A future without ACA?

As predicted by Ezra Klein:

I think that path would look something like this: With health-care reform either repealed or overturned, both Democrats and Republicans shy away from proposing any big changes to the health-care system for the next decade or so. But with continued increases in the cost of health insurance and a steady erosion in employer-based coverage, Democrats begin dipping their toes in the water with a strategy based around incremental expansions of Medicare, Medicaid, and the Children’s Health Insurance Program. They move these policies through budget reconciliation, where they can be passed with 51 votes in the Senate, and, over time, this leads to more and more Americans being covered through public insurance. Eventually, we end up with something close to a single-payer system, as a majority of Americans — and particularly a majority of Americans who have significant health risks — are covered by the government.

One question is whether having both Medicaid and Medicare (and other programs) function as a “single payer” system, but that is arguably semantics.  In any case the American system is likely to remain fragmented.  I am also not sure if this process would take a decade, as sometimes a single election cycle can feel like an eternity.  In any case, I see that as likely a superior outcome to the current ACA track.  I have never thought that a mandate is workable in a fragmented system with employer-based care and high health care costs and high income inequality.

I also would not be surprised to see Romney, if elected, and if ACA is struck down, resurrect some version of the McCain health care plan with tax credits, maybe some more federalism, and less of a Medicaid extension than was in ACA.  I don’t know if that would pass but I suppose I think not.  I also don’t see much hope for a much-needed “supply-side” competitiveness plan.


If the mandate is unconstitutional, I don't think any federal health care can successfully use the private markets. Adverse selection kills them all.
That includes Paul Ryan's plan for Medicare, it would seem.
But given the Democrats' experience in 1994 and 2010 (lost 117 seats and two House majorities), I wouldn't expect a lot of further dabbling at the federal level.
More at:

Very good link.

Terrible link

Again, you force people to give something away, other people will take it and not pay. Hey, I'm Jesse Jackson!

Next you have to say "well, Americans don't want to let people die in the street blah blah blah..." because you never want to address the logic you have to then jump to the safety in numbers logical fallacy. "Hey, all these other idiots vote!"

This is you guys' argument in full:

"We MUST give medical services for free, therefore, since we can't charge, we must give medical services for free."

"Everything else lacks a way to coerce consumers into the market"

Good link?

Would you please, please just listen to YOURSELVES for 15 seconds?!?

OK, I'll break in line here, since a scan of the 68 comments so far didn't turn up any discussion of state-by-state reform, in the event ACA falls. Seems odd on MR, to forget that possibility! I saw a quote from a Washington State state rep the other day saying that is where all the action is now - lots of states have reached out to, e.g., Johnathan Gruber, for ideas. Tyler suggests the individual mandate is a tough sell in a "fragmented system with employer-based care and high health care costs and high income inequality." One might predict that states with less income inequality, and perhaps "Massachusetts-type" politics might lead the way on this. Brandesian laboratories could deliver some interesting test cases on, e.g., the effectiveness of carrots (limited sign-up windows, catastrophic care-only mandates) as opposed to wimpy sticks, serious cost control, and so on. Personally, I love the Massachusetts system, and used the exchanges for a few years in-between having group coverage. I wouldn't be surprised to see a band of states from the upper Midwest to Washington and Oregon doing their own variations rather quickly.

A mandate isn't the only way to prevent unraveling of the insurance market. Non-coverage of pre-existing conditions will drive risk averse people into the market, also shifting to a high deductible paradigm (i.e. health insurance actually acting like insurance) would reign in a lot of the price inflation going on. You could also increase the supply of doctors through increasing internship slots and reducing regulations (like allowing physician assistants write prescriptions for basic maladies like colds and the flu.)

And, like Andrew' said below, if you're going to force providers to care regardless of ability to pay, an ex post loan program would work as well, it doesn't have to be pre-paid insurance.

There is no reason for the health insurance market to equate to the health care market.

Has, It would seem you cannot ignore the fact that hospitals have to provide care, in which case no coverage for pre existing conditions rule you posit would still motivate people not to buy insurance.

In fact, we have today what you propose, and we see people Not getting insured, but instead free riding.

What we need is to give medical providers the right to repossess for non-payment, like cars are repossessed if you can pay for the car or for fixing it.

Euthanizing the deadbeat patient and selling the body parts will be one option for recovering costs, or put them into indentured servitude.

In a free market, the work done by the medical system needs to be given property standing and treated like property.

The prospect of being dismembered for failure to pay all medical bills would deter dead beats and force patients to be responsible and comply with commerce contracts.

Not sure if Ayn Rand...

...or just trolling.

Mulp is the rare bird that can fail every ideological Turing test, Fry. But yes, this is him trolling.

"If the mandate is unconstitutional, I don’t think any federal health care can successfully use the private markets."

Of course it can. The Obamacare mandate is unconstitutional because it's a coercive penalty, not because of what it's trying to do.

It's my understanding that there would be nothing unconstitutional about Congress raising personal income taxes and then offering a tax credit for having a health care policy. It's no more remarkable than Congress offering a $7,500 tax credit for buying an electric vehicle.

Throw me in with the lot that doesn't understand how one is constitutional and the other isn't despite being the same thing.

Also, throw me in the lot that thinks Obama shoulda just called the damn thing a tax in the first place.

It's legal for Congress to provide an incentive to do almost anything. Congress can effectively pay you to do something.

The Constitution specifically restricts the Federal governments ability to force behavior to pretty narrow areas. Congress can not say you must do something or we will fine you.

Right, Scalia ruled that Congress can mandate Ms Raich buy government dictated drugs to treat her medical condition from government dictated suppliers from government dictated lists of drugs, and is prohibited from not buying drugs by producing her own, and not buying the drugs she wants from the suppliers she wants, because treating her medical condition in her own home using her own home made drugs is necessary to regulate interstate commerce.

But let's be clear, she wasn't mandated to buy the drugs, but she had no alternative to buy the drugs because not buying is illegal. And she not only pays a tax, and a fine for not paying, or for paying the tax, but she could go to jail for not buying the drugs dictated by Congress instead of not buying those drugs and producing her own.

mulp is correct. It all has to do with the glories of federalism, or something.

What about people who have no income? Or income of less than $7,500?

Why am I the only guy talking about how a mandate is pre-pay while there are loans and post-pay options?

In fact, isn't a mandate the worst form of payment? No accountability. No economic rationalization. No liberty, not that that's important...etc.

