The House Passed the Health Bill | Hacker News Reader

The House Passed the Health Bill

washingtonpost.com

54 pointsraintrees163 comments

Individuals would be required to obtain insurance or pay a fine of as much as 2.5 percent of income.

This seems like a horrible violation of property rights, perhaps to the point of being a violation of the fifth amendment.

I agree it's a bit big brotherish. For a while after we sold Viaweb I didn't have health insurance, because I figured I had enough in effect to be my own insurer. I ended up getting health insurance eventually, because I found the system won't treat you without it; you can't simply offer to pay doctors with a credit card, the way you can with dentists. But from a civil liberties point of view it is a bit alarming to think the government could force you to purchase something, and jail you if you didn't. I hope they don't enforce that too diligently, or we could end up with a string of Ruby Ridges.

Leaving aside whether people like the government to do things for them or not (there are many internet libertarians here who obviously do not), is requiring you to purchase something really that different from just taxing you and purchasing it for you? For instance, I am not happy about having purchased a share of a war in Iraq or numerous other things the government spends my money on.

Also, a point for consideration: you're pretty much required to own car insurance if you want to drive.

> ...(there are many internet libertarians here who obviously do not)...

The labels seem unnecessary here. You could've said "(there are many people here obviously do not)" - there's plenty of smart people who think this bill is going to be bad for the American federal government and American citizens.

The equivalent would be saying something like, "those internet left-wingers who think everyone should be taxed all the time" -> "internet left-wingers" is unnecessary, as is "internet libertarians". The people who oppose this are just people, not internet people, not labels.

Sorry, you're right. Apologies. I think I would have removed that if I'd reread it before wandering off to fix pancakes for breakfast, as it really isn't germane to the point I was trying to make, and with which I'm sure everyone can agree: most of us have things we don't want the government to buy for us, and some of us believe the government should buy very little for us with our own money. I'm just trying to say that between "tax" and "forced to buy" there isn't a large difference, not comment on what I think of the whole thing, which I continue to believe is off topic for this site.

Not looking for comments or to start a thread, but I just now read a commentary that addresses your "between tax and forced to buy there isn't a large difference"

http://www.washingtontimes.com/news/2009/nov/07/obamas-hidde...

If you want to drive, but this would require health insurance simply for being alive, the alternative to which most of us do not consider an acceptable option.

It's also noteworthy that in most states, you can demonstrate an ability to pay for a certain amount of damage in lieu of car insurance.

If you don't consider being dead an acceptable option, then health insurance sounds just right for you!

Seriously, this debate only makes sense in a context where you consider health insurance to be an "optional extra". It's not. Health insurance is as basic as roads and garbage collection, fire departments and a police force. Out of the whole developed world, it's only in America that something as fundamental as health insurance is considered an optional extra.

There are people that compost and bring what little trash they have to the dump themselves. There are people that ride bikes instead of driving cars. There are people that are their own fire department. Why is it so had to imagine that health insurance might be optional foe some people.

Ok. Doctors don't have to get health insurance.

The rest of us, who can't treat ourselves without external assistance (and also those amongst the doctor who expect that they might at some point get ill enough to require assistance from another human being), the rest of us need health insurance.

Pardon the snideness here, but:

As it turns out, doctors are actually human beings, who are able to form relationships and make arrangements with other human beings, whether or not this takes place within the scope of formal public policy or under the aegis of bureaucratic institutions.

People who are not doctors could treat themselves too, if only it were legal.

Health insurance is optional. My parents never had health insurance and were always able to pay for medical expenses, even with six kids. I also don't have health insurance and so far I've also had no problems paying for medical care. I don't know where the idea that health insurance is a necessity comes from, but it's not based on fact.

Had you been less lucky and encountered medical bills that you and your family couldn't afford, everyone else would have to pay higher prices to make up for your failure to pay. If you want to live in a society where no one will be left to die because they can't pay, then you're going to have to chip in to make that happen. That requires insurance for large medical expenses so no one else has to pick up the tab for you.

I know some people who have crossed the road without looking many times, and they're still ok.

I guess looking before you cross the road is also "optional".

It is and there is no tax on people who don't have road crossing insurance. It's a risk that you can choose to take. If you choose to not have medical insurance and you can't pay for medical care then you might die, but it should be up to you choose if the risk is acceptable or not.

That's not the argument you previously made. You said "it's fine not to have health insurance because I didn't have health insurance and I'm still ok". That's a severe failure of logic. Anecdotal reasoning when looking at something like health insurance is pretty silly.

Unless you're the kind of person whose plan to get rich is to play the lottery, you need health insurance. At some point, in your life, it is quite likely that you will get very sick, or have a serious accident, or have some sort of mishap that suddenly smacks you with a multi-tens-of-thousands-of-dollars-or-more medical bill. At that point, if you don't either a) have health insurance or b) have lots of money, you're basically fucked.

If you pay the insurance all your life and you never actually get to use it, you should count yourself lucky. Health insurance if the kind of thing you pay every month and fervently hope that you never actually need. But if you do need it, having (good, not the american "we'll drop you if you get too expensive" type) health insurance is quite literally a life-saver.

Finally, if you declare bankruptcy because you can't afford your medical bills (and huge medical bills can happen to anyone), society is paying for your treatment anyway, indirectly. Therefore, it is reasonable to mandate that everyone must have health insurance.

_Medical care_ may be in the same category as roads, garbage collection, police department etc. (although one could argue otherwise: the latter are all examples of public infrastructure, but medical care is in most cases a personal service).

However, health insurance is in no way in the same category as any of the above - insurance is a financial tool, used as a means to achieve a desired end in a high-risk situation. Saying that insurance is absolutely essential is like saying that we can't live without zero-coupon municipal bonds. Sure we can, no matter how important the things they're intended to pay for are.

Where I spent most of my childhood, there were no roads for a few miles, no garbage collection, no fire department, and while the area was nominally in the jurisdiction of the Alaska State Troopers, it would have taken at least an hour for an officer to respond. Of course, a total lack of infrastructure would be less than comfortable in a modern city, it's entirely possible to live comfortably without such conveniences.

As for health insurance, the claim that it is necessary is absurd. One could make a much more reasonable claim than health care is necessary, but the question of the specific mechanism by which it is paid for is orthogonal to whether it should be considered a necessity in a modern society.

If you want to drive, but this would require health insurance simply for being alive, the alternative to which most of us do not consider an acceptable option.

There are a lot of areas in the US (most I'd venture to say...) where driving is essentially a necessity once someone has a full time job. Its not like we have a great public transport system. So while you can technically opt out of driving, its not really realistic to do so in most places.

you're pretty much required to own car insurance if you want to drive.

My understanding is that you need to be able to cover any damage you cause someone else, not to cover your own car damages.

This doesn't kill the analogy though. If someone goes into the emergency room and can't pay for their service, the taxpayers pay the bill. So, by the analogy, the requirement should be to cover anything that the doctor must do because the cost could fall to the taxpayer.

If someone goes into the emergency room and can't pay for their service, the taxpayers pay the bill. So, by the analogy, the requirement should be to cover anything that the doctor must do because the cost could fall to the taxpayer.

Part of the argument in defense of the bill is that the mandate will save taxpayer money because the uninsured will now be forced to pay their own way. Yet despite this claim, I don't seen any provision for returning this savings to the taxpayer? Where is this supposed savings going? Either it is mythical or it's just going to be eaten up by the bureaucracy.

And also, if the person cannot afford their emergency room bill, they won't be able to afford the insurance either, and thus will get subsidized insurance. So one way or another, the taxpayer pays.

I see a few possibilities: 1) It reduces the amount of tax money spent on emergency room bills and therefore it gets spent on something of more widespread use. 2) Future taxes would be smaller as a result. Depending on the timing, this could result in a year of double counting for that money. 3) There will be a later provision for returning the money. 4) The bill is gigantic and maybe this issue hasn't made its way into the news (unless you've studied it in detail. I would suspect not because of its length...).

As for your second point, I'm not sure thats true, but I don't have any statistics off hand. It would be interesting to see some comprehensive statistics about how much tax money goes to paying for these things vs. how much money the person makes (adjusted for whatever you want to adjust for).

Yes, it is different. Taxes are taken out of money I make or spend. This is funded by fines I owe whatever I do.

And yes, I'm required to get car insurance if I want to drive. Driving is optional. Living is not.

Taxes are taken out of money I make or spend. This is funded by fines I owe whatever I do.

Sorry, I'm not sure I see the difference. At the worst, this is an increase of 2.5% in your taxes unless you do something (buy insurance) to avoid it. They might well call it a fine but in both cases its just paying a percentage of what you make. You might not like this increase, but thats a separate point.

Let me know if I'm missing something though...

Edit: I think they are calling it a fine so that people will avoid it as much as possible in an effort to make sure people purchase health insurance.

Just to clarify-- the percentage increase in your taxes is much higher than 2.5%-- a 2.5% new tax rate is probably a 5 or 7% increase depending on your existing tax burden.

That doesn't clarify anything, it took me about 30 seconds to figure out what it was you are trying to say. It's pretty simple to understand the penalty is 2.5% of your income, most people don't think in terms of their existing effective tax rate.

