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Maybe it’s because I’m a Brit, and we have the national health service. Every man, woman and child in the UK is entitled to free healthcare from cradle to grave. [...] America is a bigger country so free healthcare is off the table. I get that.

I don't understand this argument at all. The NHS in the UK doesn't appear magically free from the sky because we've only got 60 million people. We pay for it through general taxation. This year it will cost about £110B.

Is it really the case that there's an argument that this can't work in the US because there are more people?

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No. Of course not. We have one person here per capita, just like the UK. If anything we'd get more economies of scale. But it would be socialism, and therefore inherently antithetical to the desires of every right-thinking American.

Since we cannot even fund IHS for a full year at a time with significantly less people than the entire US population, I think you might want to look at what the actual funding versus cost would be.

http://richheape.com/american-indian-healthcare.htm

Seems like a non-sequitur?

The problem with the way that Native Americans are treated in the US is a lack of political will and the totally fucked power dynamic between the political institutions that have (or have not really) developed in the shadow of Western dominance of the continent.

Canada has universal healthcare and health outcomes for the First Nations are poorer there too. It's really not an apples to apples comparison, since there's so much other fraught bullshit involved.

So, who exactly is going to protect the small business owner or the poor soul who now has to work two jobs each under 20 hours?

The point stands, if we in the USA cannot get it right for IHS or VA, then we won't get it right for the majority. If you cannot do the little things, don't expect to do the big things.

The act (which I am sure the author has not read) has already cost people insurance and failed at reducing costs for everyone else. It cut medicare money (read the act), and reduced the effectiveness of the non-employer health saving funds. We are more dependent on employers, not less. It bungled the wording of the exchanges to screw up the tax benefits (perhaps public review would have helped this point). I await the report that the fraud prevention in the act hasn't resulted in the required savings.

Uh? Maybe you didn't read what i said?

The IHS nor the VA are representative of the US population, nor are the politics around Indian or veteran affairs representative of how politicians deal w/ the general public.

Nor is there necessarily a connection between small and large projects. What's the political will to get these small things done? What are the consequences when they fuck up? Does it threaten a politician's chances at getting reelected? Is it likely to hurt industry's bottom line? Is it going to generate a significant amount of negative press?

Small projects are not necessarily representative of the governments ability to get things done, and the IHS as i've pointed out is definitely not representative for a whole pile of reasons.

I also don't get why people are so concerned that it cut medicare money. Isn't the point to reduce how much medicare costs?

Yes, I read what you wrote and disagree with it. I have seen no evidence that the USA can execute on massive projects when it has shown no ability to do it in pilot programs. If the VA and IHS don't represent the pilots for this bill then what does? That is one reason there is a fair history in the USA of pilot programs. In the US, small projects are fair predictor of larger success because of a pilot first culture.

No, the cut in Medicare is justified by the saving from fraud detection. Perhaps you are thinking Medicaid?

That is a different argument from your initial assertion.

The IHS's failure is not an indication that the us government can't execute on healthcare.

Additionally there are plenty of regulatory agencies in the US that do a phenomenal job at what they do even in the face of dire circumstances, the FDIC being a really good example. Literally hundreds of banks went out of business between 2008 and 2010 (see: http://www.fdic.gov/bank/individual/failed/banklist.html ), and the FDIC unrolled those institutions, found other banks to take over depositor accounts, without any substantial problems.

The government can and does work, even if it doesn't always. The question is how can we ensure that government's interface with the healthcare system is one of the systems that does work.

> That is a different argument from your initial assertion.

No, it is the same - the government failed with less people and now is attempting something with almost all. I then added information about how the US government generally goes about social programs (pilot -> nationwide).

> The IHS's failure is not an indication that the us government can't execute on healthcare.

Yes, it is.

As to the rest of your post, I did not and have not argued that the government doesn't do some decent things in other fields. The FDIC unrolls have happened before 2008 and they have a plan for it that worked in the past.

Once again, they are attempting a lot of stuff with no previous experience, uncertain regulations (even now), and failure in their two previous large scale programs (IHS and VA). Add to this resistance from states and even doubt casting by Senators and Representatives that voted for it, it has very little hope of working.

If the VA and IHS don't represent the pilots for this bill then what does?

Medicare? It's hugely popular and keeps prices down despite serving a population that over-utilizes health care.