Suppose you passed a law saying there will be a more or less universal $600 additional tax on everyone's income tax returns (perhaps with some exception for those who earn little or no income). But you can claim a tax credit for any premiums you pay for health insurance either directly or via your employer up to $600. Vola that's the mandate and guess what, if it is unconstitutional then it's just as unconstitutional to have tax credits/deductions for mortgages, charitable contributions, adopting a kid and so on.

That's fine.

My point is we don't need lawyers to answer this question.

Btw, when did it become:

"hey, we have to pass it to: find out what's in it, whether it's a good idea, whether it's legal"

If that's what it is, what do we need these people for?

I realize half the people are opportunistic DBs, but the rest of us should have a policy of "it's it's even close to the edge, back off and come back when you have a better idea. Not to mention, you have a little Greatest Recession you might want to think about a little."

It's a good question. I would guess - but I could surely be wrong - that the main distinction is that those deductions currently go against whatever tax you may have, and you can not engage in those activities and still manage to keep your tax burden down, all the way to zero, in other ways. The mandate is strictly buy-or-pay, and is written so.
If the president levies a surtax on everyone of $1000 and then offers an additional $1000 credit for health care, it might come close, but unless the two were tied together, presumably there would be ways out of the surtax unrelated to health care, etc. Does this make sense?

Sorry to say, no it doesn't. First of all the 'mandate' doesn't apply to someone with no income at all so it is tied up in the income tax (plus the law explicitly states that while the IRS may collect it by sending out bills or lowering refunds, it can't file criminal charges, can't file leins on paychecks or property etc. That's quite unlike a fine for a criminal act which technically has to be paid whether or not you have income).

But how about this, suppose you ditched the $600 tax increase and just said you can have a $600 tax credit for buying insurance either on your own or via an employer. Same thing. If you don't opt to buy, you're $600 less well off than your identical twin who does. But then if you strike that down as a 'mandate' you must strike all tax credits and deductions.

Man, you should have told that to Verrilli. We could have avoided three days of debate in the highest court of the land if only he knew!

The _mandate_ requires you to purchase a specific subset of health insurance policies if you don't otherwise have one that qualifies.

The _penalty_ is collected by the IRS from certain people who aren't following the mandate.

You could remove the penalty portion of the law completely and the mandate portion would still exist and still be unconstitutional.

You are confusing an enforcement mechanism for the law (the penalty) with what the law requires people to do.

If you change it to a tax break if you own qualifying insurance, you can not own insurance and still be obeying the law, you just don't get the tax break.

Would people ignore the law a lot more if there was no penalty? Sure, that's why they put the penalty in there, but that doesn't change what the law requires, just how well it will be enforced.


That you need a specific type of insurance makes no difference. To get a tax credit for donating to an IRA you need a specific type of financial account/product.....likewise for many tax credits you need to do very specific acts (i.e. buy a car with so many mpg, put solar panels on your home, donate to an organization registered as a charity or non-profit etc.)

You could remove the penalty portion of the law completely and the mandate portion would still exist and still be unconstitutional.

I disagree. The law says you are free to choose to go without insurance and pay the penalty. Going without is not actually illegal. In contrast, consider getting a $25 ticket for letting the parking meter run out. That is illegal. You technically can't treat the $25 fine as a fee you're free to pay if you just don't want to run out with an extra quarter. If you disagree please cite the actual language of the law that you think says otherwise.

That'd be Constitutional, because Congress's power to decide how to levy income taxes is pretty much plenary; provided it doesn't violate any enumerated rights (eg, I don't think an extra 20% income tax on Episcopalians would fly because of 1A concerns).

The mandate, though, was shoehorned in through the Interstate Commerce Clause. Is Congress's power to regulate through the Commerce Clause power plenary? Well, almost, but the Court has set some (pretty indistinct) limits in the past, and we're about to find out exactly how meaningful those limits are.

So if your point is that a policy could've been enacted with more or less the same effect of the mandate but through a more obviously Constitutional way, the answer is yes. But it wasn't.


I think you're confusing rhetoric about the mandate with the actual text of the law. Rhetorically claiming the mandate operates via interstate commerce is more appealing than claiming it's a tax increase (or a type of tax), but that doesn't magically alter tha language of the law itself.

The law itself seems pretty clear. It is not against the law to not buy health insurance anymore than it's not against the law to decide, say, not to adopt a kid even though doing so will mean you can't claim a tax credit for adoption. In fact, the word mandate doesn't even appear in the law.

Let me toss this question to you, as the law now stands can a lawyer ethically advise me if I don't want to buy health insurance to not do so and pay the $600 tax? I say he can, but then it's not really a mandate. Ethically a lawyer can't advise one to break the law even if the penalty is minor.


If the the two methods were truly equivalent, why didn't the Democrats do exactly that? It isn't like they weren't aware of the arguments that were being made against the mandate's constitutionality prior to passage of PPACA, but still chose to take that path rather than one based on the taxing power of Congress, and now have endangered their entire enterprise.


Laws do not say which 'path' they are taking. The law says what it says, what pundits, commentators, and lawyers say is essentiallly noise. The law directly states the IRS collects this penalty, cannot use criminal law to go after it, cannot even use civil leins and garnishments to get it. That's not a fine, not a criminal code, that's a tax. Just because politicians like to describe it as commerce regulation for the cameras has nothing to do with that fact.


Democrats explicitly defined it as a non-tax when they drafted the bill. I realize the administration tried this week to have it both ways, but the history of the bill itself, and the comments of it's proponents in Congress, were quite clear that the penalty was not a tax. Again, I ask you- if your proposal and PPACA were truly equivalent, why did the Democrats design it the way they did? I assert the two methods are not equivalent. How you go about implementing a desired policy really does matter, even if the end results can't be distinguished from one another. The Democrats in Congress clearly realized this, but they took the constitutionally risky path in order to be accused of raising taxes via the mandate. They may now pay the price for this gamble.

I've heard the conspiracy theory that the Democrats liked and like the existing health care system just fine, but as the party that brought in Medicare and Medicaid, were pressured by their supporters to "do something" about healthcare. So they "did something", in a long complex piece of legislation that no one understands, but which contained at least one poison pill to make sure it got struck down by the courts. If you ever read Walter Karp's "Indispensable Enemies" this line of thought will no longer surprise you.

An alternate explanation is that they were really scared off by the threat of a tea party like event by including anything that looked like a tax increase, but wanted a tax increase, so stealth tax increases that risk being unconstitutional. The first explanation makes the Democratic leadership more Machiavellian than they probably really are. The second explanation makes them dumber than they probably really are, since their actual course of action brought them the tea party anyway.

