Obamacare Going Down?

[Lemur]

Looks like the administration's lawyers are not faring well in front of the Supremes. Details:

CNN's legal correspondent Jeffrey Toobin reports that the court's conservative wing appeared skeptical of the Obama administration's arguments in favor of the individual mandate provision of the Affordable Care Act.

"This was a train wreck for the Obama administration. This law looks like it's going to be struck down," Toobin said on CNN. "All of the predictions including mine that the justices would not have a problem with this law were wrong."

"The only conservative justice who looked like he might uphold the law was Chief Justice Roberts who asked hard questions of both sides, all four liberal justices tried as hard as they could to make the arguments in favor of the law, but they were -- they did not meet with their success with their colleagues," Toobin said.

This gets me wondering, if the latest attempt at universal coverage is ruled unconstitutional — if the individual mandate, which is pretty much the only method for preserving a market-based system while guaranteeing coverage for most citizens, is unenforceable — what's next? Remember, the concept of the individual mandate was initially put forward by the Heritage Foundation and enacted by Governor Romney in its first real-world test-drive.

So what's next? Do we really try to disentangle government from healthcare, and strike out into uncharted waters for a completely market-based approach? Do we eventually get forced into single-payer just to keep costs under control? Do we limp along with our hybrid jackalope not-market/not-universal system for the forseeable future?

What?

-edit-

Shamelessly ganking from another thread where this came up:

The NHS provides universal cover for half the cost of the US system - there are other alternatives, but the tell is that you can have private insurrence in the UK but most people don't bother.

I assume he means half the cost per head, and I also assume he wasn't being literal.

Actually, I think he understated the case, although it's hard to make head-to-head comparisons, given that different benefits apply. Still and all, a recent, rough comparison.



I think anyone who has run the numbers can see that the US system involves the most cash for (at best) an average outcome.

Well that's pretty damning, isn't it?

Especially seeing as you wouldnt say the UK has some fabled mediterranean diet, they drink, smoke eat too much nor do they exercise blah blah and still the life expectancy is two years better with less wonga spent.

Short version of my take: Single-payer healthcare has its ups and downs, but it appears to be the cheapest method for covering the population.

A purely market-based system of healthcare may be cheaper, depending on which economic theories you choose to believe, but it has never been tried on a national scale in a developed country. (I would be a lot more confident in the Republicans who advocate a pure market system if they could point to a single real-world example. Empiricism FTW.)

Here in the USA we've managed to take the worst aspects of single-payer and fuse them to the worst aspects of a broken market system, yielding the most expensive healthcare on Earth. Yay us.

The only upside to our system is that if you have a great deal of wealth (in the form of gold-plated insurance or good old cash), some low-percentage diseases and conditions can be treated at a much higher level of competence than in any single-payer system. So if you've got some weird variant of lymphoma, and your pockets are functionally bottomless, you can buy better treatment here.

And that's about it.

[Strike For The South]

The goal should be Maximizing care while minimizing cost. The individual mandate is a middle ground which keeps the bloat of the medical industry intact under the guise of "universial health care"

I just want an NHS, Sorry for being fiscally respobsible

[Lemur]

The individual mandate is a middle ground which keeps the bloat of the medical industry intact under the guise of "universial health care"

I think this is one of the most relevant criticisms of Obamacare (and Romneycare): yes, near-universal coverage is achieved, but no big steps are taken to rein in costs. And if you compare the year-over-year increases, our system is getting more expensive at a geometrically faster pace than other systems. Big problem.

-edit-

Not very confidence-inspiring: GOP Senate majority leader weighs in. "[H]e doesn’t favor comprehensive legislation to replace it. 'We would want to more modestly approach this with more incremental fixes,' he told me. 'Not a massive Republican alternative.' Two ideas McConnell mentions are allowing people to purchase health insurance across state lines and reforming medical-malpractice laws."

Those old chestnuts? That's the alternative?

[Strike For The South]

I think this is one of the most relevant criticisms of Obamacare (and Romneycare): yes, near-universal coverage is achieved, but no big steps are taken to rein in costs. And if you compare the year-over-year increases, our system is getting more expensive at a geometrically faster pace than other systems. Big problem.

Obamacare was rushed through and hamstrung by all the worst parts of the art of compromise. To tout what will become law in 2014 as universal health care is putting lipstick on a pig. The end result will most likely be higher rates, more red tape, and a crushing effect on small buisnesses. Obama gave up to much in order to get the thing passed, quite the phyrric victory.

As you allude to in the op a purley based market system may in fact be better but it is not a practical reality unless we accept the fact the uninsured will die becuase their is no saftey net for them. I do not mean to be hyperbolic but my larger point is the American people will not stand for a pure market becuase no one is going to turn away the uninsured at the ER (nor should they). Guess who ends up paying for that?

People wait until the last possible second for medical care percisely becuase they lack or have inadequte coverage. Then everyone ends up paying more becuase they waited so long to take care of their medical issues.

I would be remiss if I didn't mention that an NHS would require a tax hike. But that's a small hurdle compared to the elephant in the room. An NHS would eliminate allot of jobs. A price I am more than willing to bear, of course I don't work in health care.

