palimp, it's not the tax breaks, it's the trickle down. The trickle-down eventually gets to the working class/poor. Not by a big margin, but it does. Which does help them, better than they were before at least. And, much better than they are currently-and unfortunately, in our near future. But, they WILL have healthcare. The middle class will not. Where will that middle class end up? Poor. But, at least their healthcare will be paid!

If trickle down actually Work, then How are you explaining that it somehow filters all the way through the middle class without having any benefit for them at all and then ends up benefiting the poor (eventually)? It's because it doesn't work. It's a fallacy.

So you believe in trickle-down, but you think it somehow trickles down to the poor and passes over the middle class. That's interesting.

FYI actual economists do not believe in trickle down. Even Forbes published "'trickle-down economics' is not real – it is nothing but pure, cynical rhetoric."

Gosh, I haven't heard that Reagan-ism (trickle down) in years! Did he also invent the "welfare queen", or was that another in the party he only espoused after becoming wealthy?

Yes, the "middle class" has been decimated -- but by "the one percent", not "the poor".

Who would want to be poor, just to qualify for whatever leftovers are 'granted' by the rest of Americans? That's the old self-congratulatory Manifest Destiny routine -- which foolishly ignores the value of public health for everyone.

" The economy for most people is much better when the leader is for trickle-down. "

" What I DO know is, that it is in fact much better financially, for me, and those around me. That is what I SEE. And, I think that is what most Americans SEE and FEEL. "

That, Oillie is because you're only speaking for people you're around .and you've previously described yourself in this thread as" higher middle class". Go back and read Lucille's comment. Have you ever spoken to those kind of people? Get out of your bubble.

Whoa, that is uncalled for IMHO, Elmer.

Please, Elmer . Reading comprehension issue??? People on boards don't put the kind of effort in their posts that they would if they were writing for a grade. And besides, my comment had nothing to do with her education or how well-read she was. It had to do with where she placed herself on the middle class income scale.

I came upon a cartoon image many years ago that I should have kept but I didn't. The caption said something like "My research and analysis suggests a major market sell-off will happen by late summer. You can believe me or not, at your peril." The image was a large dog sitting in front of a PC, typing.

The message was - on the internet, people can represent themselves to be whatever they wish to portray. Anonymity masks the truth.

" I think in trickle-down, the middle class benefits, and a smaller amount for the poor. "

You think wrong. It doesn't work, and it doesn't actually trickle down anywhere - it goes into the pockets of the executives and shareholders. In fact, a group of CEOs and company owners were asked if they would hire more people and provide more service if they saved money via tax cuts, and they all admitted that they wouldn't - in other words, they'd happily take the money from tax breaks, but they wouldn't pass it on in more employment or lower prices. It wouldn't trickle anywhere but into their own bank accounts.

a group of CEOs and company owners were asked if they would hire more people and provide more service if they saved money via tax cuts, and they all admitted that they wouldn't

Honestly, this does not make any sense, so I am not sure I believe it. The decision about whether to hire people or "provide more service" is based on the estimated risk-adjusted, after-tax return of doing so, relative to alternative investment opportunities.

The discussion of what type of policy measures stimulate the economy, which I think it what the question of trickle-down gets at, is pretty complex. It isn't really yes or no.

" this does not make any sense, so I am not sure I believe it. "

I'll try to find you the link to the video, but the question is whether money given to corporations will trickle down to the rest of society, not how they decide if they should expand employment or services....those are just 2 ways I know they claim it will "trickle down". And so you and I are both making the same point - that corporate tax breaks and bailouts don't result in those corporations providing more for people down the line, as the Trickle Down theory purports it will.

OllieJane, I hope you will remove your post from or two minutes ago immediately.

I'm not a moderator but if I were, I'd give both of ya' a time out. Cmon we can disagree without personal insults.

I was waiting to see if Elmer deleted his, and it looks like he did, so I will delete my comment.

Sheesh, you might want to ask the person to delete, who did the insulting first. That is how it works. Comprende?

I've missed the little dust-up, but I am wondering if Ollie Jane accepts that Trickle Down has been proven to be a jingoistic fallacy promoted by the 'class' that the theory serves.