It's probably partly because they people they want to "coerce into the market" don't pay much taxes.

Oh, and it's actually worse philosophically as a tax.

Either way, you are simply forcing one group of people to pay for another group of people, explicitly the people who don't use free medical services to pay for the people who do use them. It would be very easy, I could name 10 ways in 10 minutes, to make people who actually use such a service to foot the bill.

In fact, every other industry manages just fine. Why does the government suck so much?


You seem to have an interesting theory of law going on here. Because Democrats didn't talk about taxes, the bill doesn't have taxes. No need to actually read or think about the actual real life bill, it's what pundits said about it!

Suppose Congress passed a bill that said anyone with the wrong religion would be shot in the head....but instead of calling it a bill to infringe upon religious freedom it just calls it a tax on brains. Does that magically make it constitutional?

Congress has broad powers to tax. It does not have broad powers to institute penalties based on the Commerce clause. Democrat's could have chosen the tax route, they didn't. That was a mistake.

Well, I keep trying that too. The only answer you hear for that is 'but ER is free'!

We have a bunch of "(semi)-long bets" up on a chalkboard in my office; one of the them is for the outcome of the current Supreme Court health care trial. (The options were: entire ACA upheld; mandate struck down; entire ACA struck down.) I bet that the mandate would be struck down.

I think single-payer is coming in the medium term (< 10 years). I just don't see how you can have a self-consistent free-market-based health care plan when the country has decided it's not willing to let people go without health care (in the extreme, this means denying them critical care at a hospital if they can't pay).

My own philosophy (strongly in favor of single payer) is based on two axioms:

1. Health care is not like other goods. It's not like buying a TV or a car or a vacation. It's access to life itself, and thus has essentially an infinite value to an individual. I'm not sure how to express this in the proper economic terms.

2. People not taking care of themselves has negative effects on everyone else. In this way, health care is like firefighting. There is a lot of hand-wringing about personal responsibility when it comes to paying for health care but society long ago decided that that wasn't going to be a factor in whether or not the firemen extinguished your blazing house. Doesn't matter if it started because of a lightning strike or a careless cigarette.

Would you like some feedback on your axioms?

Sure. (I assume you disagree with them.)

At critical margins, degrees and thresholds. I could get into the specifics, but the first question is why do your beliefs even if held by a majority preclude any tolerance whatsoever of a mixed medical economy?

Specifically, for example, if I had a good high-deductible insurance with a well-funded health-savings account what's the problem?

Besides the fact that your hospitals and your insurers will shy away from being those hospitals which find themselves obliged to provide emergency care for free anyway, leading to a massively inefficient bureaucracy dedicated to an unending race to be ever so slightly more inconvenient than other hospitals in providing care for undesirable demographics?

If your answer to "we should have a social insurance system" is "but I save a lot for myself, so I'm not going to accept any of your proposals", you will not have compromise of a mixed savings system, because the political coalition that eventually puts the insurance system into place - and there will be one - will not include you.

There's nothing wrong with a good high-deductible insurance with a well-funded health-savings account. Obamacare actually allows for that - it would be a bronze plan, covering 60 percent of expected health-care outlays.
In fact, a lot of private companies are shifting to those plans right now, assuming they will be acceptable plans in 2014.
Also, there's nothing in either my msg. or the post I linked to that said the Supreme Court's decision is right or wrong, just or unjust. I simply say that if you throw out the mandate, it seems like there is no federal solution to the health care problem that can involve the private market.
I also point out that Paul Ryan's Medicare solution seems equally vulnerable to adverse selection.
If either of these seems wrong, I'm interested in hearing alternatives. I suspect most people want to hear them as well, as government-run single-payer is not especially popular in this country.

Doesn't the ACA get rid of HSAs?

"Doesn’t the ACA get rid of HSAs?"

Yes, it does.

PPACA provisions:
Effective by January 1, 2014
"Set a maximum of $2,000 annual deductible for a plan covering a single individual or $4,000 annual deductible for any other plan"

Spoken like someone who has never experienced the horrors of single-payer medicine first hand.

Single-payer sounds convincing to people in the abstract, but when you have to deal with the blood-spattered emergency room walls and care based not on patient need but on demographical "cost effectiveness research," then you quickly change your tune. If you *don't* change your tune, then I submit that you are not actually a very significant consumer of health care. For people with chronic conditions, though, there is no comparison.

So I'll respond to your axioms with an axiom of my own:

ANYONE who advocates for single payer health care should be forced to endure it for the rest of their lives.

"If your answer to “we should have a social insurance system” is “but I save a lot for myself, so I’m not going to accept any of your proposals”, you will not have compromise of a mixed savings system, because the political coalition that eventually puts the insurance system into place – and there will be one – will not include you."

Yeah I already know democracy sucks. That's a known issue.

What about the logic?

"Besides the fact that your hospitals and your insurers will shy away from being those hospitals which find themselves obliged to provide emergency care for free anyway, leading to a massively inefficient bureaucracy dedicated to an unending race to be ever so slightly more inconvenient than other hospitals in providing care for undesirable demographics?"

This is a non-sequitur. For one, emergency care is cheap. We've legislated that emergency rooms are now clinics. Set that aside. There are plenty of ways to provide emergency care (even under the current meaning of free clinic) and then make sure that the person who agrees to accept service, even implicitly, is billed for the service. That is exactly what the mandate is doing, except without the implicit agreement.

"For one, emergency care is cheap."

What the? Have you ever been to a hospital? I promise you'll be utterly shocked at the bill you receive, even if you have "gold-plated" health insurance.

Ryan - this is how a lot of Americans see it, having heard horror stories from single-payer systems abroad. But it is interesting that you mention chronic conditions. The UK system is single-payer and is closely attached to nursing care / caring staff also provided through the government. My mother has a chronic and progressive condition, and she has extremely good care at home provided free, with flexibility for her family to make decisions about hiring care staff and prioritizing her needs, while still offering a care manager so that the family need not take on all the work, etc. She also has doctors and medication for free, including many visits per year to general and specialist professionals. She has not received cutting-edge medicine, but she would not in the US either - trust me, I've done a lot of research, it simply does not exist.

Now, one can argue that the UK is not producing as many new medicines and technologies (though I am not sure the data back this up very much - the basic research in the UK is very top quality, even if there are fewer pharmaceutical companies). But I don't think that the care offered and the conditions in the hospitals are quite what the horror stories indicate. They make a huge splash every time they happen, but that does not mean the conditions are actually worse than in the US. I've been in emergency rooms in the US (yes, I know, those are the most 'socialist' part of the US system) where it is not single-payer, and they are bad. I've heard about wait-times in the UK, but in general I don't see it. There are good and bad, but I don't think it's obvious that single-payer must produce terrible results.