[rory_20_uk]

A nice graph of comparative costs, courtesy of McKinsey.



Those will be some of the most well heeled lobbyists in the land, and faced with a potentially life or death struggle.

Perversely, in the UK the PM has a lot more power than the President does - as evidenced by the first challenges occurring 12 minutes after the bill was passed where here changes can be more effectively deployed (whether the changes themselves are effective is a different matter).

I did some work for a friend who was looking into getting involved in preventative medicine in the USA for Diabetes. In a cohort study of the staff of one company, the ROI was under 5 years - and this for a long term illness.

I really don't know how the USA is going to sort this out. Although oft said, it can't go on - spending 20, 30, 40 percent of GDP on healthcare is insane, but based on current trends is going to happen.

[Rhyfelwyr]

What I like about the NHS is that not only does it provide a better value service than what people currently have in America, I think it strengthens British society.

From what I've seen the levels of care poor people get in America is shocking, it's bordering on third-world levels. Meanwhile the rich get the best of the best.

That doesn't happen in the UK. Rich or poor, most people will use the NHS (of course some will still go private). It's something we all have in common regardless of class, creed, colour etc.

This obviously means that there is less of a disconnect and less resentment between the rich and poor. If we are going to live together as a society then we have to have things in common. Shared institutions like the NHS, BBC, Royal Mail etc are all good examples of that.

No death panels. No communism. Just a decent level of health care for everyone.

Somtimes I wonder if the lack of these things in America is what makes politics so polarised there.

Of course the social, political, and even geographic make-up of the USA is completely different to that of Britain, so I can't presume that what works here will work there.

[Lemur]

Of course the social, political, and even geographic make-up of the USA is completely different to that of Britain, so I can't presume that what works here will work there.

Given that the USA is the only industrialized nation without some form of universal healthcare, I think that's a dodge. If it can work for a nations as racially and physically diverse as India and Singapore, it could work here. That's ignoring the baggage we bring to the table by having invested so much for so long in our jackalope hybrid system, however.

More legal analysis:

In weighing how the contemporary Supreme Court behaves, there’s a relevant precedent here. In the Citizens United case, the Supreme Court not only rejected a major piece of legislation but created a constitutional standard that makes any meaningful campaign-finance legislation next to impossible to pass.

The question is whether they will do the same with health-care reform.

[rory_20_uk]

Death panels? Oh, we are up with the Media Hype.

Until healthcare is infinite there will always be rationing. Who gets organs is decided by a panel of experts, and yes, those who don't get them have an increased chance of dying.

People are increasingly demanding of the NHS. A cough for 2 weeks - quick, off to the GP!

I am not advocating this as the "good old days" but one elderly patient informed me that pre-NHS, seeing the GP would be the pay for a day or so - not something taken lightly. I personally think that a nominal charge attending both A&E and one's GP. In France, people are expected to bring all their medical records to their doctor and this is considered normal, so I don't think paying a small payment isn't unreasonable, and would help preserve the system for the future.

[Strike For The South]

That's worrisome, to block the government from healthcare will only continue us down an untennable role.

Granted considering Uncle Sam already foots a large part of the bill I don't know how they would word it. Granted I don't put it past them either

[drone]

My understanding is that the main Constitutional challenge is the requirement to purchase insurance. This need to be struck down or else the commerce clause pretty much overrides everything in this country. Forcing people to buy something is not a power I want the federal government to have. We are already becoming a corporatist nation, no need to accelerate it further.

The best solution is for an NHS-style system (payed for by taxes/deductibles). Through that, get health costs down through tort-reform, neutering Big Pharma, and preventative medicine.

[a completely inoffensive name]

I can't wait until someone tries to tell me that only through adhering to a laissez-faire free market, can we achieve maximum efficiency in rationing medical supplies by having our money go into the coffers of insurance companies that are trying to maximize profit, not coverage.

[a completely inoffensive name]

Also, I can't wait to hear everyone cry when SCOTUS takes out the individual mandate and suddenly their state government can't force people to buy car insurance anymore.

[Rhyfelwyr]

Since I forgot to say it earlier, I offer a +1 to GC's above post. The free market is great but it is just not appropriate for peoples' physical suffering to be the source of profit for an organisation.

IMO this is another example of protecting the vulnerable, and it is the government's duty to do so.

Although, as Drone's post has made clear to me, the way they are going about this reform is sillly.

idk but would conservatives be happy with NHS style reforms being made at the state (as opposed to federal) level? Could that work?

[rory_20_uk]

Even if things were directed at a federal level, things would have to be done at state / county level. Again, similarities to the NHS where the structure is nationwide, but the implementation is far more local. Some trusts are good, others are dangerously bad.

[PanzerJaeger]

I can't wait until someone tries to tell me that only through adhering to a laissez-faire free market, can we achieve maximum efficiency in rationing medical supplies by having our money go into the coffers of insurance companies that are trying to maximize profit, not coverage.

Do you know what the average profit margin for the health insurance industry is?

