American Health Care Reform

[Mick]

Many thanks Gao, I actually don't think the subject is as simplistic as many might believe, I do think a country should have a system where universal health care is available to all. However, I am wondering if the approach taken by Obama was flawed from the outset, that reforms within the existing health care system should have been prioritized before any thoughts of universal health care.

In context, when he came into power, everyone's attention was on bail out for the banks and the government deficit. US health care costs were around 16% of the US GDP (I think thats projected to go up to around 20% of your GDP by 2019 with Obamacare, and will still increase without it). This is an anomaly for countries around the world. For sure, if a country has more wealth, they spend more on healthcare and you expect to get something in return for that extra expenditure. Which is generally true for other countries, Switzerland being at the top end of the scale at a little over 10% GDP the UK at around 8%. This article has a good discussion on the spending on healthcare in the US. What makes the US health care system so expensive – Introduction

There is one exception – the United States. We are way above that line. Moreover, it’s debatable that we are achieving better outcomes than these other countries. That would suggest that the money we are spending above the line might be, for lack of a better word, waste. Regardless, that money is more than you might expect, based on every other country in the world. If we explore how that extra money is being spent, we can start to think about where spending might be cut.

As you quite depressingly make the observation above.

If the SCOTUS overturns the purchase mandate, which I think is likely, or Obama loses and the law is repealed, I think it will be 40-50 years before another serious attempt at reform is made.

That's a tremendous failure. It sounds from what you suggest, not only will there be no universal health care, the costs remain as high as they ever did. So, my thought on this is, wouldn't Obama have been better to spend his time trying to reduce this ratio of GDP to health care first, in a time when cuts were being called for, rather than pushing a policy of healthcare reforms which under the current system, increasing the burden and eventually gets defeated anyway. Just seems to me he was trying to put the cart before the horse.

[Gao Bohan]

Mick,

I understand your point. The trouble is, there's no obvious answer to how healthcare costs can be lowered in the short term. The theory, at least, is that the ACA would pay for itself in 10 years, and produce savings within 20 years, by virtue of people seeking preventive and maintenance treatment, rather than waiting for their conditions to reach emergency status. The ACA also opens lines of communication across the health care industry that federal/state boundaries previously limited. It's a lengthy law, and contains many such provisions that will hopefully raise efficiency and lower costs.

Your plan, as I understand it, would be to introduce fully public hospitals over a period of time. I don't think it's clear that would lower costs in the short term either. If anything, I would think it cost far more to plan, build, staff, and maintain public hospitals for the first 10-20 years than to simply subsidize the poor's purchase of private insurance. But I don't know. In any case, President Obama was operating within certain political realities, and anything akin to the NHS is a non-starter. The government is heavily involved in the health care industry, and will remain so even when the ACA is overthrown, but is done from a distance.

It's been discussed previously that the ACA was originally a Republican idea, an alternative to the Clinton healthcare initiate in 1994. What may be less obvious is why a Congress that was at the time fully controlled by Democrats, and a Democratic president, could only manage to pass a Republican bill. The reason is that the Democrats do not have a united front on health care. The left wing of the party wants to expand Medicare for all citizens and legal residents, in the same manner of Canada's Medicare, or for that matter Taiwan's NHI. If there is any good to come out of five Republicans throwing out a comprehensive health care reform law with a few handshakes and signatures, it's that the Democrats may finally coalesce around the Medicare for All policy. That at least, is my hope. But I doubt it will happen right away. Indeed I doubt it will happen in my lifetime.

Gao

[Chris]

The Supreme Court case has begun. It looks like the court is headed towards a 5-4 decision against the law. So much for national health care in the US.

They're just arguing one aspect of it: the mandate (a Republican idea, by the way).

[Gao Bohan]

The Supreme Court case has begun. It looks like the court is headed towards a 5-4 decision against the law. So much for national health care in the US.

They're just arguing one aspect of it: the mandate (a Republican idea, by the way).