That said, I would not want to see the US attempt to create an NHS right now -- it is a huge country, there would be a ton of bureaucracy, there would likely be little oversight or transparency, etc. Single-payer can have a good outcome, but it should come about through democratic vote in a country ready for it, and small enough to put it into place efficiently and effectively. I think this possibly could be done at the state level in some states, and in some states perhaps universal insurance would work better instead. I'm not sure.

Frankly, I don't care. I've seen the blood spatters with my own two eyes and have been in bad emergency room situations more times than I care to elaborate on. This becomes a game of, "Who are you going to believe - me, or your lying eyes?" If you don't believe the horror stories, then fine. I have no interest arguing over whether or not my experiences are real.

At the end of the day, I have seen both systems and I am moving out of Canada, back to the USA, where my condition can be treated effectively, at least for the time being. If people want to play dumb and imagine socialized medicine to be a panacea, and ruin what little chance the USA has to make things right, then I will just move again. I simply will not subject my health to the wishful thinking of advocates who have no idea what they're talking about.

It is so comforting to see someone ready to generalize based on their own particular experience. I've had plenty of unique experiences that I would love to generalize on - for example, I once bought a stock and it went down in price - therefore all stocks go down in price. Would you like to hear some of the horrors I've seen in our beloved multi-payer system?

Dale, you're free to generalize on your own experiences all you want. It is actually far more rational to do that than you imagine that you'll be better off with a system with which you have no experiences! Seriously, is this even a discussion? Of course you should base your opinion on your own experiences! What else would you do?

You are also free to advocate single-payer and ruin the US system. If you do it, I will vote with my feet. Again. I simply will not subject myself to any more of this silliness.

P.S. I spent the last few years working as a health economist, so it's not as if I'm going by two isolated incidents or something. I'd suggest that health economists who have chronic conditions and major health care consumption costs in multiple countries have a pretty compelling view of comparative health care systems, wouldn't you?

I'm curious, Ryan. If us Americans "play dumb" and "ruin" healthcare here, where is it exactly you'll move?

I'm actually more curious what the actual cost of the repatriated Ryan's health care will be in comparison to his personal out-of-pocket costs. Assuming he's employable and therefore covered by insurance, It doesn't sound like we should be excited to dive into his new risk pool.

You should probably explain which single-payer system you're referring to here so that we can potentially learn from it.

Because I've dealt with the Soviet and UK health care system, and while they had various deficiencies (and the Soviets were pretty deficient what with re-using needles and all) - there were never blood-splattered emergency room walls. The level of competence over-all was at least as high as the US, and ease of getting an appointment and emergency care was on par or better than the US.

Why should I cater to someone waiting for a list of exceptions? "Oh, well Canada does X wrong, so that doesn't count.... Oh, well the USSR did Y wrong, so that doesn't count... Oh, well Cuba does Z wrong, so that doesn't count... Oh, well the US VA system does W wrong, so that doesn't count..."

Seriously, what evidence will anyone ever accept? What "counts?" There is no point in debating a topic if people hand-wave away all evidence.

So you are not going to tell us which country you were referring to!

doug, read my other comment above, or click the link on my name to visit my blog and profile. I haven't exactly kept it a secret...

So instead of just telling us the single payer system you are referring to, you're ... pimping your blog? I have a word for liberals who act like that, but this is a family establishment.

MD, I'm not a liberal, and I already came out and said it was Canada, right here on MR. Here, here's the quote:

At the end of the day, I have seen both systems and I am moving out of Canada, back to the USA, where my condition can be treated effectively, at least for the time being.

From my comment having timestamp: March 30, 2012 at 10:10 am

What exactly is the problem here?

Have you no more than mere anecdote. And even that only vaguely hinted.

Health care is not like other goods. . . . It's access to life itself, and thus has essentially an infinite value to an individual.

Maybe we should start by examining whether this axiom is actually true. It seems to me that treatments where it is as simple as, "If you get the treatment you live, and if you don't you die," are the exception rather than the rule. For more speculative treatments, or for treatments whose benefit is not longevity, but an improvement in quality of life, demand is only infinite if someone else is paying. The problem with the mainstream solutions on offer, one and all, is that they aim to ensure that it's always someone else paying, which seems to me akin to fighting a fire with a fire hose that sprays gasoline.

People not taking care of themselves has negative effects on everyone else

Lots of things people do have negative effects on other people. Only a very small subset of those are actionable. Most of the time we shrug our shoulders and say, "Yep. Hell is other people."

In this way, health care is like firefighting.

If you start with a bad analogy as one of your axioms, then you're going to reason to a bunch of completely worthless conclusions. For instance, health care is unlike firefighting because the risks posed to the public by uncontrolled fires are much larger than those posed by individuals not looking after their health. If I let my house burn down, your house might burn down too if it's close to mine. If I don't control my high blood pressure, it's not going to cause you to get high blood pressure. (On the other hand, for certain communicable diseases, the analogy holds a lot better. The lesson is that while there is such a thing as "public health," most health care issues are not public health issues.)

There ARE things like firefighting. That doesn't mean government has to do that OR firefighting.

But even setting that aside, why not look at the parts of medical that are like firefighting and then leave the other ones alone.

Vaccines already ARE NOT handled in hospitals, and those don't have to be.

In this way, health care is like firefighting

For things like communicable diseases, sure.

But most other health effects are easily isolated.

"Health care is not like other goods. It's not like buying a TV or a car or a vacation. It's access to life itself, and thus has essentially an infinite value to an individual."

This seems right at first glance. But if it were true, doesn't that suggest that people would automatically spend the first __% of their income on getting health insurance, no matter what? After all, if it has infinite value, it's the first thing you'd buy, price be damned. But that's clearly not the case.

So maybe it's a case of people treating it as if it has infinite value only when their backs are against the wall. Which is the very definition of the adverse selection problem.

It's only treated as infinite value when infinite resources are provided.

Of course that argument makes no sense. If "life" had "infinite value", then why would anyone do any overly dangerous activity (riding a motorcycle, skydiving, driving while distracted/intoxicated, eating Big Macs daily, biking without a helmet, etc.)?

It actually worries me a lot that as health care becomes more and more publicly-funded, that we will restrict such activities as well, since the costs are no longer borne by the individual.