I got the impression that the penalty for not having health insurance comes in the form of a tax (up to 2.5% of income). Am I misunderstanding?

It's going to be difficult for them not to enforce it, if something like this actually goes into effect. Getting those who think they can go without insurance to pay into the system is one of the major ways it is going to get paid for.

(It is, objectively, a wealth transfer from young people to old people. I find myself wondering if youth support for the bill would drop somewhat if youth realized what was being done to them. I'm not "old" but I'm past the age where I feel I can go without now, so I guess I'm out of this "youth", but I still don't like it. I am young enough that I don't foresee a single penny of this ever being around when I'm actually old enough to need it, since there's just no way in hell either the current system or this new one if it passes will hold up until 2045.)

One interesting scenario I saw (don't recall where, sorry) pointed out that the entire idea of forcing purchase of coverage like this is very Constitutionally dubious. (Where "dubious" means that I actually can't even come up with an argument I disagree with that the Federal government can do this based on the Constitution.) So it is possible this provision could be struck down, but leave the rest of the bill intact, committing to massive outlays with no way to pay for it.

>I find myself wondering if youth support for the bill would drop somewhat if youth realized what was being done to them.

Probably not since:

a) The youth are the least likely to have insurance.

b) The least likely to be able to afford it (they usually have jobs that make less money).

c) Since they meet both a & b, they'll likely be eligible for the credit/handout that they can use to buy the insurance (if that's still in the plan, hard to keep track of and I don't feel like reading through 80 different versions of a 2000 page bill).

Thus it's more a transfer of wealth into the insurance companies. Even with a public option (which I believe in the last rev of the bill, states could opt out of), most people will probably just end up with private insurance.

> So it is possible this provision could be struck down, but leave the rest of the bill intact, committing to massive outlays with no way to pay for it.

This is probably where this will be in 3-4 years. Which will give lots of opportunity then for the opposition to be able to point out how expensive this all is. sigh Not a really helpful attitude towards engineering a solution, but the GOP hasn't been on top of this issue at all in the last 30 years while every other industrialized country on Earth has at least given it a good go.

It's not that hard for even a youth to get a job that gets you past the subsidy provisions... well, at least in a normal economy... but I hear what you're saying. Part of what I'm saying though is it is not just an instantaneous transfer; as "youth" move up into their 30s and 40s, they'll be transferring wealth up the chain, and in their 30s and 40s probably still not needing a lot of medical services on average. It's not just today, it's the next 30 years of your life that you'll be experiencing a high marginal tax rate. Which as we all know, under Democratic theories of economics, nobody ever considers the question of marginal tax rates when making decisions about their jobs, of course.

"Not a really helpful attitude towards engineering a solution, but the GOP hasn't been on top of this issue at all in the last 30 years while every other industrialized country on Earth has at least given it a good go."

Well, I've actually liked the GOP proposals that I've read. Yes, the ones that do in fact exist. (Claims that the GOP have offered no solutions are one of the most blatant lies of the entire process; it's simply objectively false. You may not like them but they exist. Another example of our media being either incredibly biased or totally unwilling to follow up on the statements of politicians.... reader's choice.) It's not particularly relevant because if they had to craft a bill that might actually pass in the real world it would get bogged down in all kinds of crap, but there's so much low hanging fruit in the system that the current bill still manages to fail to address in 2000 pages, such as tort reform.

>Well, I've actually liked the GOP proposals that I've read. Yes, the ones that do in fact exist. (Claims that the GOP have offered no solutions are one of the most blatant lies of the entire process; it's simply objectively false. You may not like them but they exist...

It's funny, during these last few months of the debate, this topic has come up a large number of times among my social group (largely in a community and neighborhood messageboard startd as an alternative to my HOA board and in proper startup fashion now has advertisements).

There certainly are many examples of work done by the GOP in this area in the last administration (mostly around medication pricing), but as to this particular case the GOP has been very late to the party and has brought substantially no ideas to the table until very recently -- generally running and obstructive tactic vs. an alternative tactic.

I believe the alternative bill they presented a week or so ago was political theater mostly. There was no chance on it getting debated, voted on, or really seriously considered (particularly this late in the game), and the party knew that. That's why the opening portions of the bill didn't contain policy, but rather a stream of consciousness of party talking points. They simply wanted to be able to point to it and say "see? our ideas aren't even being considered!" knowing full well that most people won't have tracked the submission date of the bill. David Gergen offered a different but similarly minded analysis today.

What I thought was interesting is that, when I asked people, and threw out ideas almost a year ago now, the right leaning members of my community generally came up with some very good, feasible plans that addressed the bulk of this particular issues (no recision, no denial of coverage, must accept people for coverage even with preexisting conditions, balanced by an open market place, all insurance is moved nationally, breeding open competition etc.). But these weren't offered up by the Party (capital P) until many months later. Instead the Party chose to run a scare campaign that had very little to do with the actual contents of any of the proposed bills (including doing a Godwin and interjecting Nazis, which was clearly the point knew they had no appropriate counter argument in the wings anymore). It was wholly disappointing.

"I believe the alternative bill they presented a week or so ago was political theater mostly."

Consider http://thomas.loc.gov/cgi-bin/query/z?c111:S.1099: . Note the date. It may not run to 2000 pages, but I consider that a feature, not a bug.

Again, the idea that Republicans did nothing but run an obstructionist campaign is pretty much objectively a lie. What is true is that only their obstructionism was reported in the press. That said, it's not like anything they wrote had a chance of getting passed, I am aware of that, and frankly at this point I'm not a fan of either party on this point as it's pretty clearly a choice between dumb and dumber (reader's choice as to which is which), but the putative "coverage" of Republicans has been blindingly biased. Not that the press has done much more than sit there and twitch feebly every once in a while.

(Further, I'd point out that as a minority, "obstructionism" is pretty much their job. The idea that this is evil rather suspiciously dates to January of this year, for mysterious reasons.)

Nice use of Thomas. I had forgotten about this bill, most likely due to the news media showing me some shiny new thing in a different direction while they hid this one under the rug. But if I'm not mistaken (which I'm more than happy to admit I may be in this case), many of the ideas in this bill were eventually moved into the current Senate bill and the just passed House bill.

But to be honest, the legal documentation is so voluminous and it's a moving target such that I can't keep track of all this. So I may be mis-remembering. The size is certainly a bug.

I would say that it's also bad thinking to think that none of the Republican proposals didn't find their way into the present legislation. I think that there were some good ideas put up by the Party that the Democrats also latched onto pretty fiercely. They claimed it was for bi-partisanship, but I think it's more to appear that they owned all the ideas in this debate.

>(Further, I'd point out that as a minority, "obstructionism" is pretty much their job. The idea that this is evil rather suspiciously dates to January of this year, for mysterious reasons.)

I pretty much agree with you on everything you wrote here except for this and that the obstructionist agenda was purely of the media's making.

I think it's a matter of semantics. "Obstructionism" can be one of a number of things. It can be pure stonewalling and obfuscation, or it can be a presentation of alternatives.

The Republicans in this case were relatively transparent, on my plane trip today I saw no less than 20 Republican backed advertisements against "Health Care Reform" -- unqualified. Some of the advertisements asked questions that made absolutely no sense "will it guarantee I can keep my provider?". Well, lady-acting-like-a-concerned-citizen, I've got news for you, you have no guarantee of that now! And several other examples.

Now the GOP may have been taking a two pronged approach, addressing both senses of "obstructionism", but considering that the agenda I heard came from the GOP itself via paid advertisements and spokespeople/heads of the party like Steele, there really wasn't much made of the alternatives. I would say it was an 80/20 effort.

"One interesting scenario I saw pointed out that the entire idea of forcing purchase of coverage like this is very Constitutionally dubious."

There is no direct way for it to be lawful. It has to be done indirectly using an actual authority of Congress. For instance, they could say "A person shall not engage in interstate commerce unless they buy a policy or pay the fine." I predict this is what they will do; those Congressmen really love that Commerce Clause.

But note that the nondiscrimination amendment requires them to treat all persons equally, regardless of place of residence or incorporation. This means foreigners! If a guy in Cincinnati can't call California without buying insurance, then neither can a Chinaman.

If enforced, this will instantly detonate the entire global economy.

If not enforced, then foreigners will be explicitly elevated over citizens. This is not a recipe for political tranquillity, to put it mildly.

What happens now if you don't have insurance and you need medical treatment? For example what happens if you're in a car accident, do they first ask you whether you have insurance? What do they do if you don't have health insurance & don't have enough money to pay for the treatment?

1) You die? 2) They take you to the hospital and treat you

If it's (2), who pays for you? If the answer is the taxpayers then that's a reason for making not having insurance illegal.

It's the same reason why car insurance isn't optional.

But a 2.5% penalty for someone who makes $150,000 is a great deal for emergency care. Obviously family and kids change the decision-making process, but if I were single and making $150k, I'd rather pay a $3750 penalty and get free emergency room care (as anyone can today) than pay an insurance company $600/month.

In the end, passing a law that create more demand for private insurance services has little chance of driving the price down.

I don't know. We have this kind of health care bill in the Netherlands and I'm paying ~70 euros per month (not sure exactly).

Edit: that also includes liability insurance etc.