Several points are under consideration, actually. One of them is the mandate, and another is whether the rest of the bill can survive without it.

[Alkibiades]

Estimates vary, but somewhere between 40,000-100,000 people currently rely on the ACA for coverage. The nearly inevitable Republican victory in court may lead, quite literally, to thousands of children and adults dying from lack of regular medical care.

Just how "literally" do you mean that? That sounds like quite a shameless claim to me. You seem to be quite keen on eruditesque studies and policy reviews, but none of that quite conceals an ideological ax to grind, I suppose.

Were the Court to let the "law" slide, that could quite lead to the deaths of millions of children and adults and probably dogs and cats, too, as the constitutional basis of our democracy were further eroded, making the law a mere plaything of majorities aroused by exceptional claims your tidy little studies pronounce. Forty to a hundred thousand they say? I wouldn't have put it under 120,000, if it were enacted before FY2016, particularly if the unemployment rate remains above 7.5% throughout the next seven quarters. Know what I mean?

The President's laughable attack on the authority of the Court to review legislation is just an example of this contempt for government by constitutional consensus rather than manipulated majority rule. Just as the Bush administration's contempt for constitutional restraint was evident in the way it treated American citizens declared to be terrorists and stripped of their rights without due process.

But, somebody can always quote statistics about how many children and elderly will die if their law doesn't get passed or their war doesn't get fought. But, if you defend the Constitution, who can quote a nice little statistic from a think-tank or a government agency to measure the damage to the cohesiveness of the body politic? Who can estimate to what degree respect and acknowledgement of the authority of the government and mutual respect between citizens will erode , or when a breaking point might be found where a sizable minority would react violently?

In a government that is wholly dominated by majority rule, every side has the corpse of some baby or child to hoist in front of the crowds to evoke moral outrage and demands that the people have their way. This will only result in a kind of arms race of moral outrage, and increased fear and demagoguery. Or, maybe it will all work out fine. Who knows?

[Gao Bohan]

Just how "literally" do you mean that? That sounds like quite a shameless claim to me. You seem to be quite keen on eruditesque studies and policy reviews, but none of that quite conceals an ideological ax to grind, I suppose.

I mean, dead as a doornail. I don't think it's a particularly shameless, or for that matter shameful claim to say that out of 40,000-100,000 Americans currently enrolled in the government's high risk pool, that were the law to be repealed "in toto" and their insurance revoked, some percentage may die as a result. The latest figure I saw is 50,000 currently enrolled...well, let's say 10% die once treatment ends, that means 5,000 deaths. It doesn't really seem that far-fetched a possibility, when you consider that the high risk pool includes cancer patients.

Were the Court to let the "law" slide, that could quite lead to the deaths of millions of children and adults and probably dogs and cats, too, as the constitutional basis of our democracy were further eroded, making the law a mere plaything of majorities aroused by exceptional claims your tidy little studies pronounce. Forty to a hundred thousand they say? I wouldn't have put it under 120,000, if it were enacted before FY2016, particularly if the unemployment rate remains above 7.5% throughout the next seven quarters. Know what I mean?

No, not really. I don't get the "slippery slope" argument regarding health care. Laws are passed through an arduous and highly public process. I don't believe that Congress is going to turn around and ride roughshod over civil liberties just because the individual mandate is upheld. I think it's fairly obvious that the individual mandate is necessary to fund the rest of the bill...it's not a celebration of totalitarianism. And Obamacare (it's time to reclaim this word from the Right) will create jobs in the health care sector, so I don't see the connection with the unemployment rate.

I don't have time to respond to the rest of your post at the moment (sorry), but after years of hearing Republicans groan about judicial activism, I'm not particularly worried about Obama's admonition.

[Cooperations]

I don't have time to respond to the rest of your post at the moment (sorry), but after years of hearing Republicans groan about judicial activism, I'm not particularly worried about Obama's admonition.