Does anyone have stats on the various financial 'classes' of Americans over time? Is net worth the determining factor? (Is that too hard to determine?)

Someone mentioned that doctors’ residencies are paid for by Medicare. I asked my doctor about this at my appointment this week. She said that is not true. She and her fellow residents paid for their residencies. Perhaps some residencies are paid for by Medicare?

Tell me more about how much free healthcare the poor have access too? Because it's pretty obvious that the poorer the community is, the shorter the lifespans are. And we all know that for SO many households, it would take only take one major disease or accident to financially ruin them.

Your doctor is wrong. I wasn't able to find a clear cite for you but here's one, if you peruse it, you'll get the story. It's written by a professor at University of Tennessee Medical School.

Medicare pays for residency training

She and her fellow residents paid for their residencies.

I've never heard of this, at least not in the US. Here residents are paid a salary, although a woefully small one given the hours they work. The AMA website says: "The average first-year resident physician makes about $60,000...."

From the experience of a relative who went through an assessment of available locations to apply to, the salaries seem to range from the high- 50s to the mid-60s.

A residency (at least an internship, which is one year) is required for a medical license and a full residency for board certification in a specialty, even primary car ones (pediatrics, internal medicine, family medicine, etc). If you want to think of it as a Faustian Bargain, the training institution (either a hospital or medical school) provides supervised training that new grads require (that need to meet accreditation standards) and the doc in return agrees to work for a low salary. It's a fair deal no one gripes about. From the hospitals' standpoint, offering residencies provides essentially free physician resources, when considering the money underwriting they receive from Medicare.

Placement is competitive and based on board scores, letters of recommendation, other background factors and interviews. Better candidates get the more desirable spots.

Because it's pretty obvious that the poorer the community is, the shorter the lifespans are.

I am generally on the side of healthcare as a universal right. But I will say that not all of that is about health care. A few kids being killed by gang warfare for example can really bring down the average. There are a whole host of ills associated with poverty that impact longevity.

Perhaps my doctor and I misunderstood one another (or she was so exhausted during her residency that she conflated salary and living expenses.) If we misunderstood one another there, hmm hmm, what about the rest of my appointment?

It's a fair deal no one gripes about.

Well I wouldn't exactly say no one.

Physicians-in-training at top teaching hospitals across the country are joining unions, demanding higher pay and better working conditions.

The Committee of Interns and Residents, the largest group representing doctors in residency and fellowship programs, said it added chapters at five teaching hospitals last year and two in 2021, up from a prepandemic pace of roughly one a year...Inflation is high and workers are scarce, leading workers in many industries to push for better pay and terms....

“It’s impossible to disentangle the national labor movement from what’s happening among residents and within medicine,” said Philip Sossenheimer, a third-year Stanford internal medicine resident and union member. https://www.wsj.com/articles/medical-residents-unionize-over-pay-working-conditions-11673832067?st=g3klih939rtqcav&reflink=desktopwebshare_permalink

More than 1,400 residents and fellows at Penn Medicine became the first of their kind in Pennsylvania to pursue unionizing in February. They are among a growing number of medical residents exploring labor organizing nationwide, and the movement has spurred conversation among more veteran doctors about whether other groups of physicians could unionize.

https://www.inquirer.com/business/penn-residents-union-doctor-pennsylvania-philadelphia-20230228.html

Since I do believe that health care should take into account things such as poverty and violence, whatever the origins (abuse, gang violence. gun violence, suicide, etc.), when we talk about the average lifespan in a country, all those things must be considered. Poverty has a huge impact on health and lifespan. All those ills of poverty, imho, must be considered. The absence of decent grocery stores in our poorest areas, availablity of affordable fruits and vegetables, less well-funded schools, etc. often lead to shorter lives. Children with poor nutrition, living in lousy conditions, with little hope for a positive outcome in their lives have poorer physical health and more emotional and mental problems as a result of their socio-economic situations. "A few kids being killed by gang warfare" is not skewing the data. It is indeed an issue of good healthcare with a holistic approach and its availability to everyone.