I don't understand why people keep ignoring the very real fact that in absence of a "government solution," health care practitioners have been gradually refusing to work with insurance companies. Evidence: Google it. There are countless news articles buttressing the case for non-insurance health care solutions; these articles obviously waned once the ACA was passed, but prior to that the whole idea was picking up speed.

This is a "problem" that will fix itself if everyone just agrees to leave it alone. But under the auspices of "helping people," we are going to keep getting these insurance company protective measures from the federal government. Argh, my head hurts.


And there's plenty of news stories about doctors refusing to take Medicare. But then there's also plenty of stories about people opting to 'live off the grid' and not have electricity in their homes. That makes for interesting news stories and supplies plenty of ancedotes but I'm not going to short stock in the electric company because 'Amish-chic' is going to cut into their sales anytime soon.

What such stories miss is the new doctors and other health care providers who enter the market every year who take many types of insurances because even though they hate the paperwork, the delays in payments, the inability to set prices and so on they need the steady stream of customers provided by the insurance company.

If business model X is viable for some, then that is an expansion of coverage, regardless of what is true of the majority. See, the whole benefit of free markets and individual choice is that heterogeneity of goods and services is a boon to society.

Walgreen's has made some interesting contributions in this area by housing a small clinic in some locations that is staffed by a nurse practitioner. I don't think they deal with most insurance plans. My experience is that routine care was provided for less than half of the standard medical clinic cost. Private enterprise might be a major player in future affordability of health care.

Hmmmmm sure about that? Walgreens doesn't take insurance? Ohhh you say their nurse practitioner is low cost and doesn't take most insurance....and what does she or he do? Do basic exams and often write prescriptions. Where might those prescriptions be filled?

You're describing a 'loss leader', not a new type of business model. McDonald's may not make much margin on french fries, but they do on soda. But few people buy fries without a drink...same thing.

Not hardly. Low-cost prescription programs already exist at places like Wal-Mart.

The prescription likely won't cost any more than if I had gone to a regular clinic to get it so over all I am better off.

That sounds like CVS's Minute Clinic, which takes both cash and insurance.

You have it exactly backwards. Insurance companies reimburse something like 140-160% of the cost of care. Most people like getting over-payed. This covers for the underpayment of Medicare, Medicaid and gov't mandated treatment of the uninsured. It is the Government plans that providers are gradually refusing to work with.


If Medicare and Medicaid underpay so much wouldn't it make sense for many more hospitals and doctors to simply refuse to participate? They can then offer reduced rates to private insurance companies and still make excellent profits. Yet while it is often hard to find Medicaid doctors, almost all serious hospitals and large practices take it. Why?

Look do you 'underpay' McDonalds for a meal and end up overpaying when you eat at a nicer place? How can a meal in one place cost $7 or so and in another $35? Cost structure has a lot to do with it. A large practice that has a staff administer to the patients of multiple doctors, who has doctors on salary rather than as independent businessmen, has lower costs than your more traditional doc. who operates out of his home office with one receptionist, one nurse and one small waiting room. That doctor is 'underpaid' by Medicaid but he isn't charging 160% to private insurance because he's using them to make up for Medicaid losses, he's charging 160% because he is a higher cost business.

Ever been to a same day surgery center? You're looking at the modern equilivant of Henry Ford's assembly line versus the old method of master craftsmen. A huge waiting room gets filled to the brim in the morning as the patients of multiple doctors converge on a center that provides operating rooms, prep, and nurse services for them. This type of set up can often take Medicaid and make money while a doctor who has his own operating room that gets used now and then will find it impossible to cover expenses

Given the financial state of Medicare - how are they going to gradually expand it? I actually see it moving the in the opposite direction. Marginally start raising thresholds for participation and fewer benefits as they struggle to keep it solvent.

Exactly. Mr Klein lost me with "Republicans shy away from proposing any big changes to the health-care system". Hasn't he heard of a little guy called Paul Ryan? Not that I think the Ryan plan will pass its exact form, but it certainly is a major proposal, and a decent starting point for discussions for what comes next. The rest of the article is nothing more than wishful thinking and cocooning on Ezra's part.

There is a major demographic and fiscal problem looming on the horizon. A sudden economic boom might kick it down the road a few years, but not as long as he seems to think.

You can't fight the narrative. Only the Democrats care. The Republicans are nothing but obstructionists, men who want to watch the world burn.
They have no proposals for health care or the budget, just a tenacious grip on the levers of power, shouting "No!" at the light worker
who wants to heal the Earth and bring down the level of the ocean.

Stereotypes exist for a reason.

I think the best outcome would be for the mandate to be ruled unconstitutional and for the rest of the law to stand. Since insurance companies will find it difficult to survive under these circumstances, it would force drastic price reductions cascading through the system. No longer would I have to pay $8 for an advil in the hospital.

We really have two issues: major medical and routine care. You can't really have insurance for routine care because the probability of needing it is essentially 1. Therefore, there is no advantage gained from pooling the risk for routine care unless a pool can command significantly lower rates from providers. Even if they can, they have administrative costs to overcome. It is akin to buying oil change insurance for your car. How can an insurer make you better off than just paying for oil changes yourself? I am skeptical of government providing a better solution in this area than individuals acting in their own interest could provide. If we insist on public funding of routine care, a direct cash subsidy in a vehicle like an HSA would likely be the most efficient way.

Of course, major medical expenses benefit from risk pooling because the probability that any individual will have a specific, catastrophic health care scenario is much lower. Major medical care is already socialized because hospitals can't deny emergency care based on ability to pay, and those with the least ability to pay are already covered by programs such as medicaid.

As evidenced above, you are not going to get anywhere with logic and analysis.

If the Supreme Court strikes down mandatory insurance purchase, has it also effectively struck down, in advance, any law creating personalized accounts for Social Security?

The current system, where young people pay for old people, is obviously just a capped income tax dedicated to a special use. A system that actually forced people to save would look a lot more like a system that forced people to buy health insurance.

Scalia's opinion in Heller imagined a strict constructionist reading of the Constitution that clearly prevented the government from banning handgun ownership (or even mandating trigger locks), yet allowed the government to ban machine guns. His logic was that handguns are obviously 21st-century muskets and machine guns are not.

Any common sense ruling that strikes down Obamacare would strike down other laws as well. For example, what does it mean if it's unconstitutional to mandate that I purchase health insurance from the market as a condition of earning substantial income from a source that doesn't also provide insurance? As far as I can tell, that should mean that it's unconstitutional to mandate that I buy eye wash stations and chemical showers as a condition of choosing to operate a chemistry laboratory. In both instances, I've chosen to engage in commerce. In both cases, my decision to not purchase something would be punished by a fine.