I don't quite get all the chatter about what he wrote either-in fact, I wouldn't even call it an admonition. Just a couple of weeks ago, legal experts were all pretty much saying what Obama said, which is that the decision to overturn this bill would have to undo many years of precedent-from what the commerce clause allows to overturning an elected Congress' function to pass laws. If the voters don't like it, they can elect people to change it-it's not like we are dealing with segregation here.

Then, the political pundits thought that questions about broccoli (and other quite dubious slippery slope arguments) somehow meant that the court was going to reverse course. It doesn't mean that at all, actually, but many people bought into it, not knowing that the justices usually have a tough series of questions for the government. When the pundits decided it meant that they were reversing course, Obama went back to the old argument that everyone was making before, and then he got slammed for it, probably because he has a history of calling out the court. It was inappropriate, IMO, when he did that during the state of the union, but this was nothing of the sort. I think Obama will be right and they will uphold the law. But we'll see....

Side note: While I'm not a huge fan of Scalia, I was really quite shocked that someone who is supposedly one of the greatest legal minds in our country (and he is) made the broccoli argument. Seriously? He knows that a decision in favor of this law would not set a precedent where citizens would be forced to buy broccoli...either that or he has no skills in crafting opinions or has little faith that anyone else on the court can. Btw, couldn't the same argument be made about social security? Did that lead to the government telling me what to put in my fridge? Disappointing, to say the least.

[Alkibiades]

Estimates vary, but somewhere between 40,000-100,000 people currently rely on the ACA for coverage. The nearly inevitable Republican victory in court may lead, quite literally, to thousands of children and adults dying from lack of regular medical care.

I mean, dead as a doornail. I don't think it's a particularly shameless, or for that matter shameful claim to say that out of 40,000-100,000 Americans currently enrolled in the government's high risk pool, that were the law to be repealed "in toto" and their insurance revoked, some percentage may die as a result.

Fine, fine, fine, so the "quite literally" was originally meant to suggest a direct cause and effect between "Republican victory" and the deaths of 40-100,000 "children and adults", but you are hesitating a bit now. Good for you. So, let's get to brass tacks. Never mind the number, pick any you like. One death is too many, isn't it? Will repeal of this "law" cause even a single death? Literally or otherwise?

After all, there quite literally is probably a child in India right now who will not receive a meal and will most possibly die of literal starvation in the near to distant future, because I just spent NT$43 on one of those delicious 7-11 fruit platters instead of sending it to a charitable organization. Is that the degree of literalness we are talking about here?

I mean, don't run back to your numbers. You are literally trying to blame opponents of your particular agenda for the death of children, aren't you? A "Republican victory", you call it, quite literally clever, I grant you. Have the common courtesy or brazen demagoguery to say so and spare us the charade of 'objective analyst'.

Were the Court to let the "law" slide, that could quite lead to the deaths of millions of children and adults and probably dogs and cats, too, as the constitutional basis of our democracy were further eroded, making the law a mere plaything of majorities aroused by exceptional claims your tidy little studies pronounce. Forty to a hundred thousand they say? I wouldn't have put it under 120,000, if it were enacted before FY2016, particularly if the unemployment rate remains above 7.5% throughout the next seven quarters. Know what I mean?

No, not really. I don't get the "slippery slope" argument regarding health care. Laws are passed through an arduous and highly public process. I don't believe that Congress is going to turn around and ride roughshod over civil liberties just because the individual mandate is upheld. I think it's fairly obvious that the individual mandate is necessary to fund the rest of the bill...it's not a celebration of totalitarianism. And Obamacare (it's time to reclaim this word from the Right) will create jobs in the health care sector, so I don't see the connection with the unemployment rate.

I am afraid my sarcasm was supposed to bite, not chew. Do you hail from the Midwest?