"It's the same reason why car insurance isn't optional."

You can choose not to drive.

I live in a country with universal health care (Romania). Being forced to pay insurance is annoying, in theory. What happens in practice is if you don't pay it and need insured medical care you have to pay for the last 6 years, with penalty (about double, in the worst case). That would be the "fine". Not being employed I was able to delay paying for about a year, without penalty and being insured in the meantime.

What you get for it is the knowledge that you'll never have to budget for medical expenses. I did have to pay occasionally, like when I wanted a better yearly checkup, but it's never been an amount I couldn't just take out of my pocket.

Anyways, I always felt that if there's something worth paying for it's a healthy society. At least as much as all the other givens: police, military or emergency services.

There's also the option of the way the UK does it. You pay insurance. It's even called that - National Insurance. There is no alternative. Not having a National Insurance number is like not having a SSN. If you are in specific situations (student, low income, self-employed below a certain threshold etc) you become exempt from stamp, but it's still insurance.

It's so well-entrenched and forgettable (comes out along with tax and student loan repayments - but I shouldn't stir that hornets' nest!) that hardly anyone realises what it is, or its origins as, quite descriptively, a nationalised form of healthcare and unemployment insurance.

It's the same thing here. I was describing this from a freelancer's point of view, who has to actually take out the money, but if you're in the system in any way (employed, unemployed, student) you don't even know you pay it.

Romania's society isn't especially healthy (life expectancy is lower than the U.S.). Neither is its economy, with a per capita GDP of less than $12,000 a year.

Don't buy the myths of government-run health care. It increases corruption and political control of our lives, the new taxes hurt entrepreneurs, and it will reduce overall health care innovation.

The US system needs reform but the bill passed last night does nothing to address the drivers of higher costs. Instead it forces more people and resources into the current system.

Romania's society isn't especially healthy (life expectancy is lower than the U.S.). Neither is its economy, with a per capita GDP of less than $12,000 a year.

Two possible reasons spring to mind:

  1) this is the fault of public healthcare
  2) this is because Romania was basically a Soviet
     principality for fifty years

Perhaps you should try looking at, say, Canada if you don't want an comparison that was rigged from the beginning.

Like gloob said below, a lot of Romania's population is old, poor and lives in rural areas. This particular segment probably drags down the average a hefty amount.

I do agree with the corruption being rampant, though. But I'd blame this on particulars of the Romanian society - there's hardly any aspect of it that's not touched by corruption.

Strange enough the system encouraged a lot of private medical practice which is both good and corruption free. Their income is both public insurance and direct pay.

Wait wait wait wait wait wait.

You had 7-8 figures in your brokerage account, and that was when you decided you didn't need health insurance?

Sure. Insurance is just a way of pooling risk. If you have enough money you don't need it. If you're an average risk, you save both the insurance company's profit and the tax you'd have to pay on the money you'd have to make to pay them.

A normal person has maybe ~$70k to lose if they get seriously ill or injured without insurance.

You have millions to lose.

I'm not making a moral judgement. It just seems crazy that you'd risk losing so much money just to avoid an expense that had to have been a rounding error to you at the time.

I found the system won't treat you without it

Now there is something that could use some reform. I have a hard time picturing a good solution coming from a government though; something that looks like more like a union than an insurance company might be effective.

I really think they need to look at the input costs to health care and take a serious look at tort reform. For a look at how bad hysteria and court run amok can be look at the history of asbestos cases.

I found the system won't treat you without it

I find this assertion strange... my wife and I lived for several years on a cash-only basis with little trouble. Granted, there were no catastrophic expenses, but we never had any trouble paying cash for ordinary doctor's visits and the occasional minor emergency.

...But from a civil liberties point of view it is a bit alarming to think the government could force you to purchase something, and jail you if you didn't. I hope they don't enforce that too diligently...

I'm still trying to wrap my head around that sentence.

Are you saying it's bad for government to take away all those freedoms? Or are you saying that it's a little bad for government to come strip you of your property, but hopefully they won't do it too much?

It sounds like you are equivocating. Either it's more bad than good or not. Right? And -- assuming you reply -- if it's just a little bad, where is the line where you know the government is overstepping where it should go? If your party does a little bad this year, and the other guy's party does a little bad next year, after 100 years we're not going to be in such a good spot, are we? (Made even worse by having nobody to actually blame for our predicament) But hopefully nobody will enforce all those laws too much? (scratches head)

Luckily it likely won't get to that: http://news.google.com/nwshp?hl=en&tab=wn

the reason behind this is simple. A basic task of the state (a framework for society) is to insure[sic] that its people can live (even at the eventual price of others' lives, albeit in other states). This is why the state would (normally :) not kill you, and to the contrary, has to do everything to keep you alive (think euthanasia controversy, obesity, tobacco and alcohol price in healthcare). Therefore, when you fall ill, in most normal[!] societies, people would have to help you -- even before validating your PIN code, or even if you are not holder of a visa or mastercard (are there any other credit cards left?). Like the neighboring lady looking after the kids you were alluding to once. And this inevitably has monetary costs to the society: this is why the compulsory health insurance.

The downside is, that it is wide open to abuse by those who only wish to profit themselves from society. Many countries in Europe introduced universal healthcare after the World Wars, because they learned the hard way, that health and lives and peace are the most important in [to] the world (and ie. not getting rich from online pr0n trade). A great wealth has been amassed, and it has become too tempting to chip off bits and pieces (as always with any huge value) hoping it will go unnoticed. This has happened in most countries (.de, .uk) along with the pension funds (think Enron: the millions who lost their pension savings). Currently there are little safeguards against these white collar crimes (no coincidence either, the politicians don't really make laws against their own interests).

The worst part of the mandate is that every health care interest in country will start lobbying Congress to ensure that their procedure is covered by the mandate. Thus we will be forced to pay for care we don't want, didn't need, and doesn't work. This is exactly what has happened in Massachusetts since the mandate passed, and costs have continued to rise even faster than before. The dirty secret of medicine is that most we spend a huge amount of money on stuff that just doesn't work ( http://www.cato-unbound.org/2007/09/10/robin-hanson/cut-medi... ). The mandate will make this even worse. Recently I got a letter from my health insurance provider that by law they must cover mental health drugs now. This is despite the fact that these drugs do not work ( http://www.overcomingbias.com/2008/06/anti-depressant.html ).

I believe this is by design.

The underlying philosophy is that health care is such a basic part of human life politicians must be in control of it. So from now on (assuming passage) when you have a health care problem, you'll be going to your Congressman to fix it. Insurance not covering something? Go to your congressman. Public plan not covering something? Go to your Congressman. More people need coverage? Go to your Congressman. Rich folks getting really cool benefits while poor folks don't have them available? Go to your Congressman.

Trying to balance the budget? Thought Social Security was impossible to change? You haven't seen anything yet. Try touching national health care once it's rolled out.

It's not "solving the problem" that sucks. We all know there are problems with the free market when it comes to paying for health care and we all know insurance pooling isn't optimum. The problem is the side-effects a huge national solution is going to have.

And those side effects sure look like they make Congressmen even more powerful than they are now.

I don't anything that comes out of the American political process could be called "designed". Nor do I think the Congressman have some malicious intent to grab power. Rather their is a selection effect whereby people who are over optimistic about the ability of government to solve problems end up in positions of power.

"Design" -- an underlying formula or pattern.

How could 2000 pages not have some sort of design? Have you seen the diagrams of all the things the bill creates?

I'll grant you that perhaps for many members they are so inept as to have this design be implied instead of explicit, that doesn't make the underlying pattern go away.

This is like the discussions we have with programmers who say they have no time for design. Look - you can't code without designing. The question is whether you're upfront about it, haphazard about it, or whatever.

You can't have 2000 pages of law without implementing some kind of design, no matter how you went about getting it.

"This is despite the fact that these drugs do not work "

You go from a report on SSRI anti-depressant medication not working to claiming no anti-depressant medication works?

Well, read this book if you want more information than a single article can provide: http://www.amazon.com/Mad-America-Medicine-Enduring-Mistreat...

SSRIs are not the only kind of "mental health drugs". They aren't even the only kind of anti-depressant drugs. Nor does the single meta-analysis cited even claim that they "do not work".

Starting next year, private insurers could no longer deny anyone coverage based on preexisting conditions, place lifetime limits on coverage or abandon people when they become ill.

Worth it!

I also don't think suggesting that this violates the Fifth Amendment is very convincing. 2.5% of the average American income isn't very much, if you do the math! Even a family making 100k per year (well above average) would be penalized $2500, which is fairly light when you compare fines for other crimes.

The point is that making it a crime to refuse to buy something is what violates the Constitution. It doesn't matter if it costs 2.5% of your income or 25 cents.