It would have been a good start. Figure out how to get the fraud down and fix the payment / paperwork. Pilot a few different schemes and look at some of the state programs. Cutting the funding was not the most brilliant part of the bill.

If you're looking for a specific pilot program for the affordable care act, how about the Massachusetts law? It's not quite as popular as medicare, and it looks like MA residents don't think the law is perfect, but they also seem to prefer it to not having it at all[1]. I don't think anyone who is serious is saying it is a failure.

[1] http://www.politifact.com/truth-o-meter/statements/2011/may/...

It wasn't run by the Federal government and really doesn't have most of the characteristics of the final law. Its a different beast.

[edit: can we stop treating PolitiFact as if its not bias - there math handling is spotty at best and their half-truths are also biased]

I really don't get this attitude some Americans have that any kind of public service designed to make the lives of your less fortunate peers just that little bit easier is some how a bad thing. It's as if 70 years of brainwashing that all "commies" are evil has irreparably warped their brains and now any piece of legislation that doesn't propose proverbially kicking struggling families in the "nuts" is seen as socialism and, by extension, wrong.

Capitalism is all well and good so long as peoples lives are not put in danger; and I'm not talking about luxuries here, I'm talking about whether people live or die. But what we have happening instead is a closed market dominated by a small number of monopolistic drug companies who abuse patent systems and extort their customers just because they can. Surely at some point, even the right-wings have to appreciate that neither closed markets nor putting peoples lives put in danger because of the greed of the few is neither in the spirit of capitalism nor the Christian thing to do (and I only reference the last part because of the emphasis that many right-wings place on religion).

One 'good' thing about the Cold War was that it 'put the fear of Communism' in the heart of every Commie-fearing capitalist.

We had a moral obligation to be seen as and actually provide a better life than that experienced by those behind the Iron Curtain. We had to pay attention to the negative aspects of market-based economics and at least attempt to mitigate these problems.

It also showed people what 'real' communism looked like. It's big joke that people think we're measurably closer to anything resembling socialism.

The idea that capitalism itself is a moral end to achieve in and of itself, regardless of the reality, seems to have taken root. People who are left worse off are dismissed as stupid and lazy.

As someone with an economics background I'm strongly in favor of markets and capitalism, but it's worrying when people forget that the strength of this way is based upon the health of the economic institutions that enable it to function.

> it's worrying when people forget that the strength of this way is based upon the health of the economic institutions that enable it to function.

...which would be markets, correct? There is no free market for welfare.

Right, markets are an institution but not the only one. It's a problem that people forget and think it is only one we need.

Economic institutions encompass everything that allow it to function including basic ideas like private property rights, rules and regulations that enforce contracts, and functions that account for the welfare of people.

Markets are what people with diverse motivations and rights to dispose of their property "do" when they wish to dispose of their property (or deliver services) or when they wish to acquire new property or have services performed. The market as a concept isn't something handed down by the gods, nor instituted by decree.

I agree that there are other concepts that dispose of people's "property" and require them to seek or deliver services; in the past we called them things like theft, war, and slavery.

> I really don't get this attitude some Americans have that any kind of public service designed to make the lives of your less fortunate peers just that little bit easier is some how a bad thing.

I think the problem is we like to have the freedom to select our charities (and charitable giving amount) rather than have them forced upon us by statute.

It's not a charity though. It's about providing a minimum service for people. Even with "free" health care in the UK, it's not free (it's paid for via National Insurance taxes and many facets still have additional costs (prescriptions, regular dressings, dentistry, etc) albeit often highly subsidised.

Surely it's better to have a subsidised minimum service than to rely on charities?

And more over, if your objection is purely because you don't want to be told that you should look after your fellow Americans, then that's either a really sad representation of how little respect Americans have for their kin, or the facet of a childish mentality where kids deliberately disobey their parents because they like to test their boundaries. Either way, it's just a terrible attitude to have.

> Surely it's better to have a subsidised minimum service than to rely on charities?

See, it depends on who you are. If you are a well-connected member of the political class you prever to give charity because it's you who directs the flow of money. If you are part of the unwashed masses you prefer a subsidy, because there is the democratic process involved, and experts in public policy and the general public might have influence what is done with the funds.

> Surely it's better to have a subsidised minimum service than to rely on charities?

No. Charities have to maintain efficiency because they are not subsidized, if they want to continue to operate they need to prove to contributors that their contribution is going to the cause to the extent that a market critical mass of contributors cares to know.