I will speak more literally. The Constitution binds our republic together. Not religion, not race, not even language, nor geography. This is not the slippery slope argument. The Constitution is the only thing we all have in common. And, the Constitution deserves respect, because it was designed so that any major change in our society that a majority had in mind has to jump a number of hurdles. That is why we have a federal system of government. That is why we have a bicameral legislature. That is why one branch is apportioned by state and not by population. That is why individual members of that branch are elected every six years. That is why the President, who is elected by an electoral college that is apportioned according to a combination of the two legislative chambers' respective apportionment criteria, has to ratify most legislation, unless it can be passed by a supermajority. But, that's not all. Wisely or unwisely, the Supreme Court was given final say within the government over the constitutionality of legislation. And, changes to the Constitution have a specific "arduous and highly public process" that this legislation did not endure. If the president were so confident of the popularity of his legislation, he would take it through the constitutional process, which was designed to test just how genuinely popular a piece of legislation is.

The term "judicial activism"--I am just going to pretend as if I believe that neither you nor the President knows better--refers to those instances where the court steps beyond its constitutional mandate: to check "legislative activism" and "executive activism". Not to rubber stamp the governing party's agenda like a two-bit dictatorship. But, the President did not simply (and preemptively) question this particular Court's aptitude to judge this particular case. That would have been bad enough. Rather, he deliberately drew attention to its supposed lack of democratic legitimacy (never mind that each and every one of the appointees went through an "arduous and public process", although they were nominated and confirmed by the next two least democratic elements of the gov't, the president and the senate) and called any attempt to negate legislation "unprecedented".

He was ever so careful to describe his pet legislation as "duly constituted". Well, so is the third branch of government. If people like you and the President intend to threaten the constitutional pact, to simply steamroll the only branch of power that you do not control, what do you think the result in the long run will be? A breakdown in voluntary social cohesion. Your very attempt to force people more closely together in a society that is increasingly culturally and ideologically disparate will only result in a further collapse of social trust in the long run.

Once that break in trust occurs, there is no policy that will fix it, no matter how many political "scientists" and eminent academics you hire to concoct policy papers and studies and conjure up statistics. It takes generations to restore, if ever, and usually after each side has exhausted all its strength, usually in blood.

I am not worried about "totalitarianism", as you called it. I am worried about the unfettered competition that ensues when all power is concentrated in any single entity, whether it be president, congress, court, party, clergy, region, or economic interest. Countries usually turn to dictatorship for relief from that ceaseless striving for power. That's what is becoming increasingly worrisome about this entire episode. If we allow the rules of our society to be set by fleeting majorities, then each side will continually ratchet up the rhetoric and demonize the opposition and run roughshod over legitimate constitutional opposition.

When the Republicans were in power, they did the same thing when it came to national security. Opposition to unconstitutional wars and unlawful detentions of citizens was met with aggressive questioning of one's patriotism and attempts to deny the jurisdiction of the Supreme Court in Guantanamo.

And, this already seems to be happening with you. Otherwise, why suggest your opponents of "literally" being responsible for the deaths of children?

[Alkibiades]

I don't have time to respond to the rest of your post at the moment (sorry), but after years of hearing Republicans groan about judicial activism, I'm not particularly worried about Obama's admonition.

I don't quite get all the chatter about what he wrote either-in fact, I wouldn't even call it an admonition. Just a couple of weeks ago, legal experts were all pretty much saying what Obama said, which is that the decision to overturn this bill would have to undo many years of precedent-from what the commerce clause allows to overturning an elected Congress' function to pass laws. If the voters don't like it, they can elect people to change it-it's not like we are dealing with segregation here.

Oh, so that's the standard now. The Court can overturn the will of the people when the people are wrong, but when the people are right, the Court has no authority. That is an ingenious constitutional mechanism. They should just slide that up to the top of Article III.

Never mind that the problem with Obama's little speech is not that he thinks his law is constitutional, rather that he questioned the constitutional authority of a whole branch of government, specifically because it is not directly elected.