IANAL, but the text of the Fifth Amendment doesn't support your claim. Let's look at it piece by piece:

No person shall be held to answer for a capital, or otherwise infamous crime, unless on presentment or indictment of a Grand Jury, except in cases arising in the land or naval forces, or in the Militia, when in actual service in time of War or public danger

Not applicable

nor shall any person be subject for the same offense to be twice put in jeopardy of life or limb

Not applicable

nor shall be compelled in any criminal case to be a witness against himself

Most people express this as "You can't incriminate yourself," but this is a much more specific clause and pertains only to criminal cases.

nor be deprived of life, liberty, or property, without due process of law

This deprivation of money would be within due process of law

nor shall private property be taken for public use, without just compensation

Not applicable

(end of text)

In terms of self-incrimination, the Fifth is used entirely in situations relating testimony and criminal proceedings. Furthermore, were it unconstitutional to incriminate yourself through inaction, "duty to rescue" laws (http://en.wikipedia.org/wiki/Duty_to_rescue), though often unexercised, would also fail to be Constitutional.

I don't think the deprivation of money would be within due process of law. Aside from that point, where does the constitution say the government can mandate participation in an insurance plan, public or private?

Why is this more of a violation of property rights than any other form of taxation?

In a strict sense, it may not be, but how a government might fund itself without taxation is a subject for another discussion. It took a constitutional amendment to legalize a Federal income tax. Regardless of any moral objections, the income tax is about as legal as it gets[0]. I'm not sure what legal theory would justify mandatory health insurance under the Constitution.

[0]I'm aware of various claims that the income tax really isn't legal, but I don't think any of them attack its constitutional authority.

Taxation takes a portion of what you make while this imposes a burden to buy something even if you don't have anything. I don't see the argument for how any of this violates property rights, but it's different from taxation.

With taxation if you wanted to exclude yourself from a world of currency and live a "simpler life" without any form of modern money (and somehow found land to do it on, which I acknowledge is a tricky aspect) you could. With this new bill, for the first time ever, this way of life is closed for all Americans.

Or not really, since the penalty simply appears to be (I'm getting all my information third-hand.) that if you don't buy the mandated insurance you won't get care, which seems semi-reasonable enough to me. Not optimal, but hardly the violation of rights I was worried about.

Actually, the penalty is a fine... I've heard everything from $750 to $4000, but I can't find any solid numbers (and I don't make a habit of skimming monstrous legal texts)

This penalty is apparently supposed to be a source of funding for the bill, the logic being that many people will choose to pay this fine rather than buy (presumably more expensive) insurance.

This seems contrary to the purpose of the bill... it can only be properly funded if people aren't covered, but it's goal is to expand the number of people covered...

This seems contrary to the purpose of the bill... it can only be properly funded if people aren't covered, but it's goal is to expand the number of people covered...

My understanding is that the more people that are insured the less money the bill needs. If you get private insurance, government money isn't needed. Obviously there is some overhead cost, etc... that means this won't out when few enough people are insured, but if we get to that point we'll need to rethink things anyway.

This seems like a horrible violation of property rights

I couldn't agree with you more. On a related note, there is apparently a religious conscience exemption:

http://www.pajamahadin.com/?p=1376

Reminds me of the Amish exemption from Social Security:

http://www.amishnews.com/amisharticles/amishss.htm

And so it came to pass that in 1965, the Medicare bill was passed by Congress. As Wayne Fisher writes in The Amish in Court, "Tucked into the 138 page bill was a clause exempting the Old Order Amish, and any other religious sect who conscientiously objected to insurance, from paying Social Security payments, providing that sect had been in existence since December 31, 1950. After Senate approval in July, the signing of the bill by President Lyndon B. Johnson on August 13, 1965, made it official and canceled tax accounts of some 15,000 Amish people amounting to nearly $250,000."

The challenge comes in the definition of a minimal insurance plan. What exactly does it have to cover to count as insurance? Am I going to have to put my policy number on my 1040 next year? Many things to worry about given the sordid history of bureaucratic implementation.

I'm pretty happy with my high deductible plan. I'm guessing this bill will put the kibosh on that, though I'm not totally sure. I'll add reading the 1,900 page bill to my todo list.

The sad part is that a conference committee will come up with the final legislation. The Senate has their own version, then the conference committee will write the final. For example, it is likely the "no pay of abortions" will be removed there.

part of the requirement is the deductible. So, people who have the $2,000 deductible (because you have other means to deal with the smaller stuff) would be out of compliance.

So does this mean we can all quit our jobs, live off our savings and get free health insurance from the government? Because I find that prospect exciting, if not morally dubious.

So health insurance was the only thing keeping you from doing that so far?

Nope. Quite the opposite. If you quit your job, you'll be required to buy the government health care.

Who needs to add value to the economy and satisfy your customers when you can just point a gun to someone's head and say, "buy my product or I'll just take your money anyway, and then strip you of your other rights."

You'll be required to buy some health care. Not necessarily the public plan. Any plan is fine.

So are they going to jail homeless people if they can't pan handle enough cash to pay the premium?

I'm sorry, how does this make anything better?

It's interesting to see people who supported Obama, or even paid attention to the '08 election at all, acting surprised about the health insurance mandate. Obama was pummeled over the concept during the race, most notably by Clinton during the primary. This was a long time coming.

As for the concept of a mandate, it's simply the flip side of guaranteed issue. Without a mandate, guaranteed issue screws insurers: it creates --- as a matter of law --- an incentive for people not to get insurance until they get sick. Adverse selection is the enemy of insurance.

It seems to me that you can't argue about whether an insurance mandate is confiscatory or overreaching without at the same time arguing about whether people with preexisting or chronic conditions (or some statistical disposition to same) should be excluded from the health care system. And yet: all I see here is arguments about whether politicians should run the health care system.

Finally, I'll just note that the dollar amounts being discussed for the fine accompanying the mandate are a fraction of what someone would pay for actual health insurance, and probably lower that one would pay even for low-deductable coverage. I think lots of people don't realize that, because right now, the cost of coverage is very stealthily deducted from their income at the fiat of HR directors and the health insurance reps that instruct them.

Couldn't you just allow cross-state insurance pools, insurance portability, require direct payment and encourage the states to have their own pooling solutions, much like some states currently do with automotive insurance?

I don't think it's an either-or question -- pooling/mandate or not -- at the national level. Sure, I think lots of folks would like it to be that way, but it doesn't have to be. It doesn't have to have a centralized answer for it to have a solution. Co-ops, for instance, have been left on the floor so far.

Cross-state insurance seems like such an obvious proxy for insurance de-regulation that I'm surprised its advocates don't just come out and say it: "we should work with the minimum possible regulation on insurance companies".

I'm wholly ambivalent about whether states or the federal government should operate the government-sponsored risk pool.

You already know where this discussion is going to go with me, so think about whether you want to wade into it. Pick your poison: government by the Government, or government by the insurance companies. I'm not wild about what the federal government is coming up with (though not because of the mandate, which seems sensible), but the major insurance companies are both inept and actively evil, and the system we have today is rigged to favor them decisively whether we regulate or not.

We have a system where the cost of cool things to extend and improve your life is greater than your ability to pay. The problem here is that somebody is going to have to say "no".

Right now the evil insurance companies are saying "no" in order to control costs. Those damn capitalists! Describing a new system as a deal where "you are guaranteed not to pay any more into it, but there's no limit for how much you get out of it" as I just heard the speaker describe is completely crazy.

Our national politicians are great at a bunch of things. Cost control isn't one of them.

Government has a role in defining open markets. Right now the product of insurance is so confusing and convoluted that there effectively is no market. Defining what policies are, where policies can be sold, or how long you can keep them -- that makes a lot of sense. There's a lot of other things that government can do that make a lot of sense.

Trying to legislate a new solution to a problem of the pool of uninsured? Its like trying to create a startup to suddenly manage 40 million customers. It's crazy. Large systems don't work like that. It's completely idiotic.

You can try to slant this as "government" or not, but it's a lot more nuanced than that. The choice isn't just "minimum possible regulation" -- and nobody said it was. This is about problem-solving versus ideology. This is about what types of systems work best for problem-solving.

Give me a break. You're talking to someone with firsthand experience of the arbitrariness of the health insurance system. "Those damn capitalists!" refused to insure my wife, despite any actual pre-existing condition, even with an exemption on the policy. Women of childbearing age are routinely screwed by the system we have now. That's just one example.

You really think this is your best argument? Sticking up for Blue Cross and Kaiser?

The government does a fine job providing insurance to many millions of people. Private insurers do a calamitously bad job, and moreoever are part of a collusive system to simultaneously jack up the cost of care and fund it with a private shadow tax on everyone who works for a large company. I'll go with the devil I can vote out of office every couple years, thanks.

You had a bad experience. Thanks for sharing.

I had a bad experience with government-ran health care.

You want we should compare belly-buttons? Or talk about the underlying issues? Because anecdotes are free and plentiful.

Nobody is sticking up for anybody.

The government is currently going broke providing the existing programs. As much as the plan is supposed to be "save $500 Billion in Medicare" it's a historically unsupportable standpoint.

So the same guys that are spending more than they make in retirement, healthcare for seniors and poor people is now going to suddenly become as efficient as ten thousand possible insurers and insurance co-opts? Would you take the largest, poorest-ran insurance company and force another 20x into their customer lists?

If you have anything more than angry hand-waving I'd like to hear it. Perhaps I'm smoking crack. Been wrong many times before. But you're not making your case so far.

My bad experience refutes your claim about what the insurance companies are doing. They aren't simply minimizing costs by saying no to unreasonable treatments. Way to move the goalposts there, friend.

