The Senate health care bill

Here is a good summary and analysis from Megan McArdle, here is one key part:

But while there are a few things to like in this bill, overall, it’s a mess.  All of the problems created by Obamacare’s architecture remain, and some of the problems will get worse, because lower subsidies, higher deductibles and no mandate penalty probably means that a lot of people will exit the exchanges.  Those people are likely to be the folks we most need to stabilize those exchanges: healthy youngsters who don’t use much health care.  Which means that the exchanges will be at further risk from the death spirals we’ve already seen in some states.

I agree the bill is a bad idea.  That said, I do hope you keep in perspective some of the more, um, lurid critiques running around, including from health care economists (the Great Firewall won’t let me link to Twitter, and right now VPN is down).  You can read them as sociology, however, with a rather chilling effect.


Are you seriously quoting Megan McArdle? She of the argument "Grenfell Tower deaths are an acceptable tradeoff because if housing prices were higher more people would die in automobile accidents getting to work"?

Uhhh because it IS a trade off lefties don't consider at all. They spent 8 million pounds renovating Grenfell towers but once again the poor make POOR decisions and didn't invest it in fire prevention. Not really Megan's fault.

the poor make poor decisions? It was the landlord, tve local municipality, that made the decision to save on fire prevention. Alternatively it waz the contractor that fiddled, uskng the cheaper stuff, therby savkng 5,000 pounds

Tenants are well-represented on the management board.

And the private sector for profit always delivers the safest products at the cheapest possible price.

Clearly it was a government run business in the US that sold an excessively priced cladding that was completely and maximally unsafe to the private sector UK contractor.

In developed countries like the US and UK, how much of the variation in real estate prices is due to different levels of fireproofing?

Who can know maybe tonnes the point of Megan's smart analysis is to tell people there are trade offs so we should get upset.

Nope, I know very well that a $500K home in the US is probably not 5 times as 'fireproof' as a $100K home. I know if I have a $350K home and want to increase its value to $400K, no plausible 'fire proofing' is going to do that....even that stupid NEST fire alarm.

Tradeoffs do exist but there is also low hanging fruit that can be secured relatively cheaply if it is done at the right time (say before the structure is built or remodeled). Fireproofing is a good example. Huge fires in skyscrapers are almost unheard of today (I think you'd have to go back decades to find one in NYC assuming you don't count 9/11). There is largely no evidence this has been because we made a massive trade off decision that forces people to live in suburbs in fire traps rather than safe city buildings.

'Fireproofing is a good example. Huge fires in skyscrapers are almost unheard of today'

I'm guessing this escaped your attention - 'Flammable cladding blamed for the rapid spread of the fatal Grenfell Tower blaze was pinpointed as contributing to another fire in a high-rise apartment building in Melbourne, which narrowly avoided loss of life.

A fire at the Lacrosse building in Melbourne’s Docklands on 25 November 2014 is strikingly similar to London’s Grenfell Tower fire, which has left at least 17 people dead and many more injured.

The rapid spread of the Lacrosse building fire, which was sparked by a cigarette on an eighth-floor balcony and raced up 13 floors to the roof of the 21-storey building in 11 minutes, was blamed on flammable aluminium composite cladding that lined the exterior concrete walls.

The same type of cladding was installed on the Grenfell Tower in 2016, as part of a £10m renovation.'

What is true that in the U.S., which generally has strict, and strictly enforced, fire codes, such a fire as in London or Melbourne would be unusual. Including the fact that the London residential high rise apartment building did not have multiple stairwells, a building fire alarm system, or sprinklers.

Agreed. Everything is a tradeoff. The leftist refusal to acknowledge that tradeoffs exist is all part of their general self-inflicted ignorance about economic. Resources are finite. The state makes tradeoffs all the time. Socialism doesn't make money grow on trees.

There is material abundance and there are very, very few real tradeoffs. There are plenty of tradeoffs caused by the system of money, but that is a very different proposition.

You can't possibly be serious.

Li Zhi: "You can’t possibly be serious."

Please explain, what was the tradeoff to installing a sprinkler system in Grenfell Tower, according to McArdle?



So, do funerals cost less when done on a mass basis?

That was the trade-off, you realize - a few tens of thousand pounds saved, at the cost of dozens of dead people.


Jeff, I ALREADY WROTE ABOVE above that there are plenty of illusory tradeoffs, caused by the system of money. But that is a very different proposition than saying there are real tradeoffs. There is material abundance, e.g. there is enough for sprinklers everywhere. There are very, very few real tradeoffs.

If something costs a lot of money, it's not because an evil genie appeared and made it cost more, it's because people want more of that thing than is available. Money and prices and markets are not illusions that make things appear scarce, they expose what things are actually NOT "materially abundant".

+1 Lee A Arnold. Hazel Meade et al have no clue about how the world works. Greenfell is a criminal / fraud case. But that's just how capitalism works, people with power, try to rob the powerless. White people, leave brown, black people to die etc.

'they expose what things are actually NOT “materially abundant”.'

Are you attempting to honestly argue that something like sprinkler systems or multiple stairwells in high rise buildings is something that the UK is too poor to afford, with the UK lacking the necessary material abundance?

Is the problem that non-flammable and legal cladding is simply not a trade-off worth paying for, even after other high rise buildings have burned in exactly the same fashion several years before this tragedy actually occurred, with the cladding being installed two years after an essentially identical fire in Melbourne?

Or is it the other way round - lives and buildings are so cheap, who cares when they burn?

That was the trade-off, you realize – a few tens of thousand pounds saved, at the cost of dozens of dead people.

Well, really the *risk* of dozens of dead people - it's not like there's a guarentee of a fire, or even whether it was predictable. I'm not going to comment on whether it was the right choice. But you can't really expect low-end apartment high-rises to be built out of high-end materials. Anyway, I heard the cladding was there because of energy efficiency and the "sustainability" agenda. They could have had no cladding and just spent more on heating costs. Trade-offs all around.

I'm just making a general point that tradeoffs exist and resources are finite. I have no idea whether they made a prudent choice in the Grenfell towers case.

@prior_test2, I’m just making a general point that tradeoffs exist and resources are finite. I have no idea whether they made a prudent choice in the Grenfell towers case.

That point is utterly banal.

That was the trade-off, you realize – a few tens of thousand pounds saved, at the cost of dozens of dead people.

Thank you. We have people in this thread denying that tradeoffs exist.

Hazel Meade: "If something costs a lot of money, it’s not because an evil genie appeared and made it cost more, it’s because people want more of that thing than is available. Money and prices and markets are not illusions that make things appear scarce, they expose what things are actually NOT 'materially abundant'."

Yet almost all material things are abundant. Indeed they have become more so. Earth has no lack of metals (or plastic) to forgo making enough sprinkler systems, for example. Britain has enough unemployed labor to install them. How do you avoid the conclusion that money and prices have created an illusion?

"That point is utterly banal."

It is. Yet people are freaking out over its very mention.

McArdle didn't even say installing sprinklers was wrong. Here are her words:

Maybe sprinkler systems should be required in multifamily dwellings. It’s completely possible that the former housing minister made the wrong call. But his comment indicates he was thinking about the question in the right way -- taking seriously the fact that safety regulations come at a cost, which may exceed their benefit. Such calculations have to be made, no matter how horrified the tut-tutting after the fact.

"It is. Yet people are freaking out over its very mention"

Because it's an obvious, boring, and banal point, the only reason she would raise it at this point is to be callous.

“That point is utterly banal.”

It ought to be, but it is not. The phony belief that material resources will always be scarce enough to make tradeoffs necessary, is being transcended by economic developments themselves -- in other words, capitalism's success has begun to put itself out of business -- yet it remains a major creaky tenet in the libertarian production of nonsense.

Hey idiot. Everyone knows about trade-offs, There's nothing but banality in this arguement and McMegan writes like a freshman. I just posted that to churn out all the cucks who post here. Mission accomplished.

Some people don't know about good manners.

Megan McArdle has consistently provided the best analysis to Obamacare for years.

This is true.

Yeah, she has promised that free health care is easily made available if the government stops paying anything for it, and every individual stops paying for insurance. In that system, people with no money will get all the medical care they need for free because the free in free market means free health care.

She has never pointed to any nation with a better health care system that meets her approval. Africa meets her criteria for how health care is financed, but she never praises Africa nor advocates the US be like Africa.

She's classically free lunch.

Actually, her health-care proposal, the TLDR version, is this: "zero out all the existing subsidies and just have the government pick up 100 percent of the tab for medical expenses that exceed 15 or 20 percent of a family’s adjusted gross income"

That's roughly the same as my proposal. Somebody please critique it (hers, since you haven't seen mine).

Not just Obamacare.

Actually Megan McArdle's analysis of Obamacare has been consistently terrible and is entirely bad

If nothing else, it provides the teachable moment to stop housing poor people vertically in expensive cities.

Give them vouchers and tell them to go look for housing in less expensive cities. Also, it's an island: you should only allow a certain number in.

Out of curiosity, what is the magic number for people allowed into London?

"Out of curiosity, what is the magic number for people allowed into London?"

Those willing to pay £11.50 daily.

The congestion charge keeps poor people from both visiting the city and leaving the city and coming back in. That's not an accident.

Is that Tube fare? A bit expensive compared to Berlin, then.

No, it's the congestion charge for drivers who enter the central part of the city.

The Tube fare is GBP 4.50 per ride, or more depending on distance, if you buy rides individually, but is quite a bargain if you buy the Oystercard or Travelcard - GBP 33 for unlimited travel for a week within zone 1.

You mean where there are no jobs?

If people are living in a place, there are jobs within commuting distance.

Regional unemployment rates in the UK vary between 3.4% and 6.8%. The national mean is 4.8%. It's 5.5% in Greater London and lower in proximate areas composed of suburban tracts, small cities, small towns, and countryside. 'East of England' (East Anglia + adjacent zones), which has only small cities and non-metropolitan territory, has a rate of 4.5%. "South-east", which is 40% suburb, ~12% small and middling cities w/ the rest non-metropolitan, has a rate of 3.4%. The West Country, which has one city of note (Bristol) comprising 15% of the region's population, has a rate of 3.7%.

What do you mean no Jobs any way - always blow Jobs at my house for passersby (but not me) courtesy of my wife! WINK!

So you want to throw the poor at sea? Althought I wonder if American/European welfare money wouldn't last longer in Cambodia or other countries that could use the money injection. It depends, I guess, which sharemof a poor person's budget is government's money and how much got through work or grey market activities. Depending on the answer, paying poor people to reallocate themselves to Cambodia or Laos can be the solution.

Pass legislation to provide for the incremental elimination of any residuals rent controls in Britain, revise planning and zoning regulations to allow more private housing construction, put the remaining public housing on the auction bloc, and add an income tax credit to improve the real incomes of the impecunious generally. Forget housing vouchers and any subvention to the purchase particular goods and services other than medical care, long-term care, schooling, and legal services.