> if your objection is purely because you don't want to be told that you should look after your fellow Americans, then that's either a really sad representation of how little respect Americans have for their kin, or the facet of a childish mentality where kids deliberately disobey their parents because they like to test their boundaries. Either way, it's just a terrible attitude to have.

Effigies should only be burned in street protests when there are teeming masses to rile up. They are less effective in print.

> No. Charities have to maintain efficiency because they are not subsidized, if they want to continue to operate they need to prove to contributors that their contribution is going to the cause to the extent that a market critical mass of contributors cares to know.

Having worked for a number of charities, I can promise you that not all charities are efficient. In fact some are even worse for wasting money than government bodies.

What's more, most people pay even less attention to just how efficiently their money is put to use in charities because: 1) it's considered bad etiquette to question charitable organisations, 2) it's assumed that charities are full of volunteers working for free on a shoe string budget out of the goodness of their hearts.

The reality is, many charities are run as businesses - with high paid salaries and paid expenses just like any other business. Obviously I don't want to tar all charities with the same brush, however my experiences certainly call BS to your generalisations.

> Effigies should only be burned in street protests when there are teeming masses to rile up. They are less effective in print.

That doesn't make the slightest bit of sense. I'm assuming you're objecting to my comment, but given the brevity of your previous post and the context of my comment that preceded it; it's hardly surprising that I took your reply to mean what I suggested it may have meant.

However with you now expanding on your point, I now realise that your lack of comradeship is based on blissful ignorance rather than pure selfishness (though I suspect there's an element of selfishness driving the lack of motivation to investigate this topic otherwise you'd be advocating people giving up their free time caring for the less fortunate rather than complaining about who gets your money)

Government-sponsored monopolies produce economy-wrecking effects. National health systems are that.

How to fix the American health system in several easy steps, from a governmental perspective:

* Stop all current governmental subsidies

* Outlaw medical insurance

* Purchase expensive medical equipment, and most importantly the means of production of such equipment, and resell to new medical enterprises at a reasonable price (most likely resulting in a severe loss)

* Provide a matching program on qualifying doctors' medical school debt

* Radically reform and/or remove medical licensing programs to focus on apprenticeship more than academics

* Reform pharmaceutical patent protections to allow drugs to proliferate freely

This will get us to a ground-up, self-sustainable medical system that is based on ordinary rules of supply and demand, without giving a blank check to the administrators of the current system, which is already irrevocably corrupted by paper-pushers. The whole thing just has to be torn down and started over.

In an ideal world I'd probably agree with you. But what you're proposing is even less likely to happen (particularly the pharmaceutical patent reform) that a national health system.

That is a fancy way of saying "we don't like to share". There is no matchingincrease in charitable giving when tax burden changes suddenly.

Oh, it's because USians hate giving. Totally makes sense.

Oh, wait. https://www.cafonline.org/pdf/World_Giving_Index_2011_191211...

> That is a fancy way of saying "we don't like to share".

I like to share with my family, not the collective mass of Americans who make less than me; whose sole claim for charity is that they make less than me.

The lack of consistency is what gets me.

- You have the RIGHT to education in the United States.

- You do NOT have the RIGHT to be alive to be educated.

* Additionally, you MUST treat someone in the ER if they are dying, but if they will be dying a week from now, send them on their way.

That is one thing I give to hardcore libertarians, they seem monstrous at times (no public schools, let sick people without insurance die, can't afford food then starve, etc) --- but at least they are consistent and honest. Also, they will claim that private companies / charities will stop this horrible stuff from happening.

>(no public schools, let sick people without insurance die, can't afford food then starve, etc)

Just want to emphasize (I see your little tacked-on afterthought there) that just because a libertarian doesn't believe the money to do these things should be forcibly extracted from the taxpayer's pocket doesn't mean that they believe people should be left to die. They simply trust non-governmental entities to capably care for their fellow men. It's about the proper role of government, not Darwinism.

As an example, consider Social Security. The government told us that they needed to save our money for us, since we were too stupid to do it ourselves. And now they've spent it all. lol?

> If anything we'd get more economies of scale.

No, because there are also diseconomies of scale. Some services are best provided by smaller-scale organizations than an entire nation, much less one the size of the US. It is perfectly plausible that a service that worked well for the UK might not work at the scale of the US. Making an organization bigger means adding more layers of bureaucracy, which puts the ultimate decision makers farther away from the problems they are trying to solve. It also creates more room for resources to be absorbed by political infighting within the organization.

