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You do realize that Massachusetts has had this system in place for a while now, right? The insured rate went from 86.6% in 2006 to 96% today. The uninsured rate is 3 times less than it was just a few years ago.

On this topic, you can look at real data and not rely on idle speculation. I just don't see a reasonable way to draw the conclusion that "the government's expectation that everyone will buy health insurance just because they're enacting tax penalties seems somewhat naive." Unless you literally mean every single last person.

I am not American, but as I understand it, if you earn so little that you can't afford a plan, you can get vouchers to cover the cost. I'm not sure of the specific boundaries and I think it varies per state.

If you detail more information I can always Google.

If I can't afford my lunch after being given so many opportunities to earn it myself, then it would be unfair for me to ask my countrymen to foot the bill. It's my problem, not theirs. I would have an extreme moral aversion to seeking a handout, even if that aversion is to my own personal detriment.

Perhaps I should be trying to maximize every possible opportunity offered to me. But I just can't stomach the idea of taking money away from other people to pay for my own personal problems.

The thing is, what you think is your "own personal problem" doesn't really affect only you. If your neighbors can help keep you healthy and productive, there's a benefit in that for them as well.

"If your neighbors can help keep you healthy and productive, there's a benefit in that for them as well."

Economically and socially, of course, but epidemiologically as well!

If you go to the emergency room with an untreated, preventable illness that has become critical, and you can't pay the bill, other people wind up footing the bill anyway.

Maintenance is cheaper than repair.

Except mandatory "maintenance" doesn't lead to fewer repairs in this case. Google Oregon Medicare study and Emergency Room usage.

A comment from reason.com sums it up nicely: "Emergency rooms are required by law to treat it. If you are poor, they are unlikely to ever collect the bill for doing so. So why would a poor person wait days or weeks to see a doctor then they can go down to an emergency room and see one in hours?

Moreover, if you are being forced to pay for health insurance, you are more likely not less likely to seek treatment since you will rationally think "well I am paying for it so I might as well use it.". The idea that making people buy insurance will reduce overall healthcare costs has always been an insane one."

http://reason.com/blog/2014/01/02/no-obamacare-wont-reduce-e...

> So why would a poor person wait days or weeks to see a doctor then they can go down to an emergency room and see one in hours?

Because if you don't have a life threatening condition, you're not going to see a doctor in "hours" in the emergency room. You're going to be triage'd to the lowest possible slot, and it's my understanding that if they believe you can just be sent on your way, they'll do that. You can't go in for an ear ache.

> Moreover, if you are being forced to pay for health insurance, you are more likely not less likely to seek treatment since you will rationally think "well I am paying for it so I might as well use it." The idea that making people buy insurance will reduce overall healthcare costs has always been an insane one.

First of all, there are plenty of respected folks who don't think that's "insane". Presumably more respected than "John" from the comments section.

But regardless, that's what co-pays and deductibles are for. Let's also not forget that going to the doctor is still not a joy ride. There's forms, and there's a wait. I have health insurance, and I don't take a trip to the doctor's office like it's the local candy shop. Why would the poor, who feel the impact of a co-pay even more than I do?

In Australia you can go in to emergency for anything, but you'll be waiting until there's nothing more urgent in front of you. If you are triaged as having a trivial condition and you insist on a doctor instead of the triage nurses advice you're in for a looooong wait.

You're spot on about doctor visits not being fun. We also have free GP access and people will see a doctor if they have a reason but most people would rather stay home and rest than go out to the Doctor's just because they have a sniffle.

My wife has had a couple mysterious illnesses that sent her to the ER. She saw a doctor within a couple hours. In both instances, there wasn't any life threatening issue. Granted the ER was pretty empty, but waiting a few more hours rather than weeks wouldn't have been a big deal.

Copays aren't that big of a deal when you're in extreme pain. Ours was $100 per ER trip. Surely that would dissuade people with ear aches. Had it been a 20% coinsurance charge, then we probably would have tried urgent care first, or waited longer. But you can see how having insurance (or a certain type of insurance) can affect your behavior, in a way that's not so predictable. Many policy makers were surprised by the results of the Oregon Medicare Study as are many people learning about moral hazard for the first time. It's counter-intuitive.