While we're at it, amend the extant welfare legislation so that immigrant populations enter the client pool for public benefits incrementally (as they work and pay taxes). You might have a right to a legal aid lawyer immediately, school vouchers or berths in state schools after x years, a right to term-limited unemployment compensation after x+5 years, disability benefits after x + 10 years, and so forth.

Megan is excellent at pointing out the nastier moles that might pop up if you try to use Washington DC as your mallet.

If you've not read her Bloomberg columns about the differences between Walmart and Costco, don't do it if you're a progressive. Your head might explode. OK, maybe not explode, but you'll get a booger on your screen. :-)

We get that you like to pretend that trade-offs don't exist, but out here in the real world they do exist. All the pretending in the world isn't going to change reality.

If we just tax the rich more there will be enough money to buy everyone a three-bedroom house in London.

It would help if you actually read the thing you were told to hate.


Reading it won't be much "help". The typical progressive isn't an intelligent person. See above comments.

This is the save a life at any cost argument.

Any legislation (ACA) that locks in the non free market based exaggerated fraction of GDP which is healthcare is toxic for the overall economic health of the nation. If this bill can only be neutralized by trickery, then trickery is the best possible outcome.

Splease, you are calling for mass unemployment?

Congress has jumped the shark. They propose uneconomic, punitive legislation that would produce worse outcomes. Cui bono?
Look at the difference in cost compared to other countries for the same services. Then look at donations by pharma, insurance and other parasites that game the US system. Is it any wonder that there is such revulsion in American homes and, increasingly, on streets?

"Then look at donations by pharma, insurance and other parasites that game the US system."

"Donations" to whom? They're not "gaming the US system"...that is the US system.

Enquiring M. are you suggesting violence, or only condoning it?

Look at Venezuela.

Congress is doing what the people elected it to do.

Here is one "mean" part of the so-called repeal. Young, healthy people will not be forced to pay for expensive health care insurance they neither need nor want.

Re: Congress is doing what the people elected it to do.

A remarkable statement when this is quite likely the most unpopular bill ever proposed to be voted on by the full Senate. Usually proposals that poll with numbers similar to cockroaches and diarrhea die in committee or they are deep-sixed by the leadership justifiably worried about the next election.

I do not condone violence. I do recognize that Congress does not listen to the citizenry very much, and tends to focus much more on the Citizens United groups that vote with their donations. It is possible to get the attention of senators and congressmen, and their local equivalents, through contacts, attendance at events and peaceful protests.

Of course there is no evidence to support the notion that independent expenditures allow such groups to buy elections. Members of Congress do in fact reflect the views of the voters in their districts most of the time.

Have you ever considered in the slightest that insurance schemes create large pools of distributed risk. Have you ever considered that fact that the lack of moral hazard for the young and healthy would allow them to free ride?

If Congress and Trump were elected to eliminate mandates but magically and with fairy dust style lower premiums and deductibles and co pays, please enlighten us.

So, the Senate, keeps Obamacare intact, with a lot of tweaks to make it cheaper. However, it will likely hasten the collapse of the exchanges.

Ho Hum. Status Quo maintained.

Tax cuts. Tax cuts. Tax cuts. Mission Accomplished.

Indeed. Using very large amount of OPM's will always illicit a reaction.

Secrecy often comes as part of the package of 'illicit.'

msgkings, It's me again.

Higher taxes. Higher taxes. Higher taxes; and let's wreck the health care financing systems to force single-payer. That was ACA in brief.

Because higher taxes produce higher employment, higher GDP growth, higher prosperity, higher . . .

I see it as less stealing from your neighbors with the government as middleman.

ACA Tax Hikes:

The Individual Mandate - a tax otherwise SCOTUS would have ruled ACA to be unconstitutional. .

Medicare 1.45% to 2.35% - up 62% - and the money isn't going to Medicare.

Top Bracket 35% to 39.6% - up 13% - the hated rich got off easy!

Cap gains/divs 15% to 28% - 87% - only 60+% of Americans are affected.

RE Trans tax 0% to 3.5% - Get them rich scum that sell their houses.

Nothing that requires other people’s enforced sacrifice for your benefit is a right.

If legislation is passed that makes it a right, it is. A simple concept.

The US healthcare system is grossly inefficent, horrendously expensive and near universally unpopular with the electorate.

In terms of making it cheaper, when the CBO scored the house bill it found that some people would either end up with premiums of near infinity or so high that they would opt not to buy insurance at all. This was counted as a premium of $0 and used by Paul Ryan to argue that it would 'bring down premiums'.

In following this line of thinking, you could pass a law saying all new cars must be top of the line Mercedes. Since most people can't afford that, they simply won't buy any new cars next year which means I can claim credit for saving people thousands on car spending!

You cannot make anything cheaper. In the short and medium term, you just shift the costs around.

For the long-term, you can remove perverse incentives which in turn would lower-the rate at which factors of production are deployed to the medical sector, allowing the share of household budgets devoted to medical care to decline.

In other words, the economy would spend less on cars if you banned half the population from driving. Success!

Your having trouble understanding people, but fancy you're here to instruct them (in a notably prolix way).

On the other Hand cucks like me are well acquainted with the BBC.

"For the long-term, you can remove perverse incentives which in turn would lower-the rate at which factors of production are deployed to the medical sector, allowing the share of household budgets devoted to medical care to decline."

Then the US would be much more like Africa!!! Make America Great Again by becoming Africa!

Basically same with housing.

I wish NIMBYs would not put forward BS arguments about neighborhood character and zoning technicalities. Pro-development groups should also articulate better that a best case scenario for deregulation and and building boom is that long-term costs slow/flatten and become a smaller share of household budgets over time.

Bought a PC recently? A flat screen? Maybe you should look at the list price of a solar panel (not to mention its yield) compared to a decade ago.

Then there is that whole smartphone thing involving wireless Internet access - maybe you have missed it?

Bought a PC recently?

A personal computer is an ordinary consumer good. Ordinary consumer goods are not under discussion here. The medical sector is.

What you wrote was - 'You cannot make anything cheaper. In the short and medium term, you just shift the costs around. '

So, how much does a CAT scan or MRI cost today compared to three decades ago?

Or what is the cost of all the defibrillators now found in various places, compared to two decades ago?

Lasik surgery? Or any now outpatient eye surgery involving a laser?

I'm sure you can come up with plenty of examples yourself, if you just give yourself a minute or two.

MRW when Prior-approval accidentally makes the argument in favor of free markets.

Now I've seen everything in the comments.

When Obamacare blows up, will the public blame the Republicans, because they were the last ones to touch it? They certainly are making it more likely to blow up. Why mess with a bomb? Are they trying to lose?

Agreed. It would be better for Republicans not to pass anything. On the other hand, the Leftwing portion of the media will blame Republicans for Obamacare blowing up even if they don't change anything.

This may be a no win situation.

WHEN it blows up? Wow, someone needs a reality check. It's been in a death spiral since before the first exchange opened. Its basis was to lump the uninsurable (preexisting conditions) together with the 20-somethings who didn't need it, and allow people to game the system. Undoubtedly the dumbest major piece of legislation to come out of DC this century.

Re: . Its basis was to lump the uninsurable (preexisting conditions) together with the 20-somethings who didn’t need it,

Group policies do exactly that, and yet have worked tolerably well for decades.

"Group policies do exactly that, and yet have worked tolerably well for decades."

Those have generally been largely voluntary. The Mandate was not voluntary. That doesn't mean it will fail. However, it does mean that a lot of the best "Customers" are looking for a way out.

You're talking about employer medical insurance?

You don't start and quit jobs to game having medical insurance. There's a massive cost to exit: your income. You can buy Obamacare whenever you need it. You can't have a job with benefits whenever you feel like it.

Having insurance tied to employment is a disaster, but that's the obvious upside. It increases the marginal cost of leaving your job. You have a medical condition and need insurance, so you continue working.

It also perversely creates economies of scale when there wouldn't be otherwise.

I agree with Megan Mcardle, who has for some reason been insulted in these comments. Dismantle the whole thing and pay anything over 17% of income. If we want 17% of GDP to be healthcare, then make everyone pay. But make it a choice.

For the nudgers, if necessary, have a automatic deduction in income of 17% that sits in an HSA until you need it. when you die you can bequeath anything you don't spend to your children without penalty.

Tying insurance to employment is a bad state of affairs, but it was the one part of the health insurance market that was well-functioning and the way a sick person could get insurance without filling out a 40-page form. There's a reason "if you like you insurance you get to keep it" was so important: Obama was signaling that he wasn't gonna screw up that market.

I still say that insurance should be equalized in tax treatment whether you get it yourself or through your employer. Ideally by making it taxable like any other benefit your job gives you.

Great comment but I wouldn't let you cuck me because Chinamen have tiny penises and it doesn't make the cucking good to watch. Sorry.

O-K Mr. American Man, I no want to be part of youh cucko pohn.

Not dumb. Just all that could be passed in a political environment that could not eliminate insurers.

I would like to see Medicare broken into three programs: 1. Health insurance for the poor, 2. Health insurance for the disabled, and 3. Long-term care insurance. Lumping three distinct programs and the people and money spent, does little to foster a basic understanding the program, while allowing politicians to demonize cuts as killing children. With three separate programs you would see how much money is collected, how much money is spent and for how many people.

I think you mean Medicaid. Medicare does not provide l/t care.

or insurance for the poor or disabled (with a few minor exceptions)

IIRC, the adjudicated disabled are enrolled in Medicare if they qualify as 'fully insured' from their work history. Dialysis patients also have Medicare benefits.

Two years after judged disabled and qualified for SSDI you can now buy Medicare coverage that probably costs more than you can afford, so State Medicaid programs pay for it by increasing other benefit payments so SSDI benefits can pay for Medicare insurances, three premiums unless Medicaid places you into a manage care plan in which case Medicare pays it as MA with the State payment reduced.

About 25% of Medicare beneficiaries are dual eligible also covered by Medicaid. and 20% of those on Medicaid are those with needs in excess of Medicare benefits and costs.

Medicare costs on average $3000 a year in insurance premiums without accounting for out of pocket expenses. With SS benefits of the sick and disabled around $10,000 a year, almost all need Medicaid and additional State welfare.

Medicare does provide health insurance for those on Social Security Disability. But otherwise the poster probably means Medicaid.

Wrong. It provides skilled LTC.

The truly weird part about TrumpCare is the people on Medicaid get to keep their insurance until after the 2020 election. Some people get a trillion dollars tax cut. And the middle class (>350% FPL) gets hosed. Worse insurance, more expensive.

What happened to the tax credit idea. People get to keep their subsidies but if you are a dollar over the limit, too bad.

It's everything ppl hated about Obamacare.

Not weird. All part of the plan. Delay the catastrophe until after the election.

Delay the cuts until the voters are no longer polarized about Obama and now Republicans can find Democrats to delay the cuts to Medicaid year by year with compromises included to jack up the block grants per capita plus added bonus payments to red States which end up with less money after the per capita formula is increased to give blue States as much real money as Obamacare gives them today.