We should stop discussing this. You'll never convince me of anything. I know what your politics are. I'll never convince you of anything. You know where I stand. Fortunately for me (I believe), my side's winning.

No it doesn't. Geesh. We can compare stories until the cows come home. The only thing it'll show is that people have unique experiences with both government-ran and insurance-ran healthcare.

Insurance companies are rational actors. If they are acting in ways that are socially unacceptable then define the market such that they are unable to do that. It's called governance. Not control, but governance.

Come now, you know more than to take your experience and extrapolate it to an entire society, right? And even if you did, why the need for demonization? Just assume things need tweaking and find where the adjustments need to be made. If my doctor got drunk and paralyzed my grand-dad I'd look for cross-checks to prevent drunken doctors from operating, not demand that all of medical care would need overhauling.

To answer my question -- nope, not more than hand-waving. You are indeed correct: I know exactly how this goes. You'll keep up the snide and personal barbs in an effort to draw me out to say something stupid. Either you'll win or not, but in either case you're not interested in what I'm saying, only in the inevitable rebuttal that you'll make.

C'est finis.

You're right, Daniel. I wasn't particularly interested in what you had to say. I don't think you can say you weren't warned.

Threads like this (and, be honest, most of the other threads on this article) are why we should keep topics like this the hell off Hacker News.

I'm just going to keep assuming people want to have a conversation, tptacek. Next time if you're only replying -- because why exactly? -- as a game or something you can save us a lot of time and effort by pointing that out, instead of thinking I'm going to remember your nick or style.

What you see in politics and religion I see in every discussion that goes on at HN. People have preconceived ideas, and act mostly on emotion. The question is whether or not they (and me) can move past all that posturing.

So nope, I don't see much at all special about this subject. To me it's the same as "what should I do with my life?" or "C++ or LISP: What should I try first?" or "What types of footwear do you use when you hack?" "Does Country and Western music go with VB programming?" "Has Microsoft stopped being the most evil company on earth yet?" or any one of the 1000 other issues and questions that require people of differing worldviews the chance to converse. (not debate) I enjoy having a conversation, asking questions, and learning stuff. Quite frankly some of the other topics, as emotional as they can be to some, bore me to tears any more.

The most sensible package of market- and technology-friendly health reforms I've seen proposed:

http://www.willwilkinson.net/flybottle/2006/03/19/health-car...

In particular, it doesn't call things 'insurance' that are not insurance, and faces the reality that some people are going to be charity cases, and that society will (one way or another) ration the care that goes to charity cases.

The house bill hides difficult choices in mandates that turn 'insurance' into something else entirely -- a compulsory social service, run by 'companies' that have essentially become federal agencies collecting taxes. Nationalizing the industry outright would be more honest.

I just cannot understand how we can keep looking at medicaid, medicare, and social security projections and think that this will save us money. I find the rhetoric and fiscal foolishness of this bill to be beyond the pale.

Also, how is this the top priority. Perhaps some of the congressmen need to check the unemployment rate and economic numbers.

It's pretty simple math. The U.S. pays 2x the (nationally) for health care for comparable (and usually a more poorly ranked) level of care.

The U.S. ranks relatively poorly -- near the bottom of the industrialized countries -- on almost every measure of performance. The only exception are measures where simply paying unlimited amounts of money into your care will get you something.

If we can move cost down from 20% of GDP (or whatever the figure is), to a level that everybody else enjoys, like 10% of GDP, we'll have realized a very large savings at a national level. Even if the cost of the program grows north of all estimates.

> The U.S. pays 2x the (nationally) for health care for comparable (and usually a more poorly ranked) level of care.

The United States also has only 5% of the world's population (304M/6,700M), but produces a heck of a lot more than 5% of the world's medical innovation. Over the next 20 years, one side effect of this sort of bill might be to slow that innovation down.

> The U.S. ranks relatively poorly -- near the bottom of the industrialized countries -- on almost every measure of performance.

With an incredibly unhealthy lifestyle, it's pretty incredible how long American longevity is. A fine on obesity would probably do more to increase American health than a fine on being uninsured, but that's unlikely to happen.

> Over the next 20 years, one side effect of this sort of bill might be to slow that innovation down.

There was an article in The Economist recently (unable to find the link - read a hard copy) which dispelled this myth. Research was done in some European countries (including the UK) which showed that introducing the NHS has not slowed down innovation. They also suggested some incentive plans to make sure innovation did not take a hit.

In either case, I think it's a long stretch to say that this bill, among other things, will lead to a reduced drug innovation. The money in the Drug business in the US and around the world will ensure that does not happen.

I pretty sure it's possible to find examplars in other industrialized countries with modern healthcare systems where their lifestyles are unhealthy.

I can't speak for the UK (but I believe I've seen a study that claims obesity rates in the UK are in fact higher than in the US), but Germans aren't exactly the pinnacle of healthy living, majority smoke, drink and eat outrageously bad (thought incredible delicious) food. Koreans likewise engage in lots of walking about, but the air quality in the major cities is very poor, they have remarkably sedentary lifestyles until college, and then as "salarymen", they probably compete drink for drink with the Russians and Korean food is full of high protein and high fat food sources -- ever sit down and eat 2 kg of Sam Gyeop Sal (Pork Belly) at a sitting? My friends in Japan report a similar lifestyle in Japan.

What's remarkable is that Americans, who generally like to stake claim at being the best in everything, tolerate a system that ranks them down with 2nd and 3rd world countries fighting for what, 40th place between Colombia and Brunei?

Over the next 20 years, one side effect of this sort of bill might be to slow that innovation down.

Is that definitely true? There are no exceptions etc... in the bill for newly discovered drugs?

Even if it is, there is the argument that the American people are paying the price for new drug invention that the rest of the world (eventually) gets the benefit of.

Note: I'm not making a pro-American argument here, just looking at what I think are some important consequences.

A fine on obesity would probably do more to increase American health than a fine on being uninsured, but that's unlikely to happen.

At some point I think they were considering a reward for preventive measures. If that includes eating healthy and regular exercise, it would be great!

I agree everyone should eat a healthy diet and exercise regularly, but that is impossible to verify.

How would the government (or a private insurer for that matter) attempt to verify whether I ate Kashi cereal for breakfast instead of an egg mcmuffin and coke at the nearest mcd's drive-thru? Random blood draws and expensive blood analysis?

How would the government attempt to verify whether I exercised getting my heart rate above 120 for 20 minutes at least 4 times a week? Mandatory wifi-enabled heart-rate monitors for everyone, to be worn 24/7?

In either case, there would be massive fraud, and efforts to combat fraud would lead to wholesale violation of personal privacy in contravention of established 4th amendment constitutional law.

Tax on unhealthy food would encourage healthy eating.

It's a good tax too because eating such food increases healthcare costs on the public.

See http://gregmankiw.blogspot.com/2006/10/pigou-club-manifesto....

This idea has been floated before. I think it's actually a good one, though defining "healthy" and "unhealthy" foods can be a bit nebulous.

One could start with a few well known food items and move from there I suppose.

I.e. milk goes from 4% fat --> 0% fat (skim).

For meat, there are well known measures of how lean the meat is.

For bread, the more grains it has makes it more healthy (I think).

You would only be able to tax the extremes though. For different people, different amount fat, etc... are correct depending on their body types, exercise habits, family history, etc...

For eating... your right, I can't think of a good system.

For exercise, some insurance companies give benefits for going to a gym some number of times a week/month/year. Its not perfect, but I would suspect it probably has few false positives.

What the bill provides:

>>Required coverage for preventative care

>>Starting next year, private insurers could no longer deny anyone coverage based on preexisting conditions, place lifetime limits on coverage or abandon people when they become ill

>>Insurers would be required to disclose and justify proposed premium increases to regulators, and could not remove adult children younger than 27 from their parents' family policies.

>>the House package would immediately offer discounts on prescription drugs and reduce a gap in Medicare prescription drug coverage, closing it entirely by 2019.

>>Uninsured people who cannot get coverage could join temporary high-risk insurance pools, and unemployed workers would be permitted to keep their COBRA benefits until the public plan and insurance exchanges started in 2013.

>>Tax-free benefits for domestic partners just like health benefits provided to the family of an employee married to a person of the opposite sex.

>>Provide grants to states for home visitation programs in which nurses and social workers counsel pregnant women and new mothers in low-income families.

>>Nutrition labeling requirements for snack food sold in vending machines and many restaurants.

This seems like it will be a rare political discussion on HN that won't be flagged, so I'd like to take the opportunity to copy/paste a comment I made on reddit a while back about how the public option is a bad idea, and see if intelligent discussion follows this time around.

A government run plan will be able to easily attract customers because it gets free advertising, making it more attractive than even private, non-profit insurers. Once the government plan has enough customers, it will be able to demand lower prices while still getting the same quality of care for its customers. If doctors refuse to accept it, they'll be turning down a huge chunk of potential customers. The government's even lower prices will draw more customers, thereby intensifying the effect until we get to the point where the government dominates the insurance industry and can set whatever price it wants.