Yet, I'm sure we'll find that the ACA is somehow fundamentally different.

Healthcare is different from other goods...except when we need it to be the same.

"If it’s unconstitutional to mandate that I purchase health insurance from the market as a condition of earning substantial income from a source that doesn’t also provide insurance?"

I don't think anyone is arguing that the Fed has the power to do this, but the currently enacted mandate is broader than this.

should be that the Fed does NOT HAVE the power to do this.

The mandate is: you need to buy insurance if you don't get it from the government or your employer and you earn enough money per month that the cheapest insurance plan would cost less than 8% of your monthly income. How is that broader than what I said above?

It is fundamentally different. Eye wash stations and chemical showers are directly related to operating a chemical laboratory. Health insurance has nothing to do with working at a job. The government can't just tie two completely unrelated things together and argue that is their commerce clause hook- they didn't even try to argue that.

Private health insurance is directly tied to employment--it has been since the IRS decided that health insurance benefits weren't taxable. More people are insured through employers than insured privately. Employment and private health insurance are tightly linked in America and have been for some time as a result of Federal regulation.

I didn't say they were not tied (by the government), I said they were unrelated. All of the things you mention are totally irrelevant to that question. You will never be able to convince me that somehow health insurance and employment are related, because they are not.

You can't pass a law saying "we give preferential tax treatment to health insurance bought at broccoli stands" and then say "well, you have to buy health insurance in order to eat, which is totally constitutional because it is just a condition of entering the food market."

The law doesn't mandate that health insurance be tied to employment. It recognizes that is the custom in the US which is both a legacy of old regulations from the days of WWII as well as tradition. In fact the law actually attempts to open the door to letting insurance be separated from employment, which is a good thing but would be very tramatic to try to force in our political climate.

The connection that doesn't exist with broccoli is simple. IF I blow all my money on Shamrock shakes at Mcdonalds and I happen to have an itch to eat broccoli, I'm out of luck. If I can't beg, borrow or steal some little trees for my dinner plate, I go without. That is not the state with health care. If I slip and hit my head and end up in a coma for ten years, I pass those costs onto everyone else.

All else equal, if you were an employer that did not provide insurance, would you rather hire someone who was insured or someone who wasn't? The insured employee would be less likely to get sick and sicken your other employees, more likely to prevent or manage chronic illnesses that plague both blue collar (back pain) and white collar (carpal tunnel) employees, more likely to catch cancer at an early stage, etc. Health-related absenteeism is a universal concern for employers.

Also, health insurance and healthcare was tied to employment long before WWII. There are examples of private, employer-provided care/insurance (sometimes mandated by the Federal government) in the United States going back to the 18th century.


All else equal, if you were an employer that did not provide insurance, would you rather hire someone who was insured or someone who wasn’t? The insured employee would be less likely to get sick and sicken your other employees,

First your assumption isn't quite clear. The uninsured person may very well be healthy and the insured person sick. Consider a person whose been unemployed but has been spending $600 a month to keep his health insurance. Odds are he has some types of illness and knows he needs to keep his coverage as much as possible.

Second communicable disease isn't a bit part of health care cost and issues in developed economies. things like cancer, diabeties, heart disease and so on are major health problems for us. Not the plague or typhoid fever that will infect other workers if untreated!

Zach: doesn't the same argument apply for any other harmful activity you could take? And yet most employers don't care, and often encourage these activities (drinking, for instance).

Not if the personal accounts are optional, e.g., you have the choice of taking SS as-is, or in exchange for reduced future payouts from the govt, you get to manage a portion (perhaps up to all) of your SS payments in a personal account.

So, there is no difference between a tax break and a fine?

Makes sense, except for the fact they they are different.

That's not to say that either are good. They are both bad. But it is possible for two different things to be treated differently.

Optional doesn't save you here. If I put $1200 into an IRA my taxes are less than someone who wants to spend their $1200 on other things. End of story, by the logic here the government is 'mandating' that I buy stocks and bonds and such inside a special product provided by banks and financial firms.

If the SC strikes down the law but doesn't strike down a whole boatload of other things with it, then we know we have a purely partisan decision made simply based on the Republican members of the court deciding which laws they like and don't like and nothing else.

Scoop: "If the Supreme Court strikes down mandatory insurance purchase, has it also effectively struck down, in advance, any law creating personalized accounts for Social Security?"

Technically no, because Social Security is a tax, and Congress has a lot more authority under the taxing power. The individual mandate was specifically not a tax because it would have become too unpopular for the Democrats to pass as a tax increase.

I don't think you understand the legal arguments against the mandate.

If the ACA is struck down without a decision that provides guidance as to exactly what sort of universal healthcare would be constitutional, the only thing one can be sure of is that universal care won't happen until it's done by a Republican government or the Supreme Court changes in a significant way. The idea that it would be constitutional if not for the mandate is absurd. Insurance reforms of the sort that Klein envisions are just as if not more lacking in precedent than the ACA, and are thus as vulnerable to inventing some legal rationale to strike them down. Specifically, Medicaid and Medicare target populations that mostly cannot afford insurance. Expanding eligibility for Federal insurance will increasingly poach profitable customers from insurers, and I'm sure some enterprising law professor could make an equally compelling argument that effectively nationalizing health insurance is beyond the scope of the commerce clause -- in fact, people made this argument during debates over the public option in 2009.

The idea that [UHC] would be constitutional if not for the mandate is absurd.

You really, really don't understand what's being argued in front of SCOTUS, or even to have listened to any of the news reporting on it. The Justices seemed pretty clear that the government providing health care services to the people was Constitutional.

So why did they spend a day debating whether the Medicaid expansion was constitutional? Clement provided no clear limiting principle for his argument against Federal manipulation of how states manage Federal funds. Practically any universal insurance program would run into similar Federalism questions. A Medicare expansion (not administered through matching funds) would still meddle with Federalism issues such as a states' ability to regulate health insurance.

There are a number of constitutionally uncontroversial ways to provide universal care. You can tax everyone up to 100% of their income and provide each person their own publicly funded doctor and infinity free federally run clinics. No one can or does deny this. The time spent arguing about medicaid was because federalism is a complicated feature of the constitution, and there are cases that deal with how federal programs/funding administered by states can and cannot work. South Dakota v. Dole allows the Fed to condition its funding to states, but doesn't provide clear guidance on the limits of this principle, so maybe this is implicated by the medicaid provisions. In the Printz case federal meddling with state administration of federal programs was not allowed, and while possible not directly at issue here, it is another precedent in the ballpark that complicates things. That said, the arguments against the mandate are much stronger than those against the new medicaid rules.