" It's a fair deal no one gripes about.

Well I wouldn't exactly say no one."

Poor word choice on my part. My view - this is like someone moving to a home in an airport's takeoff zone and then complaining about the noise. There is much about the experience of becoming a medical doctor to dislike and take issue with. The vast majority accept what's involved.

Getting back to the concierge mode of care delivery, I find it hard to believe that in the middle of the night your MD is going to give you any treatment past telling you to go to the ER. Any practice has an on call MD that would give you the same advice for less money.

Popularity as an MD does not equate with skill. One of our docs was loved by her patients and very popular. Did you want her there when SH** was hitting the fan? Oh no way. Her skills and decision making ability were awful!

I am also assuming that a Concierge MD would not have hospital privileges so they would not round on you when hospitalized. Hospital privileges comes with things like ER call, committees, etc that many would not want. Those tasks are part of the reason behind switching to a Concierge care delivery method.

Wrong RN Mom. They do have hospital privleges. And, like any good physician, they would listen and then advise accordingly: Hospital, urgent care, or perhaps it doesn’t need either, but maybe what they need is an ice pack, Tylenol, or one of many other options. And, call back and let me know how you’re doing in however many hours, or whenever.

@LynnNM. I am assuming the privileges issue depends upon local. The few concierge docs in my city do not have privileges and when a new hospital system came to town, many docs relinquished their privileges because of the responsibilities that came with them. Having them at 2 hospitals was more than most wanted.

Docs in primary care practice rarely have "hospital privileges" these days. For whatever reason a patient is hospitalized, other than those in critical care where that specialty (or even pulmonologists) work, care is overseen by "hospitalists". This is true for surgical patients too. These docs are typically internists, some but not all of whom may have obtained additional training for the care of hospitalized patients.

Gone are the days when an internist would call on individuals from their office practices who become hospitalized, for whatever reason.

Lynne, if your husband was a primary care doc and called on hospitalized patients, it was either some time ago or in a smaller town where the shift to hospitalists hasn't taken place. It has in most cities and towns.

Do not get me started on hospitalists. Okay, get me started. Hospitalists regularly changed my mother’s medications and dosages while she was admitted. We always had to return to her various doctors afterwards to straighten things out. Ugh.

Just from a personal point of view, if I was ill in a hospital I would want to see a primary care I knew and trusted.

When I was hospitalized my concierge doc came to see me every day (not as part of rounds, just on his own in the late afternoon or evening.) And if my husband wasn't there at the time, he called him to ask if he had any questions. The guy is a gem, and I don't begrudge him a penny of his concierge fee.

My Mom also had a concierge doctor. She actually came to the house when my mom could no longer go out.

lucille, your expectation is unlikely to be the case unless your hospitalization wouldn't be happening in or near a populated urban/suburban area. Just for fun, ask your doc the next time you have an appointment if you would expect to see them if, for instance, you were hospitalized for an appendectomy.

Elmer, it is not an expectation.

Fine, then it's your preference or hope. I'll consult the OED next time. It still won't happen.

As for those hospitalized souls visited by their concierge docs, that's a kind gesture but I have to think (OED, expect?) that such docs didn't have privileges at the hospitals and other than being accorded collegial recognition as visitors, would have played no role in supervising the patients' care.

Elmer, you're no doubt right about that. However, if I had any concerns about the course of my care (which I didn't - the hospital was excellent all around) I would have been happy to have someone there who knew me and could advise me - a built-in second opinion, as it were.

I had to look this up but all MD's in a concierge practice are Primary Care Physicians. If you have something serious, they send you to a specialist. So why in the world would anyone pay $$$$ for a PCP? Common sense should rule.

I miss the days when PCP's could actually operate on us.

The doctor who is treating and admitting you to a hospital, does have privileges, because they are in charge of your treatment.

I guess you missed the conversation. Most primary care doctors don't have hospital privileges and as a result can neither admit patients to the hospital nor care for them when they're in. In-hospital care, even for surgery patients, is overseen by hospitalists. At over 75% of US hospitals, per a stat I found from a search.