In a functioning market with several players, prices stabilize at a level that customers are willing to pay for the goods or services in question. Healthcare costs have been rising so much because we've always valued healthcare greatly, and lower costs of food and other necessities leave more money for us to spend on it. As a result, advances in medicine come fairly quickly. If the government uses its power as the dominant insurer to drive down prices, advances in medicine will come more slowly because less money will be available. Most of the arguments I've seen for the public option seem to assume that cost reductions will come solely from eliminating non-medical expenses, like advertising. If you think that's the case, can you explain how that will happen? When the government tells doctors what its willing to pay for certain services, are they going to pay no less than private insurers are paying? That's not what happens today with Medicare, and that's not what a private insurer would do if it became the dominant insurer. This isn't about hating government; it's about how markets don't function properly when few players rule them. A public option will almost guarantee that outcome.

The public option is undoubtedly the best way to lower the cost of healthcare. However, I don't think that should be our goal. Our goal should be to maximize the quality of care for everyone, not minimize the price. We should ensure that everyone can afford healthcare by subsidizing it for those who can't, but trying to create dominant government insurer so we can provide healthcare for everyone isn't necessary. Let's get rid of silly things like preexisting conditions and the antitrust exemption, then pay what it costs to ensure everyone is insured and maintain the progress in healthcare technology that we enjoy today.

I'm genuinely interested in the debate on Health Care Reform, but I will be the first to admit I have neither the political chops or core knowledge of the bill to really back up that interest with a solid argument. So instead, I'll try some questions.

1) I've read somewhere that there are some states, Alabama I believe was one, where there is basically a single dominant health insurance provider. As your post suggests, when few players rule, the market doesn't function properly. How is this scenario any different than what you proposed will happen under the HCR bill? If it does indeed exist already in the private sector, how do we go about putting end to these monopolies (I know that's the wrong word here, but it's the best I could come up with), without government regulation?

2) My brother works at a very small game studio based out of Florida. The company has maybe 20 people, at best, and because of this it has been impossible for the company to procure any decent rates on insurance for their employees because they do not have the leverage that a larger company would have. Why should he have to pay amounts in excess of several hundred percent more for insurance than he would have to pay at a larger company, for the same coverage? How can that be fixed without regulation?

3) You mention that without the high costs of private health care, there will not be enough funding to assist with advances in medicine. You suggest that cures and treatments will come at a slower pace as more people switch to the public option or as more and more private insurers fold up shop because they can't compete at the new, lower costs of health insurance. And yet, on the opposite hand, I continually run into, what I consider to be intelligent conversations, that would suggest that advances in medicine are actually held back by these large organizations. That it is more lucrative to treat diseases than it is to cure them. Is your stance that these discussions are merely brought on by conspiracy theorists and have little to no merit, or do you believe that there is some validity to them?

I realize the position I hold is probably apparent, but I really am interested in hearing your (or anyone else's) opinions on these items.

> ... without the high costs of private health care, there will not be enough funding to assist with advances in medicine.

I think that is the token defense phrase used by the big pharma companies. In fact they spend more on marketing and advertising than on research. A lot of research is actually done by the public universities.

The three counter-arguments that make the most sense to me:

1) One proposal was to allow insurance companies to compete across state lines. This would allow smaller contenders to make their offerings on a larger scale, and sidestep the Alabama issue you mention.

2) The point here, I think, is that your brother shouldn't "have" to pay for insurance at all. Allowing individuals to receive the same tax breaks on insurance as businesses do would allow people to choose their own plans, open up the market more, and allow more consumer choice.

3) This is the first I've heard of this one. I find it hard to imagine not wanting to cure a disease... even in the nastiest, greed-driven environment, I think the byline "We cured colon cancer!" is worth more money any amount of incremental profit from treatments. So yeah, going to go with the conspiracy kook option on this one. :)

To clarify, my position is far from the Republican party line on the issue. I agree with most of the new regulations in the bill that I'm aware of, but I would vastly prefer a bill without a public option.

1) The scenario you described isn't as damaging because it's just a single state. If doctors are underpaid by the dominant insurer in Alabama, they can move elsewhere. Even if they don't, losing money from just Alabama isn't going to set progress that much. Losing money from the whole nation will.

2) They shouldn't, and regulation is necessary to fix that.

3) I don't think insurers and pharmaceutical companies hold back cures for diseases, but they definitely do push forward treatments that will lead to long-term revenue. This is why non-profit research funding is an important part of the system.

You talk about moving between states like it's changing a pair of pants. That's a pretty big deal for most people. A monopoly in an area the size of Alabama is like a monopoly in an area the size of Bosnia.

It's more than just moving. Fewer doctors will choose to practice in the state. I'm not saying that things are fine since they can just move; I'm saying that thing's aren't fine so some of them will move.

I will reply to you and Calamitous both here, since you both had some solid points and follow ups. I should also clarify as well with my 2nd question.

It's not that he's being -forced- to pay for health insuranceh. It's that the insurance provided to him through his work is outrageously expensive for him and his family, even with the company assistance. He's said that going outside of his company and acquiring insurance on his own is even more costly. So I agree with Calamitous on this in that it would be great if individuals and small business received the same tax breaks as large companies do, well that would be a great thing. This, in some form, is in the bill, correct?

As for the first question, I agree that comparing a single state's situation with a single dominant provider is very different from something on a nation wide scale. Although the issue with doctors being underpaid wasn't exactly what I driving at. I was more concerned with the provider charging exorbitant rates and the residents not have much of a choice but to pay them. As Calamitous suggested, allowing insurance companies to compete across states lines seems like a good way to level out the playing field. I'm curious if this, too, is in the bill?

As for the last item, I agree that the thought that any company would actively suppress cures for diseases is hard to imagine. However, I still haven't written the possibility off completely. If you do agree that they at least promote treatments that offer better long term revenue streams over quicker and cheaper methods, then my unfortunate state of pessimism doesn't see the withholding of cures as much more of a step. Your comments about non-profit research do offer a good argument and I would agree with you there as well. I'm curious to know if any of the premiums that will be collected via the public option will go towards these research funds or if all of that will be wrapped up in actually paying for the plan itself.

"The public option would effectively be just another insurance plan offered on the open market. It would likely be administered by a private insurance provider, charging premiums and copayments like any other policy. In an early estimate of the House bill, the Congressional Budget Office forecast that fewer than 12 million people would buy insurance through the government plan."

http://www.washingtonpost.com/wp-dyn/content/article/2009/10...

"Any public plan is likely to have a relatively narrow scope, as it would be offered only to people who don't have access to coverage through an employer."

If that is what ended up in the bill, then I agree that it will be mostly harmless. I was under the impression that anyone would be able to enroll in the public plan.

I believe you can, but not sure. The key point, though, is that the plan would be yet another private insurance plan. It won't be government run.

I'm going to step out on a limb and predict that if this passes both houses and is signed, the Supreme Court will strike it down.

You just can't have a law that requires people to buy something. There's nothing in the Constitution that can be remotely construed to allow the government forcing people to purchase things.

Now at the state level it's a different matter entirely. Congress could have easily come up with some kind of reward-punishment system that required states to find some solution. And then you'd have 50 states each trying different ideas. They could harvest the best from each other. But it does not appear (to me) that the goal here is iterative, incremental solutions to a pressing problem. It appears that the goal is Big Design Up Front, Top-Down control, and over-engineering every possibility.<sarcasm>An obvious recipe for success</sarcasm>

In the last decade, and with this bill especially, I think we've finally reached the end-game of the American federalist experiment. It's become obvious that we can't meet our current obligations, and it's also become obvious that politicians get elected making promises for even more obligations, not fixing the ones we currently have. So the goal isn't to "fix the system" The goal is to gin up new and various ways to keep making more promises while blaming all problems on the other party. The party's over, but it might be another 20 years before the cops show up, so let's have fun while we can!

The best thing about my new gig at oneforty is that I'm in Massachusetts and I can get health insurance via the Massachusetts exchange. I seriously, seriously believe that if health insurance doesn't pass that startups who aren't looking to raise money locate in Massachusetts for this reason alone (and there are a ton of other good things about the community here).

My issue with this is that it presumes "healthcare" and "medical care" are the same thing. Study after study after study indicates that diet and lifestyle are major factors in health outcomes and greatly influence your odds of suffering the deadliest conditions. But getting a prescription for a pill is a lot easier than making dietary and lifestyle changes, so a great many people will go that route and then complain about the high cost of medicine when they wouldn't need medication and frequent doctor's visits if they just took care of themselves. If you really want to bring down medical costs, people will have to start taking better care of themselves. Restructuring how we pay for it won't do a heckuva lot towards lowering costs if people continue to pursue self-destructive lifestyles. To the degree that it adds regulation and bureaucracy, the odds are good it will increase costs.

Why can I buy car insurance across state lines, but not health insurance? The funny part is that the "public option" crosses state lines, but current insurance companies can't.

You can't. Your car insurer needs to be licensed in your home state.

And especially Massachusetts where car insurance is completely run by the government, and few regular insurance companies operate there. (Every plan by all companies costs exactly the same amount - AAA has a 5% discount for members, so the other companies are allowed to offer a discount too if you ask for it.)

You are correct in the "McCarran Ferguson Act" leaves health, auto, homeowners to the state regulators, but it sure seems to be easier to buy my car insurance from a national company then any attempt at health.