Which is why here in Canada the health care is provided by a province-level organization, which is partially funded by the federal government.

Then maybe the organization shouldn't be national. The law does need to be national, or Texas and Alabama will send all their sick people to states that provide free care, much as Nevada now buses out its mentally ill.

There's no real argument, but he had to say that in order to not be sidelined as an extremist.

I know it sounds insane, but the average American's idea of nationalized healthcare is something akin to waiting in Soviet Union breadlines just to get an aspirin. There's a whole cadre of talking heads employed full-time to make the rounds on Fox News et al promoting this sort of willfully ignorant line of thought.

There are lots of reasons to be against nationalized healthcare. Some for practical reasons, others for legal reasons -- just because you want something doesn't mean it can skip the legal process which is what obamacare tries to do in a lot of places.

One simple reason to be against it is that the current implementation is crazy bad and has no way of dealing with costs and is anti-democratic. It creates outside bodies that don't answer to congress, etc.

Citations needed. The primary argument used against ACA's constitutionality was struck down by the supreme court [1]. And there already exists at least 50 government agencies that reserve the right to pass regulations without congressional approval [2].

1: http://www.huffingtonpost.com/2012/06/28/supreme-court-affor...

2: http://usgovinfo.about.com/od/uscongress/a/fedregulations.ht...

Unfortunately I couldn't find a great text example but here are two sources on: IPAB

More recent: http://www.cato.org/multimedia/media-highlights-tv/cato-inst...

From one year ago (shorter ~ 7 minutes): http://www.cato.org/multimedia/daily-podcast/ipab-obamacarea...

Ever been to an ER full of Medicaid patients? Soviet breadline is not far off.

Medicaid has some serious problems that are not addressed in the act. One of the main problems is the number of doctors that will no longer take Medicaid (not Medicare) patients. This is generally the result of lots of paperwork and smaller payments to the doctor.

It would have been an amazingly smart start to health care to really focus on the Medicaid patients. Encourage more urgent care centers and fix the payments / paperwork.

Instead, Medicaid is going to get more painful.

Huh? There are no private-access-only ERs, so none to compare against medicare.

Most ER waiting patients are there because they don't have primary or urgent care.

Not at all. We've seen it first-hand and up-close with our neighbors to the north. Taxes through the roof, and the only way to get good care is to "go private."

I severely doubt the average American has any sort of experience with the Canadian health care system whatsoever, let alone "first-hand" or "up-close".

The average American probably didn't even know Canada had universal health care before 2009. Shoot, the average American might still not know that.

Some Americans can't even find Canada on a map.

http://www.pajamadeen.com/world-news/canada/why-americans-ca...

Man-on-the-street interviews show a depressing inability to point to Canada on a globe. Whose hand does your first-hand experience come from?

> Taxes through the roof

The highest federal marginal tax rate in Canada is 29%[1], kicking in at taxable income over $135,054.

The highest federal marginal tax rate in the US is 39.6%[2], kicking in at $400,001. At 135,054 of income, you're in the $87,851 – $183,250 tax bracket, and paying 28%.

Provincial / state taxes can ratchet those numbers up depending on where you live.

> the only way to get good care is to "go private."

Have you ever had medical care in Canada? There are situations where going private will get you much speedier care (for an MRI for a non-life threatening injury, for example, could take you months to get). But generally speaking, going public will get you high quality care delivered on an appropriate schedule (life threatening: right away... not life threatening: appropriately quick).

[1] - http://www.cra-arc.gc.ca/tx/ndvdls/fq/txrts-eng.html

[2] - https://en.wikipedia.org/wiki/Income_tax_in_the_United_State...

[3] - http://www.tax-services.ca/canadian-tax-calculator/income-ta...

[4] - http://www.tax-brackets.org/californiataxtable

As an American living in the UK, I have actually seen it first-hand. This belief that because we border Canada that we somehow have first-hand experience of their medical system is exactly the type of willful ignorance that I was calling out.

> Is it really the case that there's an argument that this can't work in the US because there are more people?

The simplest such argument would be that there are diseconomies of scale - it's conceivable that the bigger you make a bureaucracy the less responsive/effective/efficient it gets. That certainly could be true - whether it actually is is an empirical question.