It will be the doc fix rerun with a final solution in 2035 to use Medicaid as government single payer with employers and blue States adding enough to match the developed world, and red States settling for China mainland or India health care quality, which ever is worse.

Iirc there are 140 Republican amendments in the final ACA Bill.

There were 100 hearings.

It took 14 months to craft the bill.

60 Senators voted for it.

This commenting software...

Meant as a reply to FYI below.

"Iirc there are 140 Republican amendments in the final ACA Bill."


Half true. This analysis doesn't count "technical amendments" as "significant."

Wait a second, if republicans had time to put forth and pass 140 'technical amendments' how exactly does that bolster the case that the bill was 'jammed through' on them.

"I didn't have time to even read this contract. I just was able to write up 300 spelling and punctuation corrections and get 140 of them adopted...." Hmmmm.

It's amazing how Left Wing politifact has become. But I admire their Chutzpah, they put the truth right on their page, and then ignore it when they declare their verdict.

From the link you so helpfully provided:

"Timothy Jost, emeritus professor of law at Washington and Lee University School of Law, told us that "the basic statement that hundreds were adopted is wrong.""

"Only two of those Republican amendments were passed via roll-call vote. One of these amendments required members of Congress and congressional staff to enroll in the government-run option and the other involved biologics medication."

Yep making Congress participate in Obamacare, completely makes it a Republican plan!

"During that markup, about six Republican amendments were adopted via roll call vote, and others were adopted by unanimous consent, without objection, and via voice vote, according to coverage by Congressional Quarterly. "

"On the House side, some Republican amendments to the Affordable Care Act were accepted in committee; 24 Republican amendments were incorporated in the Energy and Commerce Committee, and six were incorporated in the Education and Workforce committee. Republicans sponsored 38 amendments in the Ways and Means committee, and each one was rejected. "

"Jost said by September 2009 that period was over and from then on, the bill was strictly a Democratic piece of legislation."

But I thought technically correct was the best kind of correct....

Yep, jammed thru by radical leftist Marxist led by life long Marxist Arlen Specter who was so leftist Democrats never nominated him for office and he could only run as a Republican because the Republican party is so big tent they welcome and nominate big government Marxists for the Senate.

Joined by radical pacifist Joe Lieberman who was too far to the left he was booted out of the Democratic Party and so independent and leftist he campaigned in support of John McCain because Obama was more scary than Goldwater.

I will include the progressive view that Pelosi is so right wing she should run as a Republican, and she's the reason Democrats lost recently because she was used to scare progressives into voting for the leftist Republican instead of the Pelosi right wing Democrat.

I grew up when Pravda was a reality and Republicans promised everything was very costly.

Now Republicans promise everything is both easy and free, and if they are elected, they will prove everything will be fixed easily and for free.

Donald Trump was the distilled Republican message. Health care will be cheaper, give you the choice of everything you want in treatment, and cover everyone. Not even Bernie could out promise Trump on free lunch health care. Bernie could not out promise Trump on trade with cheap imports without any high paying jobs being lost, and cheap goods made in America by jobs paying more than union wages.

Trump fully embraces free lunch economics, economics given legitimacy by the right-wing control of the Republican party.


What exactly did people hate about Obamacare? Was it stuff they actually experienced, stuff they thought others were experiencing or stuff they simply associated with Obamacare?

That last item could be anything someone doesn't like about the health care system but may have little or nothing to do with Obamacare. Premium increases every year, doctors shifting in and out of your network, even long wait lines in the office are things that happened before Obamacare and will continue to happen but it was easy for lots of people to blame Obamacare.

Of the remaining two, I think most people experienced very little actual direct issues with Obamacare but heard a lot about other people's experiences. This is because:

1. If 1 person has a horrible experience but 9 people have a good one, the news will cover the first person and the other 9 people will hear about it but no one is going to do 9 stories about where it worked out ok.

2. Coverage went up.....

Whose coverage was worse for more money? Those who got on Medicaid from a state of zero coverage clearly got more coverage for less money. Those who purchased plans might have been spending more than they wanted but we don't quite have an apples to apples comparison. A $300/mo plan from the exchange is not exactly like a $150/mo plan that doesn't cover anything and makes you jump through such a pre-existing condition filter that anyone who actually needs it is screened out.

The reality is the 'hate of Obamacare' is more hot air than real. There are real problems with Obamacare. For example, if someone gets a tiny raise and moves themselves above Medicaid they land in a massive pit where they once had coverage for nothing and now look at plans with deductibles and cost a few hundred a month. But getting rid of their Medicaid doesn't actually solve that problem. The exchanges aren't a great solution in rural areas because there are few providers and insurance companies can't negotiate good rates. They aren't ideal for the 'gig worker' who buys his own coverage versus the corporate guy who gets it from his job.

But most people are not in rural areas, most people aren't gig workers, and most people are either getting coverage from their job or are older enough to be on Medicare. It's pretty hard to see how anything will fix Obamacare that isn't actually just doing more Obamacare or just leaving it alone....yes buying insurance will suck in a rural area or as a gig worker but it did before.

Disclosure - I have an exchange plan Bronze HSA compatible with a $7200 deductible per person. No subsidy. No out of network coverage. $779 per month for 2.

I think the big objections were:

1. Paying for middle class children's teeth. Paying for your neighbors childbirth or addiction treatment. Basically the required services. This made costs higher.

2. High deductible and oop costs. As if first dollar coverage all of a sudden became the ideal.

People liked the guaranteed issue. And I didn't really hear that much complaint about the Medicaid expansion. But what I did hear a lot about was the premium costs and the high deductible.

Trump promised everyone would be covered with TrumpCare. Have better insurance. Cheaper. Lower deductibles and oop costs.

This senate plan is definitely not that.

#1 That criticism cannot withstand any scrutiny. How are you paying for your neighbor's kids teeth? Assuming they are in the same plan as you don't they also have a $7200 deductible? Ditto for their kids addiction treatment. It sounds like you would rather have an extreme pre-existing condition regime where you have insurance companies screen out those who are likely to be sick or otherwise incur lots of costs. That might work for you assuming you are relatively healthy but then you are just going to pay for those who are sick out of the other pocket because taxpayers sooner or later will be tapped to pay for them.

#2 Of course the moment you have a low deductible then you actually are paying much more for things like your neighbor's childbirth, teeth, or addiction treatment. You basically have figured out a way to complain no matter what the system is.

"Paying for your neighbors childbirth or addiction treatment."

These objections would receive far from universal assent among rank-and-file Republican voters and the politicians they support. Chris Christie signed a law in New Jersey not too long ago requiring health insurance sold within the state to cover opioid addiction treatment even if the feds withdrew the requirement. Republicans have acquaintances and family members who are addicts, too, and whom they would rather not see end up dead, homeless or in jail. As for childbirth, people like Rick Santorum have long sought to ensure public policy allows normal, middle- and working-class people to be able to afford to raise a family. Most people expect to have a child at some point but they aren't necessarily prepared for the $10-15,000 hospital bill that will come with it if they don't have a generous employer-sponsored plan and if childbirth coverage is removed from PPACA.

The Republicans who voted for Trump probably believed Trump, too, just like the Democrats believe we just need "to use the system the rest of the world uses" and everything will be great.

Usually there is a problem where people don't listen to the arguments from the other side. But for health care, people haven't even listened to the smart people on their own side who are trying to tell them that the magic plan they want doesn't exist.

'just like the Democrats believe we just need “to use the system the rest of the world uses”'

Well, that is laughable - the rest of the world uses a variety of systems, the only thing that unites them is they are at least a third less expensive, and that none of the other health care systems are set up as stupidly as America's. Though all of the others are able to provide health care to essentially all citizens, something that apparently is too repugnant for Republicans to allow happen in the U.S.

Megan wants the cost and regulation and payment mode of African health care with the outcome of Japan and France.

Republicans want French health care for themselves, and the sick and poor deported to Africa to get their health care there.

“Paying for your neighbors childbirth or addiction treatment.”

It's funny no one talks about auto insurance like this. I have Allstate, so does my neighbor. I stay home most nights, but my neighbors are always going out to eat or to shows or visiting friends. I don't grumble that my money is going to cover their driving about while I sit at home watching TV. No one I know really thinks this way and I don't buy that you do either.

I imagine if they did it would be a huge improvement if some auto insurance company announced they would put an app on your car and watch where you are every moment of the day and only charge you for actually driving based on where you drive too, what time of day you drive, etc. etc. I know there's a little bit of this right now but it doesn't seem to me many people are clamoring for it so they can finally feel 'free' from 'paying for their neighbors'.

Insurers price premiums by miles driven and your claims run.

It's generally just miles driven to work, and even that is based on self-reporting and as such it is easy to game. For example, if you take a job that twice as far as your old job but keep the same insurance they won't know about it unless you make a point to tell them. Does anyone do that?

"Insurers price premiums by miles driven and your claims run."

Are all miles equal or even claims? I'm sure driving at 3AM might be more risky than 3PM. Driving while talking to someone on the phone (even hands off) is more risky than not. Unless you go full big brother mode you can't be sure you aren't on some level paying for your neighbor!

"But most people are not in rural areas, most people aren’t gig workers, and most people are either getting coverage from their job or are older enough to be on Medicare. It’s pretty hard to see how anything will fix Obamacare that isn’t actually just doing more Obamacare or just leaving it alone….yes buying insurance will suck in a rural area or as a gig worker but it did before."

Most people were covered by their employers or Medicare before Obamacare too. But Obamacare cost tons of money and raised lots taxes, without doing much to help the folks that didn't have Medicare or employer provided insurance. It either put them on crappy exchange policies or in crappy Medicaid plans. For some of the folks in the gap, these are somewhat better than before, and for others they are worse than what they had. In my book, spending hundreds of billions a year for very little benefit is a negative.

The widespread premium increases were not too popular. People say they like more coverage, but ultimately don't like paying for it. When given the choice of how to spend their own money on healthcare they tend to pick high deductible plans.

The problems with ObamaCare were:

1) Premiums too high for some people in the individual insurance market.
2) Out-of-pocket costs too high for the bronze and silver plans.
3) Insurers finding some poorer areas not worth doing business in.

The non problems were:

1) Fake insurance had been eliminated (excepting the high out of pocket issue).
2) Medicaid expansion worked great, near universal coverage of children in many expanding states, etc.
3) The rich were still doing just fine.

These suggest a few possible obvious improvements:

1) Further increase taxes on the rich, increase subsidies to reduce premiums and out of pocket costs.
2) Further increase taxes on the rich, expand the medicaid expansion.
3) Have something more like medicaid help ensure no coverage dead spots.
4) Golly gee, medicare expansion worked great, lets just do more of that instead of all this complicated exchange-subsidy malarkey.

The AHCA, however is really only interested in solving non-problem 3, that the rich don't have enough money. Everything else, problem or not, is changed to get more money for the rich, or to try to make the other negative changes hit a minority of the population (throw the sick or the old or pregnant women under the bus). Oh wait, there is one other thing: some anti-abortion stuff, to keep the evangelical voters in line.


There were absurd incentive problems with Obamacare that caused the premiums to skyrocket.