Good to know about Massachusetts, I had never heard of a state pulling that.

This is no longer true as of a year and a half ago.

Another change in Massachusetts is that everybody must submit proof of health insurance with their tax return, or else pay a penalty.

Strange, I get full coverage anywhere I go (including other countries).

Now if we can only reform medical insurance...

Medical insurance? What a barbaric concept.

I paid $30K in taxes last year. I don't quite understand why would I even have to think about terms like "insurance" and "money" when/if I get sick. I'm not an American, although I've been living here for 11 years, yet the thought of PAYING for medical care still feels shameful and medieval.

If there isn't enough money in the budget to pay doctors then start cutting: on "defense", on bureaucrats, I don't care. Medical care must be absolutely the highest priority federal expense: not a single government employee should be paid until the last US citizen who needs medical attention gets help.

This kind of over-the-top rhetoric is great for rallying the masses, but it breaks down under the lightest of logical scrutiny. Here are three of my favorite issues with your position:

1. Why is medical care the highest priority? What about food? Shelter? Safety from rape, murder, and other forms of violence? What about electricity, water, and other infrastructure? While most people don't get very sick, pretty much everyone needs the things above. Why should medical care be the highest priority federal expense?

2. You think it's barbaric to think about paying for medical care, but guess what: you do pay for it. Everyone does. Your "right" to healthcare is not free; someone has to pay for it. And because you think you're entitled to that free of charge, someone else out there is having money taken from them under the threat of force so that you don't have to worry about healthcare. The right to private property far outweighs the right to healthcare, according to the US Constitution, but your system reverses this relationship.

3. The decoupling of supply and demand in the type of system we're about to pass is likely to result in dramatically higher costs and lower quality care over the long run, not to mention the fact that we have no way of paying for it. Granted, our current system is screwed up, but this is far from a fix. This is just moving further in a bad direction.

EDIT: Added a third item :)

There is a viewpoint, and it is strongest in Europe, that human rights extend to the basics of civilized human existence; that food, shelter and medical care are basic necessities that a society must provide for it's citizens if it is to be considered civilized. The purest expression of this can be found in the Universal Declaration of Human Rights http://www.un.org/en/documents/udhr/ (see section 25) but it is also enshrined in national constitutions the world over.

At the root of this viewpoint is the understanding that the citizens of a nation depend upon each other and have a duty to each other.

This is clearly at odds with the modern American viewpoint which declares each individual to be utterly responsible for his own welfare. As Americans we are not in this together, we are each struggling separately.

And it is readily apparent that we are willing to sacrifice any principle on the altar of our individualism. This country (my country) openly condones torture, the bombing of civilian populations, extrajudicial imprisonment and the murder of political dissidents; all in the name of Individual Liberty.

It is less surprising that we cannot do what most of Europe regards as the sane and sanitary solution to ensuring the health of the nation; and more surprising that we aren't busy legalizing the hunting of the homeless and the use of the indigent as pet food.

I understand the point that you're trying to make, but you're misrepresenting things. American culture is decidedly more individualistic than Europe's, but its unfair to characterize us as "not in it together", either as a whole or when referring to the libertarian argument that you're attempting to refute. There's no honor in being forced to watch out for your neighbor, and in the long run, it creates problems of moral hazard where you expect that someone should be taking care of whatever problem you have at the moment.

This country (my country) openly condones torture, the bombing of civilian populations, extrajudicial imprisonment and the murder of political dissidents; all in the name of Individual Liberty.

This is where you really lost me. Those things have not been done in the name or spirit of individual liberty. Quite the opposite: they represent an egregious breach of the individual liberties we're entitled to under the Constitution. Not sure how you managed to twist this issue up to be an example in your mind of the supposed dangers of individual liberty.

...and more surprising that we aren't busy legalizing the hunting of the homeless and the use of the indigent as pet food.

Thanks for making my point about over-the-top rhetoric. Have you been to Europe, by the way? I lived there for years, and they've got their own set of problems, I assure you.

As near as I can tell, the official definition of Rugged American Individualism requires that it's practitioner be a healthy white male with a net worth of more than $20,000. You can recognize one of these Rugged Individuals due to the products they consume, the (large) vehicles they drive. their devotion to their football team, and their reluctance to pay taxes for anything other than roads and weaponry.

As such the systematic dismantling of our policies to prevent torture and hold torturers accountable; our eager rush into aggressive war and our continuing efforts to thwart prosecution of our own war criminals is perfectly comprehensible in the defense of the Rugged Individualist Lifestyle.

I am sorry that I did not adequately communicate the biting sarcasm that I habitually apply to our political discourse, or the barely repressed anger that I feel in my forced complicity in the crimes of America. In such light I think that your inability to see the swiftian satire I intended to lighten the last line of my last post is perfectly comprehensible.

Dude, I'm a public-option-supporting liberal and all that but you've even lost me. Chill out.

This is a factually incorrect description of the U.S. America already has massive government-provided health care systems for children, the poor, and the elderly.

The health care system in the u.s. is immune to supply and demand. The doctors control the supply of doctors. Laws control supply of medications. Insurance companies control supply of procedures.

I agree with the post you are replying to. I think if people didn't have to worry about whether or not their health was at stake, they could make better decisions about the work they do. They'd be more productive and worry less and have more brain waves to devote to a better life.

People seem to complain a lot saying the government can't do things well. But they run our defense industry and it's the best in the world. They run the roads and we have plenty to drive on. They control the dams and those aren't breaking. Many are lasting way longer than they thought. Furthermore, plenty of governments around the world run their health care systems and they get better care for less money than Americans do.

Right, modeling health care as it is in the U.S. based on capitalistic concepts doesn't work. It simply isn't setup as a simple supplier-consumer relationship.

Disagree? Quick! Who's the supplier and who's the consumer in the present system? It's not the patients.

You know what's sad? You made very intelligent points, but people who feel the way they do are just going to glaze over them or write them off. Personally, I'd like to see original poster address those points, but too often these things are more emotionally held views than really thought out. I doubt you'll get a reply, and I doubt the original commenter changes his mind.

1. Because when you are healthy and not lazy the society provides you with enough of opportunities to obtain your own food, water and electricity. Some may even argue than a healthy and armed individual can take care of his/her own protection (debatable), but if you're ill you're done: you are 100% dependent on the society you're a part of. And it is scary to be an ill American.

2. Yes it is barbaric to pay for medical care yet I realize that doctors need to get paid, this is why I mentioned my taxes. Perhaps I should have said that it's barbaric to run for-profit businesses that capitalize on people's illness, especially when businesses don't actually treat people, i.e. like insurance companies.

3. The decoupling of supply and demand has already happened: this is why you don't see Cuban and Indian doctors on H1bs diagnosing influenza and stomach flu for $50. This decoupling is also the reason why the same drug/med. equipment costs significantly more in US than anywhere in Europe.

Lastly, I want to confess that usually I don't get much into politics but I've posted my previous comment under influence of circumstances: I am self-employed, I pay $920/mo for good health insurance for my family, yet when I got pneumonia two weeks ago, they still took $120 out of my pocket which went towards 20 minutes interacting with medical personnel and 1 pack of antibiotics. This is insane, absolutely insane.

I don't understand how paying for medical care can possibly seem strange. Single-payer systems are merely an arrangement for paying for medical care. In my opinion, it's not a very good arrangement.

Everyone who needs health care should be able to obtain it. Most people in developed countries can already obtain health care. Why insert the government into the situation where it isn't needed? Any time you disconnect the amount paid for goods and services from the receipt of those things, the market (i.e. mass human psychology) will work less efficiently. Perhaps the price the government decides to pay will be less than is needed to convince enough people to provide the services in question, resulting in a shortage.

Subsidize health care for those who can't afford it. Everyone else should pay their own way privately. Similar changes should be made to the other non-public goods we subsidize, like roads, transit and education.

Why should medical care be a higher priority than food?

And moreover, why should we have to pay for food? By God, I pay taxes. It seems so barbaric and 8th century to make people pay for the food they eat.

Your comment (and its upmods) is why, my friend, even the most educated and interesting Americans sound like incoherent cavemen when it comes to discussions about finally having a health care in this country: here we tend to look at each other as consumers and customers first, and human beings - second. What an unfortunate cultural difference, to say the least...

I have no idea where this sudden drop comes from. Do you really have to be born somewhere else to clearly see the difference between healthcare and food? You don't charge people who are scared, in pain or unconscious. It's like urinating in public or having sex with your sister: does it need to be explained why you don't do that?

> Your comment (and its upmods) is why, my friend, even the most educated and interesting Americans sound like incoherent cavemen...

Totally unnecessary to having a discussion. But I'll address your point:

> ...here we tend to look at each other as consumers and customers first, and human beings - second. What an unfortunate cultural difference, to say the least...

Many people who are opposed to the healthcare bill, including me, do care quite a lot about people. I've run charity events for St. Jude's Children's Hospital in the Stats and Great Ormond Street Children's in London. I donate to charity too, including trying to get a therapy dog program going in Tokyo.

With me so far? Okay, I care about people. I'm not looking at people as consumers or customers. I think the more say elected and appointed officials get over medicine, the worse medicine will be. Elected and appointed officials typically do a terrible job with any science, business, or production that they try to run. For every success story, there's 3-10 dramatic failures.