I can't believe how incredibly bad healthcare is in the United States, as exemplified by your comments.

I live in a country FAR less wealthy than the U.S. (Uruguay), yet basic healthcare here must sound like a science fiction future for the average American.

U$ 50/month gives me access to a doctor that goes TO MY HOUSE in hours in case of ilness (including something like a flu, ear ache or whatever), or I can go to a clinic of said private emergency service, and get a doctor in minutes (yes, they're the least trained and paid doctors, but every single one has at least 7 years of university training).

Every single freaking Uruguayan can be treated for free, and most have access to decent hospital services. Yes, there are some big downsides - getting an operation scheduled takes months, and if you don't have money, quality of life stuff is practically ignored, but not a single Uruguayan has gotten bankrupt due to a severe or life threatening condition, you get stuff up to and including cancer and HIV treatments for free.

And you wouldn't believe how cheap the very best health coverage is, I'm paying for the 2nd best one.. U$ 150/month.

If you have a difficult operation or strange disease, there's no place like the U.S., but for everyday healthcare the U.S. sounds like a Medieval country.

Claiming poverty while not accepting public assistance in the same breath is absurd, unless this is a poverty vow. In any case you represent the corner of the corner, people who would rather take a tax penalty for ethical reasons than accept vouchers. Most people in your position are falling over themselves at the prospect of decent health coverage.

Really? The plans that I have seen that could be purchased with the subsidies is no where near what I would call decent! It may vary by State, and I have only seen the "sample plans" that have been published.

How can you complain about the lack of a free luck, but then not take the free lunch when pointed out that it is indeed present?

People want everyone to be covered, which is how Obamacare got pushed through in the first place. You not getting covored can potential end up costing us more in the healthcare system (healthcare costs being the biggest reason for personal bankruptcy) if you don't take this and use it.

(healthcare costs being the biggest reason for personal bankruptcy)

This is interesting. Is this true?

I apologize if it sounded like I was complaining. I only meant I chose this life. How is it reasonable for me to choose this, and then force other people to pay for me?

The other alternative is that I should feel like a shitty human for choosing not to maximize my earning potential and getting myself into this position in the first place. But part of having freedom of choice is the freedom to choose poorly. It's my own life, a life I'm not burdening others with. If I break my arm, can't afford to pay for it, and then become bankrupt as a result, then I have suffered a personal penalty which society will remember and will punish me for. And while I may have temporarily burdened others by not being able to pay for my emergency care, I've still been penalized as a result, which seems quite fair. Whereas taking a handout to cover the same expense feels like I got something for nothing.

I admit that there are some good arguments in this thread, though, so perhaps I should reevaluate my moral perspectives. But it's extremely difficult for me to become comfortable with the idea of encroaching on other people's lives by force.

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

Relevant bit: "Although the individual causes of bankruptcy are complex and multifaceted, the majority of personal bankruptcies involve substantial medical bills"

http://www.forbes.com/2010/03/25/why-people-go-bankrupt-pers... Here's a citation on the bankruptcy statistic. Its corroborated by many other sources (and many other studies).

No matter what your intentions on the topic, if you end up in the emergency room for a preventable condition (which will lead to more treatment), you will end up costing everybody much more than simply taking the vouchers... take that fact as you will, but statistically speaking it's very likely you'll end up "costing" society more by not participating in the healthcare system.

> I apologize if it sounded like I was complaining. I only meant I chose this life.

That's nice, but earlier you did say:

> I don't appreciate the government intruding on my private life, forcing me to buy a product for at least $200/mo, a $200/mo I literally can't afford. (...) People simply have no money for $200/mo of extra costs.

Which seems rather straightforward. You want to be angry at the government for enacting the ACA, for "forcing" this $200/mo charge on not only yourself but also the "many others" in your same position. You're quite upset at this mandate that you and those many apparently can't afford. Backpedaling only after someone points out the obvious (vouchers, tax credits, etc) doesn't change your original message.

> It's my own life, a life I'm not burdening others with.

You are invited to drop your American citizenship and live on an island. Otherwise you don't really get your life and not be affected or influenced by others. That is a silly idea born out of fairy tales for kids and teenagers.