There are no caps. The liability for insurers is infinite. Can you imagine that ? In any other system?

Hi, I want to buy fire insurance for my house. It costs potentially infinite money.

Hi, I want to buy flood insurance for a house on a tiny rock in the pacific. It'll flood and you need to rebuild.

Hi, I want volcano insurance on an active volcano, but you have to keep rebuilding it every time.

This isn't insurance. Insurance is to hedge against large cost low probability events.

If we're going to spend 17% of GDP then tax everyone at 17% and pay it out. Ideally in a HSA where the government starts covering annual expenses after 17%.

I landed in Obamacare working independently one year. I went from being able to go to the doctor and pay cash, with insurance premiums at 10% of my income, to total healthcare costs out of pocket, premium + deductible, of 25% of income in the first year. I did hit the deductible, but my old plan's deductible was far lower. There was no way for me to avoid paying 25% of my income: all the plans basically work out to at least 25% of my income with the deductible. The question is do I pay a high premium and guarantee the money comes out of pocket, or buy a low premium plan and hope I don't hit the deductible? Note that I save money and live well below my means. Probably 80-90% of Americans in my shoes would have gone bankrupt, and the care wasn't major surgery or anything remotely serious.

That doesn't even qualify as a horror story. In some ways Obamacare is a like a mafioso plan. They offer you thousands in subsidies to buy a plan. Now maybe without the subsidies, you'd take no plan and pay the penalty. But you take the plan because of the subsidies and then earn a little more income during the year, losing you eligibility for subsidies. Instead of stopping the subsidies mid-year and raising your premium, they send you a bill at the end of the year for all the subsidies. There are people have a huge debt with the IRS racking up interest and penalties, all because Obamacare incentives and subsidies. It is a horrible law.

And yes, the government sent me money back at the end of the year. My tax rate was negative.

Please tell me how having middle class people pay negative tax rates in order to plow money into insurance company coffers is a sustainable system.

They disliked the name. "Obama" care.

"And the middle class (>350% FPL) gets hosed."

Hardly the entire "middle class"...nearly all of them have employer provided health insurance.

So then just the part of the middle class most directly impacted by the bill? If you're on a good employer-sponsored plan, Obamacare didn't matter much one way or the other, and this bill won't either.

Actually, it mattered a lot. By paying for the medical treatment that was being delivered but not paid for, employers saw less cost shifting from the poor for health care to the employer benefit costs.

Employer health benefits costs rose at half the rate while Obama was president as they did while Bush was president.

And with modifications to ERISA, employees got better coverage (no lifetime limits) with less increases in their costs (lower employer cost increases reduced cost shifting to employees). And Obamacare effectively increased employer coverage, reversing the decline trend that the CBO assumed would increase the cost of insurance premium subsidies.

And with Obamacare driving changes in bundling of care plus patient records, employer plans benefited from changes that even the largest employers can no longer drive by their "purchasing power". Eg, steel, ship building, and other manufacturing drove the creation of HMOs in California post WWII because a few conglomerates employed so many workers they could fund a system that had the critical mass to be the dog wagging the tail of everyone else, and only the fleas were able to escape integrated risk and care management.

After the 86 tax reform that forced risk and care management to be divided into to warring boxes, the powerful employers simply jacked up the length of a la carte services paid for generously. Ie, the Apple and Google plans worth $10-15K per median 30 year old plan costs.

Employee + employer health care contributions:

Not sure I see much of a change in the rate of increase, just cost-shifting.

Employer-sponsored health insurance trends:

Looks like a decrease to me.

But conservatives want employer health care eliminated, except for Republicans in Congress.

Might just want similar tax treatment for employer-sponsored versus self-purchased. That might result in employers getting out. But the ACA didn't do it so I'm not sure.

I do want employer health care eliminated, because it causes such terrible perverse effects on the market, but it would probably be better to approach it by equalizing the tax treatment. We shouldn't be incentivizing the employer-based system.

"I do want employer health care eliminated, because it causes such terrible perverse effects on the market, but it would probably be better to approach it by equalizing the tax treatment. We shouldn’t be incentivizing the employer-based system."

Careful what you wish for. What people forget about employer-sponsored plans is that they serve as a government-regulated safety net for those who manage to stay in full-time employment -- pre-existing conditions are covered (and were covered years before Obamacare) and sick people cannot be charged more or excluded from plans. If you repeal Obamacare and dump millions of middle class people into crappy individual plans where all of their pre-existing conditions are no longer covered, the pressure to enact single-payer or something like it would be that much greater.

When Obamacare was passed (in a partisan vote which basically started the eye for an eye retaliation we have going on) liberals would concede flaws with the law happily, saying it was a way to push for a single payer system in the future.

If we use the same cynical approach, you can see Republicans pushing this new monster as an even more flawed plan that brings people closer to a market solution health care system...

We are playing politics here folks. And both parties (and their voters) are to blame. There is no free lunch or free healthcare.

When Obamacare was passed (in a partisan vote which basically started the eye for an eye retaliation we have going on) .

BS. First, as a matter of simple logic, you can't blame a purely partisan vote on just one side. Second, Obamacare did have hearings - lots of them - and debate. It also included some GOP amendments. And it is not the Democrats fault that the GOP laid down the law to its members that voting for it was prohibited.

Stop repeating garbage.

This is a political point and as so it can go anywhere we want to. Having a "public debate" means nothing if you end up pushing what you want anyway. All republican amendments were not changing the core of the system. That is why, in the past, such one sided plans were not pushed through. Republicans were pretty clear that they would repeal if elected, and the voters decided to elect them.

Actually, if Republicans don't push their new system through they will be committing political suicide. Will that create enough pushback for Democrats to do the same thing? Likely.

Re: . Republicans were pretty clear that they would repeal if elected, and the voters decided to elect them.

The voters last year however also had Trump's promise of a universal plan that would cheaper and better. Maybe that's what they were voting for?

Sure, just like Dems voted for the plan that "allows you to keep your coverage without any change". That's politics.

You know, as much as I would favor a single-payer system if it were a real option, I think bringing back the status quo ante would be the best available solution. The system was working without killing most people and most Americans seems to be OK with it. Transitory majorities should not be the way to settle something as important as a healthcare system. If there were a clear majority one way or another, it would be fine, but there isn't so. So Democrats had to create their system on top of the market system they despise and now Republicans must create theirs on top of the Obamacare they hate.

"So Democrats had to create their system on top of the market system they despise and now Republicans must create theirs on top of the Obamacare they hate."

Every now and then Pearls of wisdom drop from TR's fingers.

It's when he forgets to change his username. Ymmv

Most people are healthy and don't experience any difference between good and bad insurance. They certainly don't experience the difference between yearly or lifetime caps and no caps.

The free market is great at delivering limited insurance for a low price.

If you really are a foreigner, you may not understand that the status quo ante had a lot of incomplete insurance, and this is a plan to reintroduce incompleteness.

Something about new yearly and lifetime caps for employer paid insurance?

"If you really are a foreigner, you may not understand that the status quo ante had a lot of incomplete insurance, and this is a plan to reintroduce incompleteness."
Most Americans do not care. Yeah, they hope to find good employer-paid (and the like) plans (I remember Mr. Carl Sagan, who was not exactly poor, pointing out he was relived for being covered by his wife's plan), but they do not care enough to like what the Democrats gave them. How many Southern poor voted Republican even as Obama was trying to cover them? Americans do not want what Democrats had to offer them, much less single-payer, which is a no-brainer for most of mankind, so why keep insisting in forcing a divided nation to jump from a system to another every two years, depending on whom controls the House? People cannot keep living that way. They were mad when it turned out they could not keep their plans, now they will be mad when they can not keep what Obama gave them, tomorrow they will be mad when they cannot keep their tax cuts and so on. You are annoying people who clearly just want to be left to rot alone.

That is why I said above that passing Obamacare on a partisan vote was a big mistake. Not sure if you are being sarcastic in what you are saying but it is true anyway. If you don't have some measure of agreement on a major change and you force it through anyway you are asking for a political war. Will the Dems repeal and replace this new plan? I think it's likely. The cycle will continue until voters stop voting in people who campaign on doing so. It is more than clear that this congress and this President were going to do this, so criticizing this is just useless.

It is sad. I can imagine such things happening in Brazil. In part, it is a feature of first-past-the-post, single-member district and a two-party system. Adoption of Brazil's many-members districts, proportional vote and multi-party system (or the Military Regime's sub-parties) would happen to create a clear mandate.

But you have rewritten history in order to call it a partisan vote.

In other words, lie.

We can't just switch back. Lots of things in politics are path-dependent.

You surely can tell people they are on their own again and they can either try the free market or healthcare and insurance or they can provide one of the sides with a clear mandate to make the intervention they want. One man (or woman), one cote. At this point, it is not the 1% preventing America to go Communist or a few Ivory Tower Professors preventing Republicans from drowing the poor. America is split.

What does it mean to undo the ban on disallowing pre-existing conditions? Are those people going to get kicked off the rolls? Politically, it's much much harder to take something away from someone than to never give it to them in the first place.

I had a republican coworker who said "Obamacare sucked, but that ban on pre-existing conditions? That was great!" I wanted to throttle him over his ignorance -- because you can't get that ban without the mandate -- but it's the exact same ignorance I've heard so many of my liberal friends make. He didn't care about the sustainability. He cared about his goodies.

Public choice, good and hard.

"I had a republican coworker who said “'Obamacare sucked, but that ban on pre-existing conditions? That was great!'"
So he wants Trump to keep his hands off his Medicare or Social Security or whatever. As you pointed out, it is ignorance. Now it is the rime to tell people they can have the government meddling in healthcare or they can have their free market utopia, they can not have both. Come on, there are only two ways. Either you cover people the markets would not cover (and it will cost someone lots of money, either taxpayers pay for it, or healthy people pay for it or insurance corporations pay for it) or you don't, allowing unlucky people to experience the extent of their lack of luck. That is it. Again, I would love Americans have a single-payer system or at least something that would protect them from healthcare expenses-related bankruptcy, but Americans can agree on a workable system. The status quo ante is a good compromisse.

If we had a policy that was "the government will pay for everything where it can get a QALY at a price of $20,000 or better" that would do a pretty good job of covering people.

But it would still end up, somewhere, being heartless to someone who doesn't make the cut and can't afford it. Which is inevitable under any health plan eventually, but Americans don't want to face it. Democrats think there is some magic in single-payer where no one gets "no," Republicans talk about selling across state lines as if it makes some kind of difference, and in the meantime we end up with a psychotic system that no one chose.

Americans choose it as a compromisse since they can't agree. If Democrats can't accept some people will hear "no" and Republicans think markets and tax cuts are magic, well Americans chose whatever is the outcome of having to accept those groups's delusions

Yep, Arlen Specter was a radical leftist Marxist so far to the left of Bernie, Democrats never nominated him but instead ran conservative Democrats against him, forcing Specter, the Marxist, to run in the big tent Republican primary for three decades.

