OT Property taxes

[trader_4]

What an outrageous lie. Even the CIA didn't see the collapse of the Soviet Union coming. Previous presidents had the policy that we just had to co-exist with the Soviet Union, that was the best we could do. Reagan had a totally different approach, we win, they lose and he set about with a plan to achieve it. He allied with the Pope to encourage the freedom movement in Poland. He got the USA out of the economic misery, restored our economy, so the people of Eastern Europe and Russia could see what a free economy and a great country can do. He rebuilt the US military at a pace the Russians tried to match, forcing them to divert more resources into a war they couldn't win, further undermining their domestic economy. He armed the mujahideen, bleeding them badly in Afghanistan. And through it all he called out the Russians for what they were, the "evil empire". He spoke of American exceptionalism, freedom, the evil of tyranny. He never let up, from day one, to the Berlin Wall speech. And it worked. He won the Cold War, the Soviet Union is on the ash heap of history, just like Reagan said it would be in 1982.

The Second Industrial

Another silly lie repeated. Reagan's policies were dramatic, the economy was recovering strongly in the early 80s. Huge numbers of jobs, 300,000

400,000 a month were created. The PC? It's numbers were miniscule in those years.

Another bold lie.

He was and is loved by most Americans. That's why he won in two huge landslides. If the times were so bad, Reagan was so unpopular as you claim, why exactly did Walter Mondale only win Minnesota in 1984? And at that point, the good times had just

*begun*. It accelerated in the next four years. Just the facts.

and was loved by big business

So, you think the govt should take 70% of people's income? Nuff said. We'll put that down as your number. I've seen lots of libs asked what that number should be, but they never will answer it. And keep in mind that 70% is just federal. Add in state, local, property taxes, sales taxes. How much is enough?

OMG. What total BS lies. In 1981 unemployment was 10%+. In 1989, it was 4.8%. Just the facts. Twenty eight million jobs were created. Month after month we had 300,000 or 400,000 good paying, real jobs created. One month we hit 1.2 mil. Why are you lying about that, instead of talking about what's happening today? Six years into Obama's recovery, economists are happy to see a jobs number over

200K. And we've only recently been getting even that.

Why the focus on Reagan? He's been out of office for 30 years. The reason is that you're desperate for *anything* to talk about instead of talking about Obama and what a total disaster his presidency has been.

[Kurt Ullman]

He raised the deficit? How does the Pres (actually any Pres.) raise the deficit when the Congress passes the budget and his ability to do much about it is limited. Especially after the political blowback from when he closed down the government.

See above. If you look at more than the top number, you will note after the first year, revenues were up to where they were previously and for the next 3 years or so (until the inevitable equillibrium that economic systems tend toward) the rate of increase in revenues was above what it had been in the 3-4 years before. If you look at the scoring from the CBO and Joint Committee on Taxation, tax receipts were almost double what was expected from the get go. Expenditures, on the other hand, accelerated as a percentage increase year over year. A big contributor to the deficit controlled by Congress.

Hardly. The taxation system (approved by the Dem Congress) added taxes but by law put them only in non-marketable government securities with NO mechanism to pay them back. The myth of bailing out SS is one that, in fairness, has been perpetrated across multiple generations of Presidents and Congresses of both parties. We have something like a127 trillion unfunded liability in SS alone.

The deal was that we would then "close off the borders" and it was to be a one time thing. It was part of a deal with the Congress (again studiously ignored by all parties, all Congresses, and all Presidents). Same deal during Bush with same outcome.

[Kurt Ullman]

Depends on the setting there is a long line of studies (from at 2000 forward) showing no differences in outcomes between alternate providers (NPs and PAs) in ambulatory settings. The same has held true for nurse gas passers and midwives. The outcomes from hospitalist and critical care isn't as robust. And so your personal experiences (the classic n=1 study) is enough to make policy on?

[Tony Hwang]

Really our local technical institute is very popular for kids out of high school. More than 90% gets hired in their trained field vs. university grads. Blue color jobs are in more demand and it'll be always. auto mechanics, plumbers, electricians, carpenters, etc. will have life time career or they can run their own business.