You are a part of a society. The moment you step out you are on a public street that someone paid for. On a private side-walk that someone else owns. You ride in a public transportation system that someone else has paid for. You are also driving a car because someone has granted you a license after you passed a test. Like it or not you are also protected from random other countries coming in and taking your stuff away by having a very very large military force.

If your house catches on fire people will come in a red car with sirens on it and drag your ass our of the building and save your life.

If someone assaulted you, you can sue them in a court of law and ask the judge to rule in your favor and force the other party to pay you some money.

If you have a family and your break your arm you know cannot earn money for them. It is not just you suffering in silence, now your children, wife, other dependents are now starving. Same happens if you happen to take up heroin and start stealing and not going to work. It is not just your doing whatever you like in a hypothetical bubble. You now your family is starving. You just going about doing your own thing have caused quite a bit of a mess.

> If I can't afford my lunch after being given so many opportunities to earn it myself, then it would be unfair for me to ask my countrymen to foot the bill.

No it wouldn't. I provide it to my countrymen no matter their condition.

> Perhaps I should be trying to maximize every possible opportunity offered to me. But I just can't stomach the idea of taking money away from other people to pay for my own personal problems.

You live in a world where your tax money already is pooled and so you already do take money from people to pay for things as simple as the roads you drive on, or the emergency services you use.

There's no moral argument to not participating. You've paid the taxes and you have a right to the return.

> then it would be unfair for me to ask my countrymen to foot the bill.

That's in your head. Realistically it's in everybody's interest to keep their countrymen happy.

That's true, but obviously the trade-off isn't one-to-one (or better) through all of happiness-cost space. It's important to ask where a particular expenditure falls.

I second the "maintenance is cheaper than repair". If you neglect your health now, and buy into health insurance later, you're asking future me to bear higher premiums and everyone is worse off - you and others. As one of your fellow countrymen presently footing the bill (in that I'm paying taxes and I have good health insurance with no subsidy), I assure you that helping get you covered is no skin off my back.

"But I just can't stomach the idea of taking money away from other people to pay for my own personal problems."

If you're found unconscious somewhere because of an untreated ailment, the "cost to other people for paying to for your own personal problems" will be dramatically higher. If you're conscious, you could maybe refuse emergency assistance, though I'd encourage you not to.

If you really need to make it up to your fellow citizens, meet your civic responsibilities: put thought and research into voting, serve - honestly and intelligently - on juries when called, etc. We ask some of you, it's fair for you to take what you're given without being exploitative.

This isn't exactly correct, there's something of a gap you can fall into.

If you earn very little, you might qualify for Medicaid, which is essentially taxpayer-paid healthcare via the government.

If you earn low amounts, you might qualify for various levels of subsidies on private insurance plans through the state-run health exchanges.

However, there are certainly situations in which you may not qualify for medicaid, and still not earn enough to afford a private plan, even with subsidies. There are definitely people in this situation.

This wasn't unforeseen, it was known it would happen.

The gap is covered in about half the states. The other half don't like Obama so they refused the free money from the feds to cover the gap for their citizens. Can't make this stuff up.

"free money"

Its not "free money", its taxes paid by taxpayers. There is no "free money" in government.

No, the money that was refused did not reduce anyone's taxes, so your statement is false. Obviously, expenditure has to come from somewhere, but when the government operates in a deficit, marginal spending comes from debt, not taxes.

Debt taken out by the government has to be paid by the tax payers in both principal and interest. There is no free money. Not spending additional federal money is a virtue not a problem.

> Debt taken out by the government has to be paid by the tax payers in both principal and interest.

That's not actually true, particularly, there is no necessary reason why, as long as economic growth can be maintained over the long term (even if that's not always the case over shorter terms) a country can't sustainably have an ever-increasing debt balance, without ever paying any of it off other than by issuing new debt.

Even if it was true, if government deficit spending increases stimulate economic expansion, the tax funds to pay for the spending can be produced by the spending.

That's just the kind of thinking that hasn't worked for anyone yet. It didn't work for Rome or anyone since. The collapse always comes when the public coffers are drained.

"if government deficit spending increases stimulate economic expansion"

Which it didn't and hasn't - the best times in our economy were when the government spent and taxed less (e.g. 1946 & 1948 fiscal changes).