Regarding the commerce clause, however, do you remember in the so-called Anti-Federalist Papers, when Patrick Henry was debating and said, 'if we grant a national Government the power to regulate Commerce, God knows what mischief theye'll get up to!' And, then one of the Federalists in the General Assembly said, 'oh, the slippery slope Fallacy!' And, Patrick Henry said, 'I know not how much Others would wager, but I would bet George Washington's teeth that they will start requiring every Citizen to buy health Insurance, if this Clause is maintained, y'all'. And, the Federalist said, 'ah-ha, the slippery slope Fallacy'. Of course, the Federalist was proved right, and Patrick Henry died an obvious fool. After all, how on earth could one get from regulating commerce between the several States to individual health insurance Mandates?

I should point out, too, that the power of the federal government to impose anything at all on individual citizens is hard to find. Eminent domain--I can see your eyes brighten at the prospect of completely reinterpreting that clause--is one. I am hard pressed to think of any others until the Progressive Era when alcohol was banned--surprisingly not by means of the commerce clause--and the income tax was instituted, again by amendment. Almost every clause in the Constitution was either written to define 'intergovernmental relations' or and to explicitly enumerate the powers exercised by the federal government. There are certainly no constitutional duties required of the citizens whatsoever or the power to force any citizen, insofar as he is a citizen, to do anything at all. But, somehow, the commerce clause granted all this power that somehow never came up in the constitutional debates. And, somehow, nobody knew that the commerce clause granted those powers until FDR became president.

You are correct, of course, in pointing out that establishment of the Social Security program did not result in an individual broccoli mandate. I can't imagine how Scalia could have missed that. Whether or not you thought his analogy was particularly apt, it would probably help if you at least recognized that it was an analogy. As an analogy, it had nothing to do with broccoli in particular as such per se, in fact. The point is that the federal government simply declares the existence of a "market" and then says, "Wait a second, a market must have commerce, and we do have that underutilized commerce clause just gathering dust over there. Why don't we just 'regulate' it according to some grand social engineering/social justice scheme we've been itching to try?" But, they don't just "regulate" it. Having justified their action under the aegis of "commerce", they somehow interpret "regulate" to mean that people who are not even in the market (i.e., those who do not buy insurance) must enter the market.

The analogy was not broccoli; it was food. And, one can suppose Scalia picked food, because medical evidence suggests that diet has some bearing on health and therefore was more appropriate than picking publishing and asking if the government could require citizens to buy particular books or magazines since publishing is interstate commerce, as well. Of course, if you are correct, then I suppose no analogy could be used to disprove your position, and all such analogies would be inherently ludicrous. But, then again, you think Scalia was talking about broccoli. I don't even like Scalia, and I think I could pick up on the thrust of that question.

Why don't you guys just say that what you want is constitutional, and what you don't isn't? The way you all interpret the Constitution makes one wonder why the Founders didn't just stop with the Preamble, or just write, "What the people wants, the people gets! (So long as it is what I want, too)."

[Cooperations]

(Obama) called any attempt to negate legislation "unprecedented".

Because in his view, all of the legal precedents would favor upholding the law. Do you have any examples of opinions where the Supreme Court has denied the federal government the right to regulate commerce? It would be legally unprecedented, which is what all legal commentators (from both sides of the aisle) were saying before the actual hearing.

Oh, so that's the standard now. The Court can overturn the will of the people when the people are wrong, but when the people are right, the Court has no authority. That is an ingenious constitutional mechanism. They should just slide that up to the top of Article III....Why don't you guys just say that what you want is constitutional, and what you don't isn't? The way you all interpret the Constitution makes one wonder why the Founders didn't just stop with the Preamble, or just write, "What the people wants, the people gets! (So long as it is what I want, too)."

Um, because that is not what anyone was saying. Interesting interpretation of what I said, but not what I said at all. There is much more nuance, which I have no interest in debating or trying to explain. For the record, I am not a proponent of the health care law...nor do I oppose it. I'm living and staying in Taiwan, so you can put me in the "don't give a f*ck" category. I'll just keep using my 健保卡 and paying my NT600/month, thanks.

Your posts are great examples of the Fox-ization of debate...I have a feeling continuing this discussion would look a lot like:

I don't have Jon Stewart's patience...