The Federal government telling State governments what they can and cannot regulate with respect to health insurance for a population that's never been insured by the Federal government before would be unprecedented. Ergo, folks would claim that it overstepped enumerated Federal powers. Anytime the government does more than it's done before, there's an argument to be made that this is the time it's gone too far.


I think your readers (myself included) would enjoy a post expanding on your last sentence. Especially if it were super principled and thrashed the standard media narrative which presupposes that single payer = winnar.

Renowned physician, editor and writer Lewis Thomas addressed the health care issue in 1976: http://nailheadtom.blogspot.com/2010/09/lewis-thomas-talks-about-health-care.html

Until the budget problems with Medicare and Medicaid are solved- and I mean solved- then there are likely to be no effective expansions of the kind Klein is envisioning, even with Democrats in control. The one good thing about PPACA was the cost control mechanisms being applied to Medicare by Democrats, but then those savings were spent on expansion to younger and richer people, and given the size of the mandate penalties, those savings were not only spent, but overspent in the long run by a significant amount.

Perhaps the court will toss the mandate and the parts of the bill that required a mandate to avoid the adverse selection death spiral. That would leave the rest of the bill intact, and we might perhaps get a test on whether or not the savings promised in Medicare actually materialize (I am guessing they won't until push comes to shove in the Federal Government's overall budget).

We have formulaic cost control written into Medicare right now. It's just waived by every Congress with the "doc fix." Obamacare has similar rules that can similarly be waived as you can't bind future Congresses. Perhaps it won't be as easy to write off the IPAB as it is to pass the Doc Fix, but given the death panel rhetoric I doubt it.

I agree 100%. The IPAB can be ignored just as easily as any other legislated act of Congress by a future Congress, and I expect it to be until there is a real constraint on the total budget of the US.

So easy. Liftetime transferrable caps.

Death panels is not about that, it's about deciding what age/procedures you are allowed to get a la UK.NICE.

Inflation-adjusted? Or "inflation"-adjusted?

And how 'bout just fund prevention clinics directly and specifically fund things (vaccines) that (1) prevent future costs and (2) require incentivization?

So what exactly is (potentially) unconstitutional about ACA? I did read the legal meta-analysis but was still confused.

The Federal government has so many extant laws and mandates that businesses in the states have to follow (say, EPA, OSHA, labor laws,FAA, Social Security); so what makes the healthcare provisions stand out?

In the American context is there a framework to understand what the federal-government is allowed to mandate and what not?


The mandate forces a citizen to buy a product from another private entity as a condition for existing. This is contrary to both the letter and the spirit of a constitution meant to provide a system of government that has enumerated powers given to the federal government. There were ways to accomplish what the Democrats wanted by taxing and providing effective insurance, but they chose the mandate method instead. The questions directed at the Solicitor General were appropriate- if the mandate is constitutional, where lies the principle that keeps Congress from mandating the purchase of anything. Claims that health care is different are hollow. Mandating the purchase of anything changes the price signals in goods and services provide- health care is not unique in that regard; and claims that the mandate is necessary because you get adverse selection otherwise are true, but irrelevant- it was the federal government itself in the other provisions of PPACA that makes that a problem; so, again, you are left with no limiting principle- Congress can just interfere in the market for anything enough to justify it's mandating its purchase.

It may turn out to be a colossal blunder on the part of the Democrats to finance their bill this way. They were aware of, at the time of drafting and passage, the arguments that were used this week attacking the mandate. If the bill is overturned on these grounds, they have only themselves to blame.

Interesting. So how does something like a "helmet law" stand; isn't that also the government mandating (some) citizens buy a closely specified product from a private entity? Or "child car seats".

Or are these passed via loopholes?

Those are likely state-level requirements for highway funding.

Now that healthcare needs to be the same as everything else, the promoters will say that it must be the same as these also bad laws.

After the case is settled, then we'll get back to your regularly scheduled "healthcare is speshull!"

I see. So it is OK for the states to require citizens to buy, just not for the Federal Government? So I guess one way around is to hold some state-funding source hostage and then force them to do the federal government's dirty work.....

Rahul, thats what the second part of the case is about. Congress tried to do exactly that with medicaid funding.

So I guess one way around is to hold some state-funding source hostage and then force them to do the federal government’s dirty work…..

That's been the usual MO.

It's not "OK,"

It's "legal."

Driving a car and riding a motorcycle are optional activities. Even more than that, they're privileges granted to citizens by the state. If you want to drive a car, you have to have to be licensed as a driver, your vehicle has to be licensed, you have to carry insurance, and more likely than not, your car has to be inspected for legal compliance with safety and/or emissions standards. All of that is implicit in the contract
you made when you signed your driver's license. If you don't like it, you can get a State ID card instead and ride the bus, a bicycle, or walk.

Regardless of what the laws say, I own neither a helmet nor a car seat. This is because I don't own a vehicle and the federal government has yet to require me to own one, though it does interfere in the market extensively (though more bad laws) to subside automobile production and consumption.

Where I live, I can be knocked unconscious, taken to the emergency room, and receive a bill afterwards for both the emergency room and the ambulance. Maybe I would have been preferred to remain untreated. Obviously health care is a different "good" than a car because if you opt not to use it you can die sooner, but in fact there are circumstances where you will use health care in this country despite not being consulted about whether you want it!

As it happens, the 24th Amendment makes it unconstitutional for the government to force people to pay a tax in order to vote. This isn't cited, but the precedent is there that you shouldn't be taxed for exercising a basic right.

Suppose a municipal government outsourced its entire sewer system to a private contractor, fined people if they didn't install a toilet connected to the sewer system (no septic tanks), and if you connected to the sewer system you had to pay whatever the contractor charged. No constitutional problem with that? The Supreme Court struck down a few of these sorts of monopolies in the early nineteenth century. At least the Romans didn't fine people for not using Crasus' fire brigade.

Helmet laws are generally local (sometimes state).

Rahul, 85% of con law profs thought this was a no brainer in favor of the bill.

We have compelled purchases today. If you have a kid, they must get immunized before they go to any school ( with religious exceptions).
The Court is following a line of cases beginning in the 1880s and ending in the 1930's. Since then, interstate commerce has reached what you might regard as purely local.

I think, regarding the purchase, Kennedy asked the question: is the purchase proximately related to the insurance market. Yes it is, if you want to regulate insurance and offer universal coverage at community rates.