"the tax funds to pay for the spending can be produced by the spending"

No, they cannot and that's just twisted logic - you cannot spend your way out of debt

> No, they cannot and that's just twisted logic - you cannot spend your way out of debt

If that was true, corporate finance would be a lot different.

Which company continued to spend money in excess of its revenues and took out debt to compensate then somehow without increasing revenue above spending paid off its debt?

Increasing revenue -- and the source of that increase -- was part of what I pointed to. So your question is irrelevant.

And who pays this increased revenue, the tax payer - so your chain of comments to contradict my original point is untrue

> And who pays this increased revenue, the tax payer

But not out of funds that they would have had without the expenditure. So they have literally given up nothing.

You must have missed how those stimulus packages actually worked or have some view of economics that isn't a reality. Debt has an upper limit and revenue increases mean taxpayers pay it. Stimulus doesn't create any wealth and hasn't worked. There is not one concrete case of what you describe working in history.

The subsidies only start after you earn a certain amount of income. If you earn less than that, you don't get any subsidies. Also, the subsidies won't pay for all of it, and the more you earn, the less subsidy you get.

The original plan was to force the States to extend Medicaid (Government provided health insurance) to cover those that would not be getting subsidies because they made too little. The problem was, the Federal Government was only going to float the bill for this for a few years, then it was going to be up to the States to come up with the money to keep it going! Many States balked and refused to expand Medicaid, citing the fact that they could not afford this massive increase in their budget. The Supreme Court agreed with the States that the Federal Government could not force them to expand Medicaid unless the Federal Government was going to float the bill.

So now, anyone that doesn't earn a certain amount of money will be without health insurance, and the cost of healthcare will be higher for them when they do get sick (For many reasons, such as the medical device tax). Fortunately, for now, if you live in a State that did not expand Medicaid, and you would have qualified had they expanded it, you won't have to pay the penalty tax.

The only reason those states didn't extend Medicaid is that they dislike Obama and what he stands for. It's 100% covered by the federal government for 3 years, and then 90% until 2022. http://obamacarefacts.com/obamacares-medicaid-expansion.php

"It's 100% covered by the federal government for 3 years, and then 90% until 2022."

Exactly this. So, who pays for the 10% after three years? The 100% after 2022? That's right, the State. Sure, maybe they didn't like Obamacare. But that doesn't mean there wasn't a real concern for a very real budget, which the legislature is constitutionally required to keep balanced.

As long as you're cool with bleeding to death on the steps of the emergency room, I'm ok with your not having insurance. But expecting US taxpayers to pay for your treatment (indirectly via higher premiums) while complaining about being forced to buy insurance is, at best, inconsistent.

As long as you're cool with bleeding to death on the steps of the emergency room

And exactly how common of an occurrence is that in the United States? Yes, one can bemoan the lack of preventative medicine and proper follow-ups, but if you show up at the E.R. of most American hospitals with a life-threatening condition, you're going to get treated regardless of how much you can pay.

If we're going to properly fight the problem, hyperbole needs to go out the window.

You read the parent wrong. Their point was that you can't take a moral stand and refuse healthcare when the standard of care is to treat emergencies.

I'm pretty sure you missed the point.

You are right that there is near to zero chance of that occuring. Which is probably what the previous poster meant. Since you can show up with a life threatening issue at a hospital and get stabilizing life saving treatment regardless of your insurance anyone who doesn't have insurance is effectively already leeching.

> if you show up at the E.R. of most American hospitals with a life-threatening condition, you're going to get treated regardless of how much you can pay.

Yes, and taxpayers are going to foot the bill. If taxpayers are going to foot the bill anyway, they might as well do it in a way that is efficient (preventative care) rather than one that is extremely inefficient (emergency care).

It depends on the situation. If a hospital is nearby that specializes in X for area A they won't admit you, will send someone outside to you, and get an ambulance to bring you to the other hospital.

Source: Second hand knowledge. Take it for what you will.

A relative of mine earns around 16k. Family of 3. The result was that he wasn't covered for earning less than 19k.

They gave no tax credits(discounts) whatsoever and took him directly to buy plans for paying the full amount.

There is medicaid but not every state is accepting new people.