[Robert Green]

(translation: if you cherry pick the data)

Which is to say "their professionalism is at issue mostly when the stakes are high." I'd agree.

Jeez. When did I say or write anything even closely resembling my desire to let my few personal experiences direct public policy?

[Kurt Ullman]

Not all , Oh Great purveyor of n=1 studies as gospel. Merely, as I went on to note, they work in some specialties than others. Not really all surprising.

Of course that isn't at all what I said. Professionalism has nothing to do with it. Some place require more intensive education than others. This is reflected in the relatively longer residencies for docs in surgery, etc. Although, now that you mention it, I probably should have elaborated that they aren't as robust largely because NPs are newer to the area and the long term research hasn't been done yet.

Get back with you in a minute on this. You snipped the part I was responding to and I can't call the old ones up with this window open.

[Kurt Ullman]

These NP/PAs are typically "sold" as doing things that it's too expensive for doctors to do, but in**** my experience ****many clinics and doctor's groups use them as much cheaper direct replacements for licensed MDs. *** The NP that my doctors use didn't impress me at all. She told me things about the meds she was prescribing that were just flat out wrong. Her understanding of my medical issues was weak, to say the least, and I was about to file a complaint with the medical board when they switched me back to an actual MD who had at least 10 years' more experience and education.****

Nothing here about any actual research you had done into the thing, but heck you are more than willing FROM YOUR EXPERIENCE to suggest that they are only being used for their cheapness.

[Robert Green]

OK - I am still waiting for the part where I want to "direct public policy." I am not sure how you translate my relating my (and my wife's) experience with nurse practitioners as my somehow wanting to "direct public policy." I think that's a stretch at least as long as Rosemary Woods made with the Nixon tapes. (-:

Or is there some issue with my being sad about it? I can't quite see "being sad" about the shift away from MDs to PA/NPs as a desire to "direct public policy." Is there any doubt that's the direction medical care in the US is trending? More PAs and NP's? And that both groups are working very hard to get greater autonomy and less oversight from doctors?

You'd probably be surprised to learn it's a trend I support in many ways but it needs to be implemented properly and from what my wife and I have seen and what we've read about it's often NOT implemented well and patients get sub-standard care. YMMV.

You're also a nurse, which could color your thinking about nurse practitioners a tad. I have no such dog is the hunt, only the experience that my last NP was fighting way above her weight and it showed. As soon as a doctor got on the case, the problem went away. I also had extensive discussion with my GP/MD about NPs and he had some serious reservations, too, about the delta in training and experience.

I've been told (but have not verified) that Medicare *requires* a licensed MD to be on site at one clinic I visit even though most patient interactions are with NP's who have narcotic prescribing authority in my state.

As for the studies showing NPs do just as well as MDs: "Physicians say this study is hardly the last word on the debate. An article published in the American Medical Association Journal of Ethics early this year said the jury is still out on whether nurse practitioners are as effective as doctors - and that previous studies on the topic, including the 2000 JAMA study, were lacking or incomplete."

As NPs strive for fewer restrictions and the ability to work independently, who's to say the outcomes won't change drastically (for the worse) when the doctor is not present to handle emergency cases? It's quite a contentious subject in the medical field as I am sure you know. It will be interesting to see how it shakes out since the need for GP's in the boonies is only increasing and the supply falling way short of demand.

Still, I think it's a little "hopeful" to think NPs can hope to replace MDs, even for general practice work. From the same article:

"even the most skilled advanced practice nurses receive just a fraction of the medical training family practice doctors get - a maximum of 5,300 hours, compared to doctors' 20,000 hours, according to an analysis by the American Academy of Family Physicians. And they don't go through grueling residency programs like doctors do, the physicians say, leaving them less prepared to handle emergencies or unusual conditions."

Fifteen THOUSAND extra training hours has to mean something, and from what I've seen, at least *some* NP's aren't up to the tasks they have been assigned to.

[Kurt Ullman]

I haven't been a nurse for over 10 years now and since I have a lowly AD degree in nursing it is no skin off my nose.