> Do you really have to be born somewhere else to clearly see the difference between healthcare and food?

They're both essential for survival. The difference is that we've made food very accessible, largely without the help of government. Medicine will get there too, given time.

In fact, over the counter medicines today are incredibly powerful by historical standards. The fact that we can get anti-inflammatories and mild topical steroids over the counter is incredible. We'd be able to get antibiotics too, if it wasn't for the government legislation requiring prescriptions. It's rationalized by saying people could abuse or mistake antibiotics, leading to more antibiotic-resistant strains of diseases. But this hasn't been found to be true in countries with over the counter antibiotics.

> You don't charge people who are scared, in pain or unconscious.

1. The vast majority of medicine isn't trauma medicine, it's fairly routine and predictable thing that you can make educated, thought out judgment calls on.

2. Doctors need to get paid like anyone else to practice their profession. Someone needs to pay them.

3. I'm unwilling to pay for other people's medicine under threat of force. I will actually pay for someone's medicine in some circumstances - I'll run a charity event, donate money, help out a friend or relative. But I do not accept being mandated to buy insurance, pay a tax, or be arrested. I think it's bad for me as an individual and bad for society.

> It's like urinating in public or having sex with your sister: does it need to be explained why you don't do that?

Look, I've seen your comments. People reply to you with intelligent points. Do you care? You talk past people, you ignore their points and respond with more rhetoric.

My points:

1. Doctors need to be paid to practice their profession.

2. I'm unwilling to pay doctors for other people's medicine under threat of force for failing to do so. You're willing to have me arrested for refusing to play along?

That's the argument. I want healthy people too. I care about society. I've done more to help sick people I don't know than the vast majority of people stumping for government run healthcare. But I think it's wrong on an individual and societal level.

I'm unwilling to pay for other people's medicine under threat of force. I will actually pay for someone's medicine in some circumstances - I'll run a charity event, donate money, help out a friend or relative. But I do not accept being mandated to buy insurance, pay a tax, or be arrested. I think it's bad for me as an individual and bad for society

That's the main disagreement right there: in what is the role of a government and what is a function of any modern society. If you don't believe that an automatic medical treatment is a basic right of any citizen then there won't ever be an intelligent discussion. It's like with evolution vs intelligent design: you quickly hit a wall which can't be cracked by any arguments from any side due to the fundamental difference in beliefs.

Even under the pressure from overwhelming evidence (http://en.wikipedia.org/wiki/Healthcare_reform#United_States) you keep believing that a social medicine is "bad for society".

And just to answer your question, yes - I would have you arrested. Refusing to "play along" and letting your fellow citizens die is a borderline murder.

Mate, I was going to write a reply, but I don't think you want a discussion. Look at this:

> If you don't believe that an automatic medical treatment is a basic right of any citizen then there won't ever be an intelligent discussion.

Your conclusion is that automatic medical treatment is a basic right of any citizen. You say that there's no intelligent discussion if I don't accept that, and compare not believing it to believing in creationism.

I don't accept that medicine provided by others under threat of force is a fundamental right. I have well thought positions on this.

> And just to answer your question, yes - I would have you arrested.

I do respect that. I mean it scares the hell out of me, but at least you'll say it. Most people won't bite that bullet. I disagree on the borderline murder thing, because I don't think being born in the same place as someone makes you morally accountable to protect them without any say on your part or agreement between you.

But seriously - I don't want to be part of this system. I don't agree that being born in the same place as me makes me accountable for your life without my agreeing to be.

But you say:

"If you don't believe that an automatic medical treatment is a basic right of any citizen then there won't ever be an intelligent discussion."

If you can't intelligently discuss this with me not agreeing with your conclusion, then it'd be kind of useless for me to continue huh? In fact, I reckon that no matter how many suggestions I put forth on a better way to save people's lives than a government run medical system, I don't think I'd change your mind.

Is it possible? Should I bother trying to explain, in that there's a chance I'd change your mind?

* If you can't intelligently discuss this with me not agreeing with your conclusion, then it'd be kind of useless for me to continue huh? *

It has been my experience, that no matter how smart and civilized, folks quickly start to sound ugly when it comes to health care. Take guests on Bill Maher show, for example. Proponents of a single payer system like myself quickly get called "communists" and it goes only down from there.

But sure, I am curious to hear how are you going to lower the cost of knee MRI exam from $1,100 to $80 (US vs Japan). You can even drop me a line if you want, my email is in my profile.

Because the majority of the voting population has no problem obtaining food.

In no small part, food is medical care. Good food is good preventive medical care. Bad food is like trying to perform a back-alley abortion.

But I take your point. Medical care doesn't have a higher priority, but its nature makes it a more important issue for government to deal with. The statistical nature of medical costs is that the vast majority of people cannot prepare for the worst without buying into an insurance plan of some sort. Food costs, although they can go up a lot during crises, never reach such heights. Barring a severe depression or massive food shortages -- which it should be noted affect everyone, not just a small portion of the population -- people living above poverty can shift their budgets to be able to afford food even if the price goes up 50%. Hardly anyone can modify their budget to be able to afford bypass surgery or treatment for cancer.

However, another side to the issue is that the government already interferes substantially in food costs and food policy. There are substantial subsidies paid to corn and soy farmers, for instance, driving consumer costs of many food products below the actual costs of production if you take away government subsidies.

Or a higher priority than endless wars for oil overseas.

But I digress...

The reason is because most people can still afford food in US, but cannot afford $3k/day hospital stays.

Isn't the crux of the problem that it costs $3k/day for a hospital stay to begin with?...

A bloated health care industry that inflates prices on medical services, making "insurance" the only viable option for payment, seems like the main issue that demands reformation.

Worse , the bulk of debate is focused on how to shift responsibility for covering that $3K/day rather than figuring out why is costs that much and how to make it cost less.

Medical care is a service. I keep myself very healthy, so I pay very little for medical service. I am willing to pay for Medical Insurance, because like automobile insurance, I may find it difficult to pay for drastically large bills that arise, and may be quite large due to the reimbursement system for emergency services.

In car collisions, pain and suffering is a scary demand. In emergency medical care, all those fancy machines to figure out what is going on with my body right now is likewise rather expensive.

A long term plan to adopt a good diet, exercise, stretch, brush my teeth, etc. is a relatively easy way to avoid paying for large amounts of medical care. And, I am fortunate enough not to have any major body/mind disability.

If you want to know where your money goes just look at this list...

http://washingtontechnology.com/toplists/top-100-lists/2009....

Nicely done on a Saturday night.

Dems must be proud of their work.

So the Dems gutted the bill(from single payer), just to gain a single Republican vote?

The bill didn't start from single payer - it started as offering a public option, which would co-exist with existing private plans, which would theoretically be available to all citizens as an option.

The United States attempted implementing a single-payer system during the FDR Administration, which fizzled before it left the white house, and then again during the LBJ Administration, which was cut down to what we now call Medicare/Medicaid via the Social Security Act of 1965.

which just goes to show you that dems don't know how to negotiate. You never start off with a compromise, you start off with something you have no hope of getting and slowly get down to the compromise position.

If you have no idea what you're talking about, please don't use incendiary language.

Incendiary language is basically what you're likely to wind up with when you discuss politics on the internet. Yes, even on sites like this one; vaksel isn't just some random guy who joined the site yesterday.

Which is why I keep harping about keeping these types of articles off this site.

Perhaps there is a case for creating a tag that can be added via flag for non-hacker news news, which is easily filterable as off topic, and is filtered out by default?

This could potentially have worse effects on the dynamics of the site than these articles themselves, but I am interested to hear what this community has to say on subjects like these.

You can't run away from issues like this; they're news, they're important. If HN is gonna survive and thrive, it's gonna have to be tough enough to get through posts like this. Really, the ratio of thoughtful-to-irrational is way higher here than on even Reddit. It's all good.

The problem is that that ratio is not stable over time. Political posts attract people interested in debating politics, which is a much larger group than people interested in hacking and startups.

Also, even (especially?) amongst smart people, there is a large range of thoughts; from some guy here whose profile says "venture communist" (whatever the hell that is) to plenty of libertarians, and everything in between. Most of us are likely to be relatively convinced of our views, making debate mostly fruitless and quite potentially incendiary.

Also, yes, you can run away from these discussions; the site is moderated. Other sites with a narrow focus (lambda the ultimate) do just fine. It's sites that grow and grow that decay.

Also, if it's "news" and "important" then there are plenty of other sites where you can talk about it all you want. There are not many other sites for the discussion of hacking and startups though.

Single payer was never on the table. Despite having majority support in public surveys, even thinking about it would galvanize all aspects of the health care system to fight tooth and nail against the bill. Big pharm would fight because they'd expect to see the price of drugs drop. Insurance companies would fight because they would no longer have a business. The AMA would fight because they have too many connections with the other two not to unify.

In fact even the massively watered down version called "the public option" is marginal. Which is why you keep on hearing about how it is in this version, out of that one, in the next, and so on.

Great, now I have buy into the screwed up healthcare system or become a felony and goto prison and lose all my rights. What kind of country do I live in now?

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