week. They are also to this day the only OB/GYN practice in Edgecombe County and the only OB physicians with admitting privileges at the local hospital. If that practice closes, there isn't a single doctor to deliver a baby in the entire county.

In order for this hospital to make a truly informed decision, they'd have to know:

• Nearly precisely how many patients they'll be losing
• How much revenue those patients generate now and will in the future
• How much money they'll be subsidized from the government which means they ..
• Need to know how many medical facilities will be closing around the country....
• ...How much the remaining facilities will receive which means they also....
• Need to know how the federal government calculates subsidies.

Are you telling me they knew that within hours of the bill passing?

Also @superrific

 

[lawtig02]

My eye surgeon is from Serbia. She did a perfect job repairing my detached retina. I love her

My spine doctor is Asian and his humane approach and treatment has been a godsend. I love him

The dentist who did a wonderful on my root canal had brown skin and was likely from somewhere in the Middle East. I love him


My primary care physician is from India and my only complaint is that she is too diligent in taking care of me, but I love her


Bottom line is I don't give twowhether I see a 'murican doctor for care. I'm pretty sure they will not surpass my current doctors.

Just to be clear, I agree completely. I just have a hunch MAGA does not.

 

[superrific]

The whole point of the medicaid expansion under the ACA was to insure as many people as possible under the premise that insured patients cost the system far less than uninsured.

I think this is a bit too strong. That was one of the points, not necessarily the main one. I mean, you're right; there was also more going on.

IIRC, Insured patients do not cost the system less than uninsured people. It's that their care is delivered at a fraction of the cost. So while we pay as much per insured as uninsured, we are delivering a lot more care in the first instance. It's the same way that Caleb Love scored about as many points as Tyler Hansbrough. One of them was a bit more efficient than the other . . .

Now, there are also distributional issues as to who pays in each case, and yes that was a significant issue under ACA and that's why some of the obscure financing provisions were in there.

 

[finesse]

I think this is a bit too strong. That was one of the points, not necessarily the main one. I mean, you're right; there was also more going on.

IIRC, Insured patients do not cost the system less than uninsured people. It's that their care is delivered at a fraction of the cost. So while we pay as much per insured as uninsured, we are delivering a lot more care in the first instance. It's the same way that Caleb Love scored about as many points as Tyler Hansbrough. One of them was a bit more efficient than the other . . .

Now, there are also distributional issues as to who pays in each case, and yes that was a significant issue under ACA and that's why some of the obscure financing provisions were in there.

Well, insured patients who get diagnosis and care early instead of waiting like many uninsured who wait until they are forced to do something are probably a bit cheaper. That's just a feeling though as is my prediction of a better overall outcome.

 

[TangledUpInBlue06]

Also, you should have proof of losses - either the losing tickets or contemporaneous receipts (something that very few people have).

Dealt with this in my law school clinic. IRS dinged the client for unpaid taxes on something like $80k of gambling winnings. The client didn't have half that to his name. Kind, elderly gentleman who just socialized with his buddies at the racetrack most days. He of course lost as much (probably more) than he won, but the issue was proving it. Figured out he had some kind of card issued by the track that he loaded money on and used to place bets. Got the racetrack to send us the record of transactions on the card. Those records came in the day I graduated and after I passed the case on to a new student attorney. Always been curious how is turned out.

 

[superrific]

In order for this hospital to make a truly informed decision, they'd have to know:

• Nearly precisely how many patients they'll be losing
• How much revenue those patients generate now and will in the future
• How much money they'll be subsidized from the government which means they ..
• Need to know how many medical facilities will be closing around the country....
• ...How much the remaining facilities will receive which means they also....
• Need to know how the federal government calculates subsidies.

Are you telling me they knew that within hours of the bill passing?

I guess we're doing this again?

1. They do not need to know "nearly precisely" how many patients they are losing. For one thing, all they need to know is whether it's too many. Think of it this way: if our football team is down 52-10 headed into the fourth quarter, we don't know precisely how many points we will end up with but we know we're going to lose.

Second, for high revenue businesses like hospitals, statistical projection methods work very well. If you have a million customers, and then next week you have 900,000, that's what you need to know. If it's 893,356 or 913,122 doesn't matter.

Third, in budgeting and all business analysis, the standard practice is to run projections on different base cases. for instance, in financial projections: you might run the numbers assuming a best case scenario of 3% interest rates going forward; an average case of 4%, and a worst case of 5%.

Put all these together and companies have a very good financial picture. They don't know exactly what will happen, but they know the likelihood. They can tell you with quite a lot of precision what their chances of survival are. For instance, they might know that they have a 10% of surviving. That's a piss poor likelihood.

2. You don't think the hospitals know each others' finances, roughly speaking? They do. They have trade associations. There are consultants who gather data. They know the reimbursement schedules, and the population in various areas. They know the doctors' salaries and staff salaries.

They might not know exactly which hospitals will close but they can predict accurately that it would be between X% and Y%.

Note: I don't know this for sure about hospitals per se, but I know this for a fact for other big businesses and I see no reason hospitals would be different given that they hire the same MBAs.

3. They do not need to know exactly how the government will calculate subsidies if they know it's not enough. I've read where the stabilization fund would have to be north of $200B. So no matter what the subsidy calculation, it's not going to cut it.

4. They know within HOURS because they've already modeled it. Hospitals employ hundreds or thousands of people in administrative/analyst roles. What do you think they do all day? Just because you pick your nose doesn't mean that's what everyone does.

 

[superrific]

Well, insured patients who get diagnosis and care early instead of waiting like many uninsured who wait until they are forced to do something are probably a bit cheaper. That's just a feeling though as is my prediction of a better overall outcome.

Like I said, the care delivered to insured patients is much cheaper. But because of that, they get more care, meaning that they are overall as or more expensive but the experience improvement dwarfs the cost.

It's like a basketball team where the leading scorer drops 20 a game shooting 35% from the field. The second leading scorer drops 15 a game with 55% shooting. The second leading scorer is clearly the better offensive player (all else being equal) but the first still scores more. Doesn't win more though.