Not actually. Those are mostly state requirements and they vary widely from having a doc to oversee to not. Medicare pays NPs two ways. If they want to bill under the doc's MCaid number at 100% of what a doc would get, then the doc has to be on site (which makes sense). If they bill at the NP rate of 80% of the docs rates then they don't have to be onsite.

And yet you call MY merely having the initials coloring my thinking? Heck under that criteria, maybe you should be running in the other direction screaming. (grin).

Largely contentious on both sides beause of the money involved. Also, it is contentious (and deservedly so as I pointed out) in some of the more specialized areas such as ERs, ICUs, etc. We'll see how the research works out. In those areas I think there will be a hierarchy established of what patients/duties the NP can safely undertake. Much to the chagrine of the NPs, docs call the field (PA and NPs) physician extenders. I think that will be more of an apt description in hospital than in the community.

Which constitute a breathtakingly small percentage of the patient population (especially in FP situations). As for grueling residencies, there has been no differences in outcomes between newly minted docs (who did their residency under an 80 hour week restriction) and docs with 10 years or more experience who did their residencies under the old essentially unlimited hours experience. (Although to my mind, the most interesting part was the seeming lack of difference I would expect just because the older doc has 10 years of experience... but I digress.) You know if it was any other endeavor, residency would be classified as hazing.

Yeah and you haven't ever run into an incompetent doc anywhere.

[Robert Green]

Since when is research required to express an opinion based on my personal observations and interactions? That's what "in my experience" means.

Nurse Ullman, are you sure you're not all charged up because as a nurse, you naturally respond on a more personal level than non-nurses to criticism of your comrades, especially their competency?

"Only?" From what I actually wrote: "in my experience *MANY* clinics use them as much cheaper direct replacements for licensed MDs."

If I had meant to say that's the *only* reason they are used, that's what I would have written. We're talking about my experience in an urban setting which is very different from the rural world. I know that NP/PAs are filling a valuable need in rural areas where the free market model fails to provide adequate general practice medicine. GP MDs couldn't make enough money to set up rural practices and it was a serious problem, one that NP/PAs are *poised* to address.

Until recently the jobs that NPs and PAs are doing could ONLY be done by MDs. You'd have to really bend reality to deny the reason for the existence of NP/PAs is primarily an economic one. That makes "cheapness" just a part of the package and impossible to avoid when talking about NP and PAs.

Big clinics, especially urban and M/Care/Aid ones, are coming more and more to depend on NP/PAs for a majority of staffing, having only one on-call MD there to cover 100's of patients. At least based on what I've seen and read. Citations to be compiled later today when I am at my desk. (-:

Historically NP/PAs were VERY restricted in their duties. Many had no or very little prescribing authority. Many states require that they work under close supervision of a sponsor doctor, etc. Doctors, as you can imagine, are not very excited about a new class of cheaper workers taking the jobs that they once had legally exclusive rights to.

The problem is that NP/PA rates are cheaper for a reason. They typically have 1/4 of the training of an MD. In the case of my NP, far less. Worse, still she appeared to have no certification of substance in her field.

I actually did quite a lot of research about NPs when preparing my complaint. This was the first NP I've run into that wouldn't escalate my concerns to an MD and who was just flat out wrong about a number of pretty well-established medical facts. I am perfectly willing to believe this NO was an exception, because I've worked with plenty of other NPs without incident or concern.

I find a world of difference between a medical professional that admits they don't know something and have to look it up and those that *think* they know something, but what they know is wrong.

There are some fascinating cases on file that I came across while researching NP's in pain clinics. One of the real dark sides of NPs is their growing use to run pain pill mills. A nurse practitioner is hurt far less by a suspension of their license (or more often their narcotic prescribing authority) than an MD would be. I'll try to find some of those cases since you're so interested in how I got to my opinions about NP/PAs.

[Scott Lurndal]

Expressing an opinion, and drawing a conclusion are two different things. You could have described your experience(s) with an NP and nobody would complain. Applying those experiences to NP's a a whole, well that's drawing a conclusion on a surfeit of fact.