This is pretty close to my own situation, and I live in Missouri, which could not afford to expend Medicaid, so no insurance for me. If I do get sick, ObamaCare only makes it more expensive for me!

Solution: move to a state which is not so rabidly against the health of its citizens that it won't subsidize healthcare for those earning below the poverty level.

Perhaps, but that is more easily said than done. For both me (to move) or for the State (to pay for the expansion of Medicaid)- remember, the State can't just print money like the Federal Government can!

As far as moving, I have many other considerations, and my wife and son have good insurance, so I am satisfied to stay where I am (physically) for now while we work on the financial issues.

> Perhaps, but that is more easily said than done. For both me (to move) or for the State (to pay for the expansion of Medicaid)- remember, the State can't just print money like the Federal Government can!

Just to let you know, this is not about the state not having the money. This is about them not accepting the money from the federal government solely out of political spite. And you and your family are on the receiving end of that.

Just so you know, the Federal Government never made any offer to pay for the cost- sure, they were going to float the bill a few years, but after that?.... Yeah, the State would have to pick up the tab.

Perhaps it was political spite, but to say there were no real concerns for how the State was going to pay for it is itself, a partisan, politically motivated statement.

Just went on a fact-checking expedition: http://www.cbpp.org/cms/?fa=view&id=3161

> CBO estimates show that the federal government will bear nearly 93 percent of the costs of the Medicaid expansion over its first nine years.

> The additional cost to the states represents a 2.8 percent increase in what states would have spent on Medicaid from 2014 to 2022 in the absence of health reform.

> This 2.8 percent figure overstates the net impact on state budgets because it does not reflect the savings that state and local governments will realize in health-care costs for the uninsured.

So no, I don't consider my statement to be partisan, given that the facts back it up. Your government just doesn't care all that much about you getting insured.

Every state will have different numbers, though, and I don't know what Missouri's are.

However, you have completely ignored what happens after the 'first nine years'. Sure, a lot of politicians don't care about the future, especially if they don't plan on being in office at that point (or being in a different office). But perhaps Missouri's legislature does?

My understanding is that the feds cover Medicaid expansion for the first year (and partially thereafter for a time?), so "could not afford to exp[a]nd Medicaid" is not quite correct - especially in the short term, though it's possible there's something I've missed (is there a requirement the state continue if they start, that hasn't been discussed? or another gotcha somewhere?). Obviously, there's possible political cost to "dropping people from Medicaid" after the one year, but that being worse than keeping them off Medicaid for that year and forward is... human, but strange.

I'm from Missouri (KC) too and would like to help you search for options. Also, if you are able to run your own business doing what your description says and are pulling in only $20k you might want to look for some corporate jobs. It may not be easiest - but I know a few places in KC are hiring and looking for talent that would pay far more with benefits.

I live about 2.5 hours southish of Kansas City.

If things don't get better within a few months, I am going to be doing just that. My profile hasn't been updated in forever (like since I opened the account) but I do or have done everything in that list. I could add Python programming to that list, as I have been teaching myself over the past year. Thanks for the offer, right now I am trying to figure out what the future has in store for me and my family.

I actually fall roughly into this camp as well. I can technically afford $200/mo, but I'd rather not. I need to figure out what I'm actually going to do in the next month and I haven't gotten around to doing so.

> Isn't this the opposite of free health care? I'm not involved in this debate one way or the other. I don't know enough about the issues.

One of the side effects of not being involved in the debate means you don't realize that the actual "free healthcare" option was taken off the table due to spirited lobbying. On the balance, I'm willing to eat the cost either way (getting healthcare, or being penalized) if it means people who were entirely unable to get it before are able to do so now.

But then again, I'm crazy. Either because I'm nominally altruistic or because I don't have health care or whatever. I'm sure a reason can be found.

I would have preferred to have the dread specter of "long lines" combined with actual free health care for everyone than this, but eh. Politics.

The idea behind the penalty is not to force people who cannot afford health insurance to buy it; your case is an unfortunate side effect. The point is to incentive people who can afford insurance, but rationally say that it costs them more then their expected benefit, to buy it.

This really doesn't have anything to do with the topic, which is about analytics rather than the SOTU as it affects you.

Where does the money come from when you inevitably fall sick and need care?