[a completely inoffensive name]

Do you know what the average profit margin for the health insurance industry is?

Not great, but still too high. My philosophy is that all money should be going back to providing health care. The stuff is just too dang expensive, it doesn't make sense to have a system that automatically takes a chunk of your money and does nothing for your health with it. The free market is supposed to provide a better product in return of being able to have profits, but the free market incentives for health care are completely out of wack. It just doesn't work. The incentive is only to cover healthy people and deny sick people, which is the exact opposite of what we want because healthy 20 year olds don't need insurance and the elderly/sick do.

It's not a failure of free market principles to admit that they just don't work for providing health care. It's just admitting that health care is a unique product with certain problems in its distribution.

EDIT: I am not asking for government control of hospitals and doctor's pay, I just want a government insurance agency that applies to everyone that is able to bring down costs by being able to negotiate with hospitals with its leverage.

[drone]

Also, I can't wait to hear everyone cry when SCOTUS takes out the individual mandate and suddenly their state government can't force people to buy car insurance anymore.

Bad counterargument.

• Obamacare relies on a twisted interpretation of the commerce clause to be constitutional. The commerce clause covers interstate commerce. What state governments do within their borders is (theoretically) their own business.
• Driving or owning a car is not mandatory. You can make the choice not to have a license. Obamacare does not give you a choice.

[econ21]

I did some work for a friend who was looking into getting involved in preventative medicine in the USA for Diabetes. In a cohort study of the staff of one company, the ROI was under 5 years - and this for a long term illness.

Rory, can you spell this out a bit? For example, what's a ROI? Can you explain this study and what you infer from your work in layman's terms? It sounds interesting.

[rvg]

Driving or owning a car is not mandatory. You can make the choice not to have a license.

Precisely. You don't need car insurance if you don't drive. All you need to be obligated to buy Obamacare is a pulse.

[a completely inoffensive name]

Bad counterargument.

• Obamacare relies on a twisted interpretation of the commerce clause to be constitutional. The commerce clause covers interstate commerce. What state governments do within their borders is (theoretically) their own business.
• Driving or owning a car is not mandatory. You can make the choice not to have a license. Obamacare does not give you a choice.

Point of car insurance is to make sure costs that people produce when using the infrastructure are not offset onto someone else. The logic still applies to health insurance. Only difference being that everyone is allowed to use the infrastructure at any time, so of course the mandate is going to apply as long as you live. One reason why health care is so expensive is because people who can't pay have their costs dumped on others who can pay and/or have insurance, which is why just like we make sure every car has insurance, every body should have insurance.

[rory_20_uk]

Rory, can you spell this out a bit? For example, what's a ROI? Can you explain this study and what you infer from your work in layman's terms? It sounds interesting.

Link this is the document that I created. It was for internal review, and yes, is gleaned from others and there was no time to properly reference it. Rest assured it was all plagiarised from online sources.

ROI - Return On Investment - this was being prepared for the basis of starting a company, but savings are equally important if it was a non-profit.

[drone]

Point of car insurance is to make sure costs that people produce when using the infrastructure are not offset onto someone else. The logic still applies to health insurance. Only difference being that everyone is allowed to use the infrastructure at any time, so of course the mandate is going to apply as long as you live. One reason why health care is so expensive is because people who can't pay have their costs dumped on others who can pay and/or have insurance, which is why just like we make sure every car has insurance, every body should have insurance.

But the problem with your analogy is that people can opt out of using automobiles. Forcing people to purchase goods/services from private entities just for being alive is a bad precedent to make, especially considering the corporate influence over our current government. SCOTUS needs to kill Obamacare for this reason. Try again with a single-payer system.

[Lemur]

Driving or owning a car is not mandatory. You can make the choice not to have a license. Obamacare does not give you a choice.

Fair point, but you can also go from cradle to grave without owning a car, should you choose. Hard to picture the same for healthcare.

I think it's more like paying for the army. Whether you want it, like it or approve of it, a nation's gonna have an army. We all have to pay for it. We can argue about how big that army should be, what it should be doing in its spare time, whether they need the latest and greatest death robots, but the fact remains that it must exist and we must pay for it.

We are all going to use healthcare at some point. (In fact, for most people 90% of their healthcare dollars will be spent in the last three months of their lives.) The question is how we pay for it, and ration it, since the appetite for healthcare is infinite and the supply is finite. Right now we ration it via paperwork and insurance bureaucrats. I would actually rather we debated it in public and made it an issue of elections. That would be vastly more transparent than our current hybrid system.

Try again with a single-payer system.

Yeah, it's starting to look like that will be the only workable option.

[PanzerJaeger]

EDIT: I am not asking for government control of hospitals and doctor's pay, I just want a government insurance agency that applies to everyone that is able to bring down costs by being able to negotiate with hospitals with its leverage.

This, like eliminating insurance industry profits, digitizing medical records, tort reform, and selling insurance across state lines, would amount to only negligible savings. Even adding all of those together and assuming maximum efficiencies, they would still only make a dent in the significant cost overruns the American system experiences in comparison to other developed nations.

The truth