So, when will Bernie join the Republican Caucus and back this bill like Spector did in 2009 in backing Obamacare ? After all, the Democrats rejected Bernie just as Democrats rejected Spector?

What we're learning is that the Republican caucuses (or crucial gatekeeper positions within them) are dominated by careerists who feed bon bons to certain clients, fret over public relations, and haven't one decent policy idea between them. They have a short list of important tasks: pass a budget w/ a portfolio of appropriations bills, provide the necessary appropriations for the Wall, compose a sensible revision to the regime of financing medical care, compose a sensible revision to the architecture of financial regulation; compose legislation simplifying income taxes, corporate taxes, and gift-and-estate taxes; and pass legislation dividing Immigration and Customs Enforcement into two separate agencies with one dedicated to chasing down illegal aliens. The smart money says they'll accomplish none of them. (And the situation in the medical insurance market will continue to deteriorate).

Complete agreement. Absolutely tone-deaf, inept, impolitic, venal, add-the-adjective.

"and pass legislation dividing Immigration and Customs Enforcement into two separate agencies with one dedicated to chasing down illegal aliens."
Why can't Immigrarion and Customs do the job?

Administrations antagonistic to immigration enforcement re-deploy resources subrosa to chasing down smugglers.

Oh, I see, I hope they got a lot of smugglers. Yes, It may help.

I Keep getting cucked by Guatamalans.

Unfortunately true.

I heard Senator Cassidy on Morning Joe this morning say that the reduction of Medicaid would cause these benefit recipients to move over to regular insurance and that this would help stabilize the insurance companies. Isn't it the case that Medicaid recipients are sicker than the general population? If so, will insurers be eager to pick these people up?

Um. I don't know if they are sicker, but they are definitely poorer. How in the world does Cassidy think they are going to pay fro regular insurance? That's moronic.

I think he just scrounged for an answer to use at that moment, and doesn't likely believe it. The man's a lapsed physician, interestingly.

The people I've known on Medicaid refuse to work overtime.

Because they'll get kicked off of Medicaid. Why should they work more?

Draw your own conclusions.

The poor would become eligible to get a subsidy that they could use to purchase a plan on the exchanges.

But why would they do that? The phase out is far in the future.

The subsidy will be less generous, immediately and over time.

The exchange policies are likely to have greater oop costs. Whereas current Medicaid oop costs are minimal.

In free lunch economics, free in free market means free stuff to everyone with no money.

Just like the homeless can buy a Tesla Model X to live in for the change collected begging at the Apple and Google employee entrances.

Hopeless, on all sides. The Stupid-Evil Party versus the Evil-Stupid Party.

"That said, I do hope you keep in perspective some of the more, um, lurid critiques running around, including from health care economists"
a tad condescending, Tyler.
Please provide your list of "good" economic fields and the "good" economists in each.

From a system analysis perspective, this is all fascinating. Congress has managed to create a system (nationalized health care) that cannot be reformed, cannot be abolished and cannot continue on as presently designed. The only "solution" is to let it stagger on until it collapses. That's the most likely results from all of this as any change to the present structure offends some power interest skimming millions from the status quo.

Nothing like this happened at all. In an alternative universe President elect Trump announces he wants a bipartisan Obamacare reform. He appoints Obama and Mitt Romney to a commission to come up with some proposals. He notes that he can get a center-right proposal by ditching maybe 10% of hard right Republican Congressmen in exchange for getting the votes of maybe 10-15 Democrats....a minority of Dems of course. If you recall Trump actually ran on that. Instead since he is incapable of actual execution of ideas he is attempting to run the gov't from a purely partisan basis when republican majorities are already on thin ice with the temp increasing.

The problem with the 'stagger til it collapses' line is that it ain't collapsing. You are basically talking about a system that provides some incentives and some sticks to get people to buy private coverage. Why is that going to collapse? The economy is filled with lots of incentives/disincentives that work to varying degrees.

Your problems here are four-fold. One is you seem to have no idea how legislation is created. Second, Romney and Obama would not have the first clue as to how to attack this problem. Third, you are operating under the old paradigm of a linear political scale. Finally, you have no idea what is happening with insurance companies and insurance markets.

Otherwise, great post.

Romney would, and has generated legislation in this area

Obama's a sometime lawyer, and knows nothing of the subject.

So, Obamacare does not exist because Obama is so incompetent he could never map out a viable path to get enough Democrats elected to pass a massive tax hike to pay for providing insurance to 15 million people without enough money to buy insurance?

Given Obama never was competent enough to get Obamacare into law and implemented, why are conservatives having so much trouble coming up with something better than nothing?

Clearly, Ryan, McConnell, Trump, et al are ten times as incompetent than the incompetent Obama, Pelosi, and Reid.

Well you're an all-time Internet cuck so congrats!

"Third, you are operating under the old paradigm of a linear political scale"

And this new Trump style is working out fantastically? I'm operating under a paradigm of those who are in government have to govern sooner or later. Calling the crappy job your doing 'nonlinear' sounds like a sophisticated way to bullshit your boss into maybe not seeing you as a fuckup.

None of which addresses the points I made. You are operating from a position of staggering ignorance. Most people would be ashamed to reveal such a thing, but you seem to be proud of it or perhaps just so dull you don't know it.

Look. You have posted a lot of comments in this thread. All of it is vapid nonsense. You are doing no one any favors with this. Close your computer. Go outside and chase butterflies.

BUT TRUMP!!!!!!11

"Look. You have posted a lot of comments in this thread. All of it is vapid nonsense."

Boonton is one of those posters whose ideology trumps everything else. I don't think he's capable of consistently admitting that the other side has smart people and has some good ideas. And I don't recall ever seeing him admit that another poster from the other side made a good point. So, you are correct, but don't expect him to admit it.

"And I don’t recall ever seeing him admit that another poster from the other side made a good point. So, you are correct, but don’t expect him to admit it."

What are you kidding me? What poster admits that the other side has good points? I know you want to single out Boonton because you're a hack like everyone here but gett he fuck off your high horse, how many times have you seen "yeah you know you have a good pont here?

There are several posters here who do not slot easily into one side or the other, and don't care about having their tribe with the argument over actual truth or actual results.

"how many times have you seen “yeah you know you have a good pont here?"

I've done so on multiple occasions.

This guy gets it.

"From a system analysis perspective, this is all fascinating. Congress has managed to create a system (nationalized health care) that cannot be reformed, cannot be abolished and cannot continue on as presently designed. The only “solution” is to let it stagger on until it collapses"

+10, this is the best synopsis of the current situation in the thread.


This man is either a systems engineer or an Econ dude, or has a preternatural ability to think this way.

Thread winner. Buchanan is spinning in his grave applauding.

Megan and Tyler, two partisan Dems, dislike the GOP healthcare bill.


McArdle is among the least politically partisan purveyors of topical commentary you can find. Neither is she a serial poseur like David Frum. She also vocally regretted the ballot she cast for Obama in 2008.

'McArdle is among the least politically partisan purveyors of topical commentary you can find.'

Best satirical comment this year, bar none. After all, you cannot possibly mean that seriously.

She embarrasses you by exposing your stupidities. That's your problem.

I also respect her out of my own shame as a cuckold

Is that what Scarlett Johansson told you to say at your last tryst? Romain Dauriac knew the whole time FYI.

Words out on what you did to Jessica Chastain.

I agree with Art Deco. She seems to call it like she sees it. And frankly, her assessment was less harsh than my internal thinking of the new bill.

What did she say that was so bad about the bill? And, as a cross check, go read what some other analysts have said about the very same bill.

I'm not sure that the argument that the bill would cause insurance markets to death spiral faster is a great argument against the bill. Why are we supposed to be saving ObamaCare? The goal should be to undermine ObamaCare's architecture as thoroughly as possible, to which end, faster death spirals might actually be helpful. As long as people have a free-market alternative they can switch to.

This is what I thought was the benefit of the waivers - states that opted out of the insurance regs would have healthy markets, states that didn't would have death spirals, and the end result would be that the ACA would remain on the books but be functionally dead. But then the Senate bill removed the waivers, so that's out.

The bill is terrible, but not because it fails to stabilize insurance markets under the ACA. It's terrible because it doesn't do anything to dismantle the ACA's core regulations.

As long as people have a free-market alternative they can switch to.

Insurance companies are selectively withdrawing from the off-exchange individual market as well, one state at a time.

That's because off-exchange plans still have to comply with the pre-existing conditions and community ratings requirements.
That's why some sort of insurance that doesn't comply with the ACA insurance regs has to be legalized for this to work.
If you let people buy and sell insurance plans that (say) require waiting periods before covering pre-existing conditions, or don't cover everything on the essential benefits list, or are allowed to charge based on risk, for example, then some insurance companies will continue to sell those policies, even if the rest of the market dies. And eventually, those will be the only plans left on the market.

They've had guaranteed issue in New York for some time. I'm not sure that in and of itself is the problem.

And NY effectively had no individual insurance market left because of it.

"They’ve had guaranteed issue in New York for some time. I’m not sure that in and of itself is the problem."

New York private policies have also been the highest priced in the nation.

And NY effectively had no individual insurance market left because of it.

My sister had individual market insurance for over 20 years, pre-Obamacare.

It's not a problem if insurers are allowed to price based on risk. Which they can't do either in NY or under the ACA.

In pre-ACA NY , you could wait until you got cancer to go purchase insurance and THEN show up at the door and the insurer would have to sell you a policy at no additional charge.

Please stop telling everyone about your cuckolding fetishes. It's wierd.

You spend too much time hanging around all the cucks on this blog.

Are you inviting me to join your secret alt-right cuckolding porn fan club? Thanks, but no.

That's not even how cuckolding works, first we'd have to be married. Man this is like the McMegan take on cuckolding - and she probably cucks her husband anyway becuase that guy is a nerd.

I'm sorry, I guess I'm exposing my ignorance about the tropes of the cuck porn genre. You've obviously watched a lot more of it than I have.

Hey hey! Whose discussing cuckoldry here without the General?

How can you be ignorant of cuckoldry, everyone who Posts on this blog is basically living the life of Little Bill from Boogie Nights. That's why they spend so much time here in the first place.

"If you let people buy and sell insurance plans that (say) require waiting periods before covering pre-existing conditions, or don’t cover everything on the essential benefits list, or are allowed to charge based on risk, for example, then some insurance companies will continue to sell those policies, even if the rest of the market dies. And eventually, those will be the only plans left on the market."

So, if insurers only insure the healthy and everyone else gets free health care under EMTALA or Medicare, then the US health care people system will be the best in the world?

Why don't you advocate for African health care system?

No tax subsidized employer health benefits
No Medicare
No Pharma
No Medicaid
No malpractice insurance or lawsuits
Patients must shop for everything, like surgeons, scalpels, antibiotics, painkillers, bandages, saline, blood plasma, etc when choosing how to be operated on.
No mandates to buy insurance
No mandated insurance coverage

Can you find anything bad about the African health care systems?