In most instances you need a referral from a primary in order to make an appointment with a specialist. The primary may make an initial diagnosis but then determines which specialist you should see if necessary. If you have a rash the primary may be able to treat it - but if it doesn't go away, or spreads, or other symptoms arise the PCP then determines which specialist you should see- -a dermatologist, allergist, oncologist, neurologist......

That depends entirely on the insurance, maire cate. What you're describing is typical for HMO/managed care coverage and not common for less restrictive coverage like PPO and its relatives. I believe Basic Medicare coverage doesn't require referrals from primary care docs to see specialists.

Perhaps I could have been clearer. I wasn't referring to what an individual's insurance may or may not require. I'm on Medicare with a great supplement and I don't have any restrictions on who I may see. I was replying to Oakley's comment that it doesn't make sense to pay money to a concierge PCP since they just send you to a specialist if it is serious. You still need a generalist - like a PCP to make that determination.

The point I was trying to make is that you can't always bypass the primary and make your own appointment with a specialist. . Obviously that is not the case with every medical specialty. Certainly you can schedule an appt with a pediatrician or an eye doctor, or OB/Gyn. But in my experience other physicians rely on the primary's consultation to refer a patient to the appropriate specialist. This is especially true for many sub specialties - DH is a retired medical Hem/Oncologist and his patients were referred to him by other doctors.

On a side note - all five of the internists in my family practice group have admitting privileges. When I spent 5 days in the hospital after double knee replacement whichever doc was on call for rounds that day came in to see me. While the orthopod was in charge of any knee related issues and pain management, and the Physiatrist managed PT, my primary checked my general condition - checking BP or reading the chart for the nurses' reports, but also asking if was I eating, sleeping, getting up and walking etc.

The goal of hospitalists and intensivists are to keep complications, length of hospitalization, and risk of rehospitalization to the minimum, by rapidly making an accurate diagnosis (using specialty consultations and diagnostic tests appropriately), providing effective treatment, and prescribing follow-up.
Medicine has become so advanced and complex primary care physicians have become the specialists of out-patient care, with hospitalists and intensivists the specialists of in-patient care.

In our area, most specialists still require a referral from a PCP. Also, I mentioned before I don't have a concierge dr. We have an internist who is our PCP and he can admit us to the hospital and he and his group still do rounds. As far as wanting a PCP for everything, no thank you. Specialists receive further training in their field and I want the best I can find LOL.

The whole idea of hospitalists makes me ill. IME they are not top drawer physicians, and...they can't know YOU. You may also have several different 'paperwork honchos' during your stay. They work for the hospital. (We can't discharge you yet. There are some tests you haven't had!)

Chisue, yes! Your hospitalist might work the first day or two you are there, but then the weekend comes and you have someone else. It’s even hard when the nursing and support staff change, but the hospitalists are decision makers for you so it can matter.

edit: I know I’ll get called on ”decision maker”, but you know what I mean. The patient or their POAHealth makes the decision, but we do rely on the doctor’s advice in a stressful situation. And they prescribe.

@ chisue, I hear what you're saying. Hospitalists are the "general practioners" for hospitalized pts, coordinating specialty consultants.

Yes, the hospital generally employs/hires them or their group to provide care, just as they do nurses, pharmacists, physical therapists, etc.

In large, academic teaching hospitals (Chgo: Loyola, NMH, Rush, UIC, UC) and some smaller hospitals with interns, residents, and fellows (on the admitting service [medical, surgical, cardiology, orthopedics, etc.] will manage patients) you'll see less hospitalists.

In a couple of larger academic hospitals affiliated with medical schools where people I know have trained in recent years, residents and fellows do not manage the care of hospitalized patients without the nearby presence and direct supervision of a faculty preceptor/attending physician. Who, in both hospital's cases for the medical services, were hospitalists who were clinical faculty members.

We're one out of five with hospitalists at one major Chicago hospital (affiliated with med school) over the last three years. DH had the good one just before discharge. I had one flake who told me that she'd tested out of becoming a specialist and one who was completely overwhelmed -- neither the floor nursing supervisor nor the cardiologist could find him at discharge.