Another possibility is that our federal system is ill-suited to the task. There's nothing really preventing individual US states from providing such services. And if most states haven't done so thus far - and in the few that have tried, it hasn't worked out very well - there might be reasons for that which we should try to understand.

Interstate immigration guarantees is a factor against single-statd healthcare.

Many individual US states are larger than individual European countries. People can immigrate within the EU, can they not? So why defend the UK or Denmark having its own system?

On the other hand, it could easily be argued that interstate commerce restrictions are a big part of the problem in the US. Suppose some company in Delaware comes up with a really cheap health insurance plan that meets my exact needs - I can't sign up for it, because I don't live in Delaware. For a company to offer health insurance or health care nationwide it has to have offices in 50 states and navigate regulatory restrictions in 50 states.

If McDonald's wants to expand to serve people in other states, they can just DO it, but Kaiser or Blue Cross can't do the same. That situation is ridiculous and needs to be fixed somehow, but I don't hold out much hope for it changing any time soon.

Health costs per capita are actually lower in the uk than the us, even after paying for all the treatment.

The problem is that pur current government are privatising the actual provision of care away from the NHS. Large chunks are already privatised and much more will follow.

We're heading to a situation where the NHS will be more like an insurer picking up the tab.

http://en.wikipedia.org/wiki/Economic_calculation_problem

The federal government can't control healthcare because of this. It would probably work better on a state level (See: http://en.wikipedia.org/wiki/Massachusetts_health_care_refor...).

On top of that I don't think the U.S. economy can handle another massive government program on top of existing ones. I am mostly referring to the wars over seas. No other country spends so much on military. The U.S. spends a ton of money on military (and locking people up for drugs).

If the U.S. stopped those two things I think healthcare will be fine, but it won't. So more shit is just being added to an already inefficient and corrupt government.

Then there is the problem of people deciding that since they pay for your healthcare, they should be telling you how to live. There will be more bands on sugary drinks like in New York (though that was struck down). Or what extreme sports you can play, etc. That really bothers me because it will mean more shit that people aren't allowed to do that only harms themselves.

We can discuss Austrian economics until the cows come home, but in the mean time, the US spends nearly twice as much as the UK on healthcare (as a percent of GDP) [1] and 45,000 Americans die every year due to lack of coverage [2]. I'm glad reform is happening. I wish it were more aggressive.

1: http://www.pbs.org/newshour/rundown/2012/10/health-costs-how...

2: http://news.harvard.edu/gazette/story/2009/09/new-study-find...

I'd prefer reform that removed the current structural inefficiencies instead of piling more on. Reform doesn't necessarily mean more government involvement.

The U.S. government also spends more on healthcare per capita than Canada [1]. Seems pretty socialized to me already. The U.S. government is a corrupt piece of shit. Passing laws mandating health insurance for everyone isn't going to fix things.

[1] http://www.slate.com/blogs/moneybox/2013/01/23/chart_us_gove...

EDIT::

Furthermore, diseconomies of scale are not just Austrian Economics voodoo.[2]

[2] http://en.wikipedia.org/wiki/Diseconomies_of_scale

That chart is admittedly pretty terrifying. But the article itself argues the big reason is because Canada's nationalized healthcare plan has more leverage and price control capabilities than US Medicare. That seems more reasonable than simply attributing it to corruption.

> 45,000 Americans die every year due to lack of coverage

Sorry, no. That claim is often made, but it's just nonsense.

Every time we've had a BETTER sort of study - had the chance to examine a situation in which people are randomly assigned to either have low-deductible health coverage or not have it - there has been no significant health benefit to having the "better" health coverage.

The first such study was the RAND study in the 1970s. The most recent one was the Oregon study described here:

http://www.thedailybeast.com/articles/2013/05/01/shocker-ore...

Quote: "a large-scale randomized controlled trial (RCT) of what happens to people when they gain Medicaid eligibility shows no impact on objective measures of health. Utilization went up, out-of-pocket expenditure went down, and the freqency of depression diagnoses was lower. But on the three important health measures they checked that we can measure objectively--glycated hemoglobin, a measure of blood sugar levels; blood pressure; and cholesterol levels--there was no significant improvement."

Good followup analysis here:

http://www.thedailybeast.com/articles/2013/05/03/how-the-ore...

I'd actually be quite interested to see polling data on this. I wonder if, given the choice, most Americans would choose to continue funding wars/national security or fund healthcare for all. I would actually imagine wars would win in a landslide unfortunately.

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