The issue is mandates on people just for being people, not for engaging in other activities. Those supporting the law claim that everyone does engage in the health care market, so it's okay to regulate that, but those opposed say that it's a mandate to engage in the market so that they can then be regulated. The states can make people do things just for being people (so it was definitely constitutional for MA to have a health insurance mandate), but the federal government can't, so the case will likely hinge on whether Justice Kennedy thinks people without health insurance are engaged in commerce or not.

The other examples you cited are all clearly regulations related to other activities people engage in or uses of taxing power, which are allowable.

You should always add "even under the current idiotic understanding of the commerce powers"

The commerce power means whatever a minimum of five SCOTUS justices says it means. The particular meaning it has at any given time is neither idiotic, nor smart. It is simply what it is, until a minimum of five SCOTUS justice gives it a new meaning.

I think the health insurance reform witout the mandate will work out just fine. Inusrance companies will scream and we can create a tax incentive/disincentive to encourage people to purchase insurance, IF adverse selection turns out to be a problem. With luck, we will break the link between health insurance and employment completely.

I'm a bit skeptical too about the 'death spiral' hypothesis. It seems to presume individuals have excellent knowledge of when they will get sick and, unless stopped by pre-existing exclusions or mandates, time their purchase of health insurance 'just right' so as to sign up only when they need, say, chemotherapy, rather than when they are healthy. I think the reality is that most people have great uncertainity about when they will need seriously expensive health coverage and likewise will opt to have it if it is affordable to them even if they think they will be healthy for the near term future.

> It seems to presume individuals have excellent knowledge of when they will get sick

Curious what you think about pregnancy/childbirth? High dollar, very common, predictable (even planned) by individuals. I just don't see how in any market based approach where one can shop around on a whim, and the company has to take you, that there can be any differentiation in service quality. How can insurance company X sell itself as "sure we aren't the cheapest, but we have the best ob/gyn specialists, let you stay in hospital for not just hours but even a _day_ after giving birth, and after that have great pediatric care". They'd be _destroyed_ by people moving to it only when starting a family. The premium would have to rise to the average cost of delivery & etc care, because after some point no one else would sign up. (Joe's medical insurance whose slogan is "we give great coverage except in one respect - we only provide the legal minimum for pregnancy related conditions" could likely charge one tenth as much as the former company.)

This may not be a death spiral as such, but it's some sort of spiral (towards equality of coverage, at the lowest level the law or public perception will permit) that I just can't imagine not being realized.

Your example works for a very limited population. Women (50% of the population out), of childbearing age (say another 25% out), who want to have a child now (shall we say another 10% of the population out?). This remainder must also be highly confident of their health status. You don't buy insurance to just cover childbirth but anything and everything.

In other words, for every highly rational, 'strategic planner' who would craftily time their entry into the insurance market just right to hit the insurance company with a big bill will probably have at least a couple of somewhat paranoid hypochrondrites who want coverage because they are worried about serious illnesses even though they are highly unlikely to get sick anytime soon. The ability of lotteries and casinos to make excellent profits indicates that much of the populationis not quite rational when it comes to probability calculations. No doubt some marketing will seek to enhance that effect even more.

I suspect the 'death spiral' will more likely be a mildly chronic annoyance to insurance companies that will sap profits but not drive the entire industry to bankruptcy.

Note that the mandate/tax was actually kind of mild, like $600 per year. A highly rational person who could know which years he or she wouldn't have serious illnesses would find it more sensible to just pay the tax rather than buy insurance! Yet the insurance companies were generally OK with the law, not thrilled but certainly not acting as if the bill was a death warrant for them.

Consider 'premium support' which seems to be the most coherent Republican alternative at the moment. Basically the idea is that you buy your own insurance if you want but the gov't will subsidize you if you have so many pre-existing conditions or are so old you'd be priced out of the market. That is basically the end result of 'death spiral', not the bankrupting of insurance company but a pseudo-single payer system where the gov't is essentially paying for predictable, massive health expenses and insurance covers the unpredictable ones.

End the tax favoritism of employer-provided health insurance. This will help break the link between employment with a specific employer and health coverage. It will also lead to the gradual end of cadillac health plans and bring price-sensitivity back to everyday health care decisions.

Totally agree but even this is complicated. On what value of your insurance policy are you going to be taxed?

The very reason people buy insurance is that the average person is not going to require the overall average cost of medical services.

Someone please explain why it's such a great idea to incentivize or coerce people to part with their money today to go directly to the medical system that is overspending today?

You probably won't drive your car into another car today, but if you did, your liability costs could be very high. Therefore, you should buy auto liability insurance to protect you from that risk. This is true even though part of the reason why liability costs are high is because many juries award too much in damages. Refusing to purchase adequate auto liability insurance because some juries award too much in damages would be cutting off your nose to spite your face.

I see no support for this. The ACA has the merit of being gently neutral on employer versus consumer provided insurance. Americans do not want a health insurance reform bill that will destroy their job-based coverage if they are happy with it. The ACA allows employer provided coverage to remain but also allows a transition to a consumer based one where individuals buy policies of their own choice thru exchanges rather than hoping their company's HR departments will buy a plan that works for them.

Cadillac plans have been decreasing in proportion for years now and it seems to yield little or no overall decrease in health care costs. The idea of making health care a good you buy out of your monthly spending money is an illusion. We are spending $8K per person per year on health. That guarantees our financing mechanism is going to be dramatically different than, say, the way we buy fast food.

With respect, and in reference to your earlier post, ACA does not force everyone to buy the "same quality" health care. Rather, it forces everyone to buy a certain minimum quality. So your point that "forcing everyone to buy the same quality car, or house, is [tough]," is true, but wide of the mark. We do in fact force everyone to buy a certain minimum quality of (new) car or house, and have for years. So also with insurance coverage--I can't sell you insurance unless I am licensed and closely regulated.

But you can alway go live in a tent in the woods, so this is different.

You can also escape the insurance mandate by reducing your income below the threshhold at which it applies.

Grinding poverty solves everything!

Don't worry. There is no way that Romney is going to be elected. He is just wasting his time.

"I have never thought that a mandate is workable in a fragmented system with employer-based care and high health care costs and high income inequality."

Germany, although with less income inequality than the US, has a fragmented system with a mandate to buy insurance for all who do not receive insurance from their employer, and the state-associated _Krankenkassen_ raise fees progressively with income level of members, such that wealthier insured are encouraged to seek competitive private alternatives.

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