At least EMTLA only covered emergencies, and not comprehensive coverage for drug rehab clinics and kid's dental care. And it only costs us money if the patient can't pay up.
So people who go without health insurance, and then get cancer, and wind up in the emergency, will go bankrupt. And the rest of us pick up what's left of the cost. BFD. That's going to cost me a lot less than cross subsidizing comprehensive coverage everything on the essential benefits list from everyone below 400% of the poverty line. Which is pretty clear from the way premiums went up.
If all that emergency room treatment under EMTLA was so expensive compared to just covering people, why did premiums go UP rather than DOWN?

Except that doesn't seem anything like reality. States like CA or NY are never going to use an opt out waiver...yet if you look at where any type of 'death spiral' is happening it's the most anti-Obamacare states....mostly more rural ones.

Opting out of coverage requirements doesn't really help. How does it 'save' a state if they declare that insurance doesn't have to cover childbirth, cancer, or heart disease? Sure premiums would be more affordable but then you're getting a policy that only covers, what, whopping cough?

Obviously, because the anti-Obamacare states can't opt-out right now. Insurance in those states has to comply with the basic structural guarenteed issue and community ratings requirements. Which won't work without the mandate. But I DON'T CARE if those provisions "don't work". I don't want them to work. I don't want to "save" any states ObamaCare markets. I want to save the free market.

How does it ‘save’ a state if they declare that insurance doesn’t have to cover childbirth, cancer, or heart disease?

Presumably consumers will figure out what sort of things they want insurance to cover. Prior to the ACA, amazingly, insurance covered cancer. It didn't require a federal mandate to make insurers cover cancer.

Why are the States that embraced Obamacare not having a problem with 3 or more insurers in almost every county?

With the exception of Washington State for some reason, with almost all the State with plenty of choices except two counties. It might be due to Klickitat being both low population, 4 per square mile, and hard right for the State. Grays Harbor seems to be working class suffering like coal country and the Rust Belt. In both with income low enough that Medicaid covers so many people, insurers don't get a good risk pool of those who do buy insurance, and few employers buy insurance, so creating a network is hard.

"As of March 2017, 1,119 people in Klickitat County and 2,227 in Grays Harbor County were enrolled in the individual market."

How much do you invest in finding providers for 3000 customers spread over a huge land area, almost 4000 square miles?

If these counties are like the rest of the State, the above average health population bought the Republican logic of not buying insurance, and taxpayers reward doctors and hospitals more than most for providing medical care to people who will never paay for it, about 10,000 in these two counties. And for the sicker population they get government funded managed care, 12,000.

The problem with Obamacare in some states is the problem with insurance markets in those states. Fewer people, who are sicker on average, combined with fewer providers, which means less ability of an insurance pool to negotiate better rates, means higher premiums.

At its core Obamacare is simply a means tested subsidy program for buying private insurance coverage. If you rant against Obamacare on free market grounds, you better not support, say, school vouchers, since that too would not be a true free market.

The Republican proposals do make little sense. The House proposed an age-tested subsidy program.....the Senate who knows. Both philosophies, though, don't really address the issue as they essentially will make taxpayers responsible for covering those who can't afford coverage due to pre-existing conditions sooner or later.

No, ObamaCare explicitly manipulates rates to force known low-risk people to pay more in order to subsidize known high-risk people. It is a socialization of costs beyond what the free market would naturally provide.

The problem with ObamaCare is that the known low-risk people correctly calculate that they are getting a raw deal and will not purchase insurance anymore. Unless they are forced to, thus the mandate.

Group policies (which are the bulk of the non-government-coverage insurance market) price on risk only at the group level-- individuals are not risk-priced This keeps the plans generally affordable for everyone-- and most people, even young and healthy people, do sign up for the workplace health plan. So no, it is not necessary to price by individual risk.

Most employers won't pay you wages for the employer-based portion of the premium if you opt out of the health plan. And they subsidize the purchase so that it remains cheaper than opting out and buying an individual policy - for all employees, regardless of their pay grade. But the perverse incentives due to group coverage remain. If your premium isn't based on your individual consumption, you're going to tend to spend more. And you're really not going to care what anything costs - which is why prices are so opaque. If we had price transparency and high-deductible policies, we would have effective price signals. We don't right now. The market is completely dysfunctional with or without the ACA, because the employer-based system (the bulk of the non-government-coverage market) is dysfunctional.

"If your premium isn’t based on your individual consumption, you’re going to tend to spend more. And you’re really not going to care what anything costs – which is why prices are so opaque."

That is totally contrary to everything I've seen in half a century of knowing people with employer health benefits. I can't think of anyone in 50 years who got unneeded medical care because it was free. No one who demanded colonoscopies at least once a year, who was demanding to see a doctor frequently for no reason. Instead I can think of quite a few people who did not seek care even when it was fairly obviously needed, with bad outcomes resulting.

And personally, I have failed to follow my doctors' advice to get more care, failed to return in 3 months or 6 months, failed to get labor tests as often as recommended, and I paid $10 to see the doctor and nothing for lab tests. And every person I know are much the same.

Bingo. You have figured out how insurance pools that offer guaranteed coverage operate.

That is why there is a mandate. Not real hard to understand. Inject moral hazard.

Insurance pools with guarenteed coverage and community rating require a mandate.
I'm opposed to guarenteed coverage and community rating.
How many times do I have to spell this out?

Who cares? The Senate bill or the Senate/House compromise is supposed to fail to pass. That's the plan -- Obamacare is preserved and can be blamed for the inevitable trainwreck. Republicans had to pretend to make the attempt because that was a major campaign issue, both for Congress and Trump. But if there is a replacement, it will have to come after the trainwreck when voters are screaming over 2018 premiums. That's when a bipartisan compromise may become possible.

A simple up or down vote on repealing ACA would have a chance of passing now, which is why it won't be brought to a vote. God forbid any Republican bill should pass, because then they'll have to shoulder the burden of responsibility.

The only reason to have a bipartisan compromise is to spread blame around or implement an elite conspiracy contra the public's interests. I'll wager you a plan with a consistent internal logic is more likely to be sustainable.

So the plan is fail to pass something now, even though Republicans have majorities and the WH. Let a huge train wreck happen right before the 2018 election (note that this train wreck seems to have eluded us since Obamacare was passed, how is this timing going to work again). Then assume the voters will correctly blame Obamacare and Democrats even though Republicans have a majority now. Then they will elect more Republicans.

Republicans with a super majority will now....what? Pass a really super health care law that people will like? Errr and what would that be? Why not write that proposal up today and try to pass it?

Republicans have no effective majority in the Senate.

So we can only have government if all 3 branches have comfortable supermajorities? Anything short of that and the only option is spinning wheels and rule by pushing executive orders as far as they can go?

Hey Buddy tell me about it, but that's the cuck life. WINK.

Although I actually agree with you on the larger point, Boonton, your comment cracked me up because it took exactly that for California to finally get its stuff together and run semi-functionally.

I'm bored by lesbian porn.

Lesbian porn? You haven't gotten on the cuck porn bandwagon yet? Neither have I because my life is a cuck porn where I'm Little Bill! Watch out for New Years!

And yet all Trump needs to do is reach out to maybe 10 Democrats to forge a 'bipartisan' bill and he will not only get it but suddenly look like a genius.

"Republicans have no effective majority in the Senate."

But why does that prevent them from writing a really fantastic health care law that all rational people in the middle will agree is super rational and the best possible option?

Why should Republicans be unable to embrace government single payer Medicaid, or medical care paid by some third party, or individual insurance, or out of pocket only with toll gates requiring up front payment to get health care, just because each of them are part of obamacare?

(Hospitals and ERs are closing because they are no longer getting government bailouts for uncompensated care, creating a tollgate for many poor in red states, ie, you need money just to get to an ER covered by EMTALA. Conservatives called for individual responsibility to end those government bailouts of hospitals. So, that's part of Obamacare.)

My senators are really delivering for Kentucky. McConnell is doing his best to sever the federal teat and Paul is suggesting we take money away from health insurance companies. Who will fund your campaign for reelection? (Hint: four letter word, starts with a K and ends with an H.) This is a tragicomedy with no happy ending.

What bill would be better within the political overton window?

"What bill would be better within the political overton window?"

My guess is a bill that fails to pass. This maybe where Republican's end up. They'll be damaged for not passing anything. However, Obamacare is spiraling down the drain. If they just don't enforce the mandate (already an executive order) Obamacare will be all but gone in 8 years.

The damage from not doing anything will be less than from doing something, when the something won't fix the collapse and will attach the blame to them.

This bill looks like something that's designed to Pass, but if the leadership quietly lets some of it's members that they won't be punished for not voting for it, it will fail anyway. They know that the Democrats are locked into voting against any change no matter what it is.

Yeah, red States are the only States in America.

California, Mass, Maryland, New York, and 25 additional States with 70% of the population, all States in better shape as far as health care delivery than ever, are excluded from the definition of the United States health care "spiraling down the drain".

Or was US health care being sucked down the toilet by a malfunction in the waterless vacuum toilet from 2000 to 2008?

The only way Obamacare is failing is by paying for the medical care provided with taxes, and Republicans want health care paid for by the tooth fairy and God showering mana from heaven that can be sold at 1000% profit.

Then they can pay for it and need no federal help. I absolutely support states experimenting and passing health care laws. The beauty of federalism.

If the liberal states want to pass single payer and band together to negotiate prices there is literally nothing stopping them.

You can have MediCal cover everyone in California. Tomorrow. Just you have to pay for it.

I call that a deal.

One that deports about 20 million illegal immigrants and their children.

My guess today is that something unpopular will pass, and that GOP senators count on partisanship counting more than personal harm.

Essentially "sure my premiums went up, and I was slapped with benefit caps, but I am not a socialist!"

"Essentially “sure my premiums went up, and I was slapped with benefit caps, but I am not a socialist!”"

Agreed, some people have ethics that prevent them from wanting to use other peoples money forcibly taken for their own benefit. As a society we've always agreed that everybody should pay a share for the common good However, the US has current Federal tax system that is one of the most Progressive, least fair tax systems in the OECD.

"As a society we've always agreed" but "some people have ethics" to what .. complain that the "common agreement" is "force?"

What else is new.

"complain that the “common agreement” is “force?”"

You need to be specific? What "common agreement" do you mean? And if you mean taxation, of course it's force.

Do you acknowledge, nay commit, to citizenship in the collective entity known as The United States of America?

Because if you do, tax is pretty explicitly apart of that bargain.

Not true. The US tax system is overall fairly proportional to income, and is not steeply progressive.

"Not true. The US tax system is overall fairly proportional to income, and is not steeply progressive."

I wonder how you can be that deeply ignorant. I specified the Federal tax system and it is steeply progressive.

Figure 1 illustrates it rather well.

To blurb .. "the most dramatic changes in federal tax system progressivity almost always take place within the top 1 percent of income earners, with relatively small changes occurring below the top percentile. For example, many of the recent tax provisions that are currently (2006) hotly debated in Congress, such as whether there should be a permanent reduction in tax rates for capital gains and dividends, or whether the estate tax should be repealed, affect primarily the top percentile of the distribution—or even just an upper slice of the top percentile. This pattern strongly suggests that, in contrast to the standard political economy model, the progressivity of the current tax system is not being shaped by the self-interest of the median voter."

Reminder that if we reduced the spending on healthcare to rates per capita similar to other OECD countries our economy would shrink by 10%. Nobody in power wants this. There is yet to be an incentive to reduce costs.

Uh, no.

"National Healthcare Expenditures grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP)."

OECD average per capita is around $3500, but we lets assume we can get down to Germany's level of $5000. That is a reduction of total spending from $3.2 trillion to $1.6 trillion, also known as a $1.6 trillion reduction of gross domestic product. You're right, more like a 9% reduction.

Uh,,,,Looks like I've been cucked again!!!!1111

Well, you could take up internet stalking. Great fun. For a while.

Yeo until you become a cuck like me!

Your original statement still doesn't make sense.

There is no incentive to reduce costs.

What are the results of bringing per capita spending down to Germany's levels? Half of the healthcare industry's revenues disappear in a massive reduction of $1.6 trillion a year. This would affect every company in the sector, a sector which makes up 18% of the US economy.

Revenue expectations would affect debt financing and loans of current companies and would likely bankrupt many if not most. Stock valuations of these companies would plummet on revenues being halved.

Not only would there be massive job losses but those that would remain would have extreme downward pressure on wages. This would affect millions and millions more prospective healthcare employees currently and potentially in training for the future. Healthcare is one of the few decent middle class income jobs left in the country, but not after a reduction of costs to standard levels.

No politician wants that, no healthcare industry worker wants that, no investor wants that. It would blow the lid on many wrong conceptions of the strength of the economy and the country. It won't be meaningfully touched until it fails completely.

HL does a better job making this point, every dollar 'saved' with lower heath insurance or health care costs is a dollar less income for someone.

Has any expert figured out the financial repurcussions of more efficient healthcare spending? That this isn't a widely discussed issue reveals how unserious we are as a people.

@HL: to be fair, capitalism is about (among other things) lowering costs, and the idea is that money not spent on food or clothing or energy or medical care or anything that declines in price gets shifted to some other spending on something else. So overall GDP doesn't go down, the consumption basket shifts.

It is sociologically interesting. I'm amazed by the relatively mild reaction from Democrats. Image, if you will, the sound of the Republican opposition if Russia had helped Hillary win the election, she had a stroke that wiped out her management abilities, speaking abilities, and understanding of how government worked, she gave away classified information to the Russians in a meeting in the oval office, fired the FBI director, and then helped write a bill reorganizing 1/6 of the economy. In secret. Hmmm?

The mild reaction of Democrats compared to the lurid, extreme reaction of left Twitter is an interesting contrast.

Obviously, the Democrats are being kept in line because the Republicans are holding back videos of high Democratic party officials participating in a pedophile sex ring operating out of a Washington pizzaria. One misstep, and the Republicans blow the whole scandal wide open.

The humor of this pales considering that a man was just sentenced to 4 years in prison for believing in and acting on such nonsense.

>Those people are likely to be the folks we most need to stabilize those exchanges: healthy youngsters who don’t use much health care

I mean, that's the crux of it all isn't it? Using healthcare as a way to transfer wealth from poor young people to rich old people. How about no?

That's always been the issue. Most people are fine paying taxes to cover the cost of basic care for the poor. What "healthcare" as a political issue has been since the 90's was about helping Boomers keep their inheritances and now their savings. In the Clinton years, healthcare reform was about making sure the old people were not spending their Boomer kid's inheritance. Now it is about making sure the old Boomers can keep their club memberships and their condos in Florida.


I'm beginning to wonder about my husband's relationship with this particular intern.


It is curious how one often mistrusts one’s own opinions if they are stated by someone else
Douglas R. Hofstadter

One of the few areas where Obamacare was ahead of its time was mandating coverage for contraceptives, setting aside the social engineering question of whether we should be reducing our native work force. The only mistake they made was not including edible underwear, personal lubricants, alcohol, pornography, and trips to Hawai'i as covered expenses.

Hazel Meade's point and missing it:

"Presumably consumers will figure out what sort of things they want insurance to cover. Prior to the ACA, amazingly, insurance covered cancer. It didn’t require a federal mandate to make insurers cover cancer."

Covered unexpected cancer...meaning you didn't have cancer at the start of the year when you began the policy nor did you fit the profile of someone who might have a higher than normal chance of getting cancer. Of course you might have coverage from your job but employer based insurance doesn't allow the boss to selectively deny coverage via pre-existing conditions or sliding premium scales.

I think your issue is that you don't like the lack of free market ideals you see in Obamacare but you're not seeing other proposals are essentially shell games. Proposals for letting people 'choose coverage' and letting insurers hit pre-existing condition come with 'risk pools' which essentially means those who have serious chronic conditions will be covered by taxpayers (either explicitly or via roundabout subsidies to insurance companies).

The 'shell game' here is you open up insurance markets to be more free market by making more of actual health care less free market. You get insurance coverage that's highly free market based for medical expenses that are either very discretionary or very large and sudden but if you have a chronic disease or condition you are sooner or later going to end up in a non-free market system of either gov't care or the gov't providing you with a very high subsidy.

But this doesn't seem very honest to me. You can carp about 'free market' in one area only by making it less free in another.

Here's the point. At least with the Obamacare model the subsidy is explicit and so is the cost. If you get a subsidy of $200/mo you know a $350/mo plan will cost less than a $400/mo one. That is a lot more transparent and market based than employer provided coverage where a lot of the cost is hidden from your paycheck so you don't even realize your '$100 /mo policy' is just the tip of the cost iceberg. The deductibles mean that unless you are really sick, you are bearing the brunt of costs so it pays to spend wisely wherever you can. It means that if you are running an insurance company it pays for you to negotiate better rates with doctors and hospitals and push back against high cost drugs and treatments that provide little value.

It appears to me the issue many 'free market' types have is that they want to exploit dislike of Obamacare to push their ideas for reform but for the most part the thing people dislike the most about Obamacare is its free market aspects. High premiums, deductibles, limited networks of participating doctors, sorting through different plans by different providers....these are what you contend with in a free market based insurance system. What people like is socialized coverage which is what Medicare/caid is as well as the gold plated job based health coverage offered by large corporations which get serious tax subsidies for providing.

It's a bit like a vegan group running for office against a guy who runs a chain of steakhouses by telling voters his plates have too many yucky vegetables and too little steak. The public may indeed feel the guy is skimping on his steak but ultimately there's no way to ideologically reconcile what they want with the vegan groups' ideology.

I'm in favor of having high-deductible policies which are designed to cover ONLY unexpected medical expenses. Which is to say, I want health insurance to behave like normal insurance. You get insurance to hedge against the risk of a large unpredictable expense, not to cover small or predictable expenses. The rule of thumb is you shouldn't buy insurance for expenses you can afford to pay out of pocket - otherwise, you're just giving free money to the insurance company.

The pre-ACA market was heavily distorted by government tax incentives to purchase insurance via one's employer. This created all sorts of distortion in the market, because employer-based insurance incentivizes overuse. Due to the tax-deductible nature, it makes financial sense to have it "cover" things that insurance would normally not cover, such as small predictable expenses. And due to the fact that iti s group insurance, it shields consumers from the consequences of overuse.

There is no reason to think that this sort of coverage - high deductible, covers unpredictable high-cost medical expenses, wouldn't cover cancer. It might not cover maternity (at least not for a planned pregnancy), or birth control pills, or annual checkups, but it would cover cancer, because cancer is (usually) a sudden large expense. It might charge people who smoke or have a cancer history more, but there's nothing wrong with that.

Now, there are other market based solutions to things like chronic conditions that people have proposed. Things like term health insurance or meta-insurances. Say you have a 10 year policy where you are renewal at a similar premium, as long as you stay current. Or say you buy a rider that protects against the possibility of steep premium increases. There's lots of ways to solve problems that are basically a matter of paying a fee to protect yourself against risk. It's what the entire insurance industry exists to do.

'Which is to say, I want health insurance to behave like normal insurance.'

No other country in the industrial world, all of whom provide health care to essentially all citizens at a cost that is at least a third less, believes in or practices such a system. Health care is not about insurance, no more than 'clean water' insurance would be. Providing clean water to all citizens is considered part of a normally functioning advanced society, in the main. Where the benefits for the individual and for society are obvious to all.

Or one can look at the cholera epidemic spreading in Yemen to see how things look where such a perspective is not shared, much less followed.

'There’s lots of ways to solve problems that are basically a matter of paying a fee to protect yourself against risk. It’s what the entire insurance industry exists to do.'

Health care is not about risk - all of us were born, most of us will age, and all of us will die. Without going too deeply into it, this is precisely the sort of attitude that makes no sense to basically anyone living in a country with a functioning health care system, where all pregnancies are covered, for example. The term 'insurance' (which is certainly used in other countries too) tends to really confuse the subject when applied to the U.S. On the other hand, considering how uniquely screwed up the U.S. is in this area, it isn't as if anyone in the rest of the world needs to pay even the slightest attention to what is truly an exceptionally American mess. Starting with the simple fact that the American version of a health insurance industry does not exist.

A blanket assertion that the provision of health care is just something that government should provide, because BECAUSE, is not a very compelling argument.

First, health care is not provided by the government in Germany, it is a private health care system (leaving aside AOK).

Second, the idea that a society denies health care just because is not only not a compelling argument in Germany, it is considered both amoral and non-Christian. The point I was trying to glide around is that most people in Germany find the American health care system barbaric, and they had also, quite incorrectly, assumed that Obama had been able to bring America up to a civilized level in terms of all American citizens finally being able to enjoy at least something approaching the sort of health care that is considered routine by all Germans.

You're more wrong than wrong Hazel. It's totally compelling because ALL the lab work and field work is DONE, and it shows that the healthcare system involving the completely government subsidized approach is superior in every way and every respect.

Bottom line, you want a healthy, vibrant, growing free market economy, then completely socialize the healthcare service sector. To argue otherwise--in all possible universes--is to court insanity.

I agree with what you are saying Hazel. But there's the critical problem of people who instead of buying healthcare insurance spend it on consumer goods. For most issues, society doesn't care. If a homeowner doesn't purchase insurance and the house burns down, there will probably be a charity event to get some of their household goods replace, but the local community isn't going to replace their house. And if they don't have car insurance and lose their car, then they can walk.

But as a society, we've decided it's unfair to allow people to die, because they are short sighted. So, we will pay for their health care even if they don't.

Here's a logical model that tries to strike a middle ground. And I know a strict Libertarian will hate it, but they need to suck it up. That's what compromise is about.

a) Congress passes a VAT tax with as few exemptions as politically possible
b) Everyone is required to have a Very High deductible health care plan (think $20K per year / $200K lifetime )
c) Everyone with children must have a Medium deductible health care plan ( $1K per year per child )
d) Plans have $0 coverage until deductible is hit
e) Children's plans cover 1 pediatrician visit per year
f) The VAT tax money adds subsidies to bring everyone's insurance premium down to no more than 8% of gross income
g) Employer health insurance premiums become taxable, with a phase in period of no more than 8 years

'But as a society, we’ve decided it’s unfair to allow people to die, because they are short sighted. So, we will pay for their health care even if they don’t.'

Or, of course, you could mandate everyone able to pay to contribute to the health care system. Like in Germany, where essentially all children are covered for free - this includes dental visits and vaccinations, along with any medicine for children not having the light co-payment requirement for adults.

We won't pay for their healthcare. We'll make sure they don't die, and then let them go bankrupt. I'm perfectly fine with that. Medical bankruptcies are cosmic justice for not buying insurance.

Caveat - there are legit problems with people getting kicked off their employer-based plans and winding up uninsurable, but those are solvable without guarenteeing that any boob with terminal cancer can walk through the door and demand coverage at no additional charge.

With the cost of healthcare so high compared to the average amount of assets there is little incentive for tens millions to carry insurance if we just made bankruptcy de jure.

We definitely need to establish functioning price signals to bring down the cost of healthcare. Having third parties involuntarily pay for everything definitely isn't going to help with that. Whether that is taxpayers or people being forced to buy expensive insurance policies they won't use.

If we have better signaling on healthcare prices where do you think we'd end up in terms of average healthcare costs. Do you think we could cut our prices in half so they'd be more like Germany's?

Funky Kingston is a good tune, it's no grand funk railroad, and new York smells funky, G-funk is okay, but on the corner is where classical music became avant garde in the programmatic sense.

'We won’t pay for their healthcare.'

You already do - the U.S. spends more government money per capita on health care than all but two other publicly financed systems, while providing much worse results (such as the large number of people without coverage - a number set to increase, by the way).

At this point, let me yet again cite this passage - 'Public spending on health care amounted to $4,197 per capita in the U.S. in 2013, more than in any other country except Norway ($4,981) and the Netherlands ($4,495), despite the fact that the U.S. was the only country studied that did not have a universal health care system. In the U.S., about 34 percent of residents were covered by public programs in 2013, including Medicare and Medicaid. By comparison, every resident in the United Kingdom is covered by the public system and spending was $2,802 per capita. Public spending on health care would be even greater in the U.S. if the tax exclusion for employer-sponsored health insurance (amounting to about $250 billion each year) was counted as a public expenditure.'

America's health care system is deeply screwed up, in large part because Americans seem to reject the principles which underlie the health care systems in other industrial countries. But this begins to stray into questions which the people running web sites like take extreme pains to dismiss, fairly effectively after more than a generation of constant work to influence American political perspectives on their part.

And while this current debate is about health care, the real purpose is to ensure tax cuts for the rich by cutting (fairly inadequate, by other country's standards) health care to the poor.

'Medical bankruptcies are cosmic justice for not buying insurance.'

The very idea of medical bankruptcy being 'justice' when it involves a 2 year old having cardiac surgery is the sort of thing that makes these American health care debates so horrifying fascinating to someone who still wonders how any person can believe such a thing.

'without guarenteeing that any boob with terminal cancer can walk through the door and demand coverage at no additional charge'

Yet, that is actually how it works here in Germany, leaving aside the point that Germany has had something resembling a universal health care coverage mandate for a century and a third (a very important point, but this idea is apparently unacceptable in American terms) But yes, if I were to suspect I had cancer right now, I could walk through the doctor's door, be tested, and if found to have cancer, I would be treated at no additional charge. If I had a five year old, the same would apply, even though that 5 year old had never paid into the system, and from a certain perspective, their health care coverage was being paid for by everyone else. (Of course there are limits and frameworks - cancer treatment is done according to certain benchmarks, and bad luck if you wish to receive experimental treatment costing a quarter million and cannot pay. But this is equally true in the U.S.)


A fair response but that does alter the fact that this actual debate is unfair. Voters hate the type of care you are proposing, they hate Obamacare because it has elements of that type of care that older systems like Medicare do not. Yet the debate against Obamacare is attacking it for the very things that would increase under any reform you proposed.....higher premiums, more gaps in coverage, more deductibles etc.

"You get insurance to hedge against the risk of a large unpredictable expense..."

Because this is what insurance was 1000 years ago? Coverage against shipwrecks.. I might as well say a 'normal' bookstore doesn't sell groceries so Amazon's purchase of Whole Foods should be opposed. Fact is you are paying for more than just a hedge with insurance. Take auto isn't just a hedge against an accident but it also is probably a buying network that controls costs for repairs, some extra services like roadside towing, even preventative services (many auto insurance).

And these days medical care is simply moving away from the 'one big event' into chronic disease management.

"but it would cover cancer, because cancer is (usually) a sudden large expense. "

My wife has cancer, has for several years. Most realistic best case, costs will be in excess of $100K but probably not above $150K each year from now until forever. Even a complete remission would leave costs around $3K per year or more (assume she will never be able to leave behind a yearly pet scan from not until forever). Practically no amount of aggressive savings would have prepared us to cover those types of costs out of pocket. Nor could you make this out to be a rare event like your house burning down that you could cover with a reasonable policy. Between diabetes, heart disease and cancer, a majority of us will get one or more of those things before we die of old age (BTW, Alzheimer's might end up being the next big player in the chronic disease market). The "I broke my leg and need to pay to have a cast done" model of healthcare is simply not reality anymore.

The fact simply is your proposed solutions are not going to alter the reality that you are advocating less of a free market in one area to offset making the 'regular insurance' market more free market based. A system where we maintain long term health insurance for chronic diseases would require a lot of regulation. For example, we would have to require companies to accept patients from other companies without increasing the premiums. Otherwise how would you secure a benefit for maintaining continuous coverage without a gap? Likewise you're either going to end up giving people huge subsidies and/or imposing a mandate on them. You're not going to be able to easily hold people to not having coverage because they let their policies lapse in their late 20's when they were acting young and stupid and now they are in their 40's with a chronic condition.

In a slightly different universe I could see the House bill making an honest and serious case for itself. Let 'regular insurance' be more free market but a different 'chronic' type insurance develop with subsidies so patients can afford to buy it and insurance companies could compete by trying to negotiate better rates from providers and push back on expensive but low value treatments. But that's not any more 'free market' than Obamacare and Obamacare still retains the free market idea of consumers picking insurance companies based on premiums, deductibles etc. with each insurance company understanding that they cannot compete by kicking off the sick.

Not in any sense except to illustrate another reason why these health care debates are so different in the U.S. than anywhere else, it is simply not true that your wife will be treated or tested 'until forever.' In Europe, people die, and this is accepted - no one is committed to spending an additional €30,000 euros to keep an 87 year old person alive an additional 2 days after their fifth stroke while in the hospital. Your wife's medical costs well continue until she dies, an event hopefully far in the future. But nobody has health costs 'until forever.' Again, just to illustrate a major difference between the U.S. and Europe, one that is definitely reflected in health care costs.


Thanks but I think actually what will happen in the future for my wife would be the same whether I was French, British, or an American professional w/employer provided insurance. Either treatment would continue until chemo/therapies lose their effectiveness or side effects become too bad, or remission would happen and treatment would eventually stop but periodic PET scans would be done for the rest of her life to see if it comes back.

Being 87 would be 43 year into the future for us so I'm not even going to speculate about that. If that comes we'd be on Medicare and who knows what types of treatments would be available then. I'm not going to spend too much time planning for that just like I'm not going to worry in 40+ years we will all have flying cars and those with flat roofs will have a cost advantage in having a landing pad installed.

But here's a point to consider. Consumer driven health care is really not an option for me and since my case makes up the bulk of health care spending it isn't an option for our economy. A higher deductible for me (currently $400 per year in network) simply means instead of paying a $400 per year tax, I'll spend $1000 or $2000. Even in the best case scenario, the first PET scan will eat up my deductible and unless we get a remission that goes on for decades I'm going to be doing at least 2 scans per year. On top of that the newer drugs coming out now are 'maintenance ' drugs which means they try to extend your time in remission as long as possible so you can avoid going back to chemo. They, of course, run around $15K per month so that's the end of 'shopping'.

So fact remains no amount of reasonable 'saving' ahead of time in my 20's or 30's would have been sufficient to handle a $10K per year deductible plan let alone simply paying out of pocket. I suppose in a different universe I could have spend $50 a month to buy some type of long term catastrophic million dollar policy that would have kicked in and cover me now....but then would I have done that? Probably not unless the gov't required me too.... Or we could have a 'free market' today but the gov't would cover my case with special 'risk pools' or subsidies.

So we return to the problem I pointed out with Hazel's position. The 'free market' here is a shell game. If taxpayers are covering me, then a lot of health care will not be anything like a free market because I'm pulling a lot from our health care system and I'm pulling from its cutting edge. Even if the 'who takes care of little johnny when he has a sniffle' is provided by a free market system that would make Ayn Rand blush, how does this address what I see? The answer needs to be something a bit better than "well I'd be fine if I was a perfect economic agent and spent money when I was much younger buying special riders provided by the insurance industry". Ask yourself not how the system would work with ideal economic agents but with sub-par economic agents. How, for example, would a proposed system work for a middle aged, divorced single mom who one day finds a lump in her breast while she's 'in between' jobs?

Obama's home state of Illinois is almost in default where not only Medicaid, but all the state government pension and employee health insurance plans are at risk and may well be worthless. California realized passing single payer wasn't feasible and is not far behind Illinois in pension default. Obamacare has failed and the Democrats have lost their minds. Ms. Palin's predictions of death panels will come into being in Illinois because due to Obamacare and default.
Republicans have agreed for many years on a contract of sorts for healthcare which includes;
1. Medicaid block grants to States with a review process in place
2. HSAs
3. Tort reform
4. Buying insurance across state lines
5. Forming group insurance pools to bring down costs.
I'll add mandating EITC payments to initially fund HSAs and allowing health insurance companies to bid on blocks of Medicaid patients in providing coverage is included in the Senate bill as I understand.
Democrats would allow every state, like Illinois, to fail and would allow everyone to lose their coverage.
Republicans should not forget G.H.W. Bush's "Read my lips, no new taxes" pledge. Only Gingrich's "Contract with America " brought back Republicans from Bush's weak kneed compromise and the contract balanced budgets. Republicans need to end Obamacare now or they'll demonstrate their lack of credibility and spine which Democrats will campaign on in the next election.
Wikipedia lists about 5 people over 112 years old in the U.S. - the Social Security Administration still has 6.5 million people over 112 on the rolls because death lists haven't been updated. Imagine all the possible waste, fraud, and abuse in our hacked Social Security, Medicare, and other systems using SSA ID numbers. 
Republicans should repeal Obamacare and establish a new Federal ID system using blockchain technology or something more secure. Imagine the savings.

Health is very important and we have to be very wise about it. I believe if we are not careful with keeping eye on health issue then we could struggle big time in everything we do. We will never enjoy if we are not up there in terms of health. I always take care of my health at highest priority which is easier with business like Forex, as I can work it according to my wish and through OctaFX, it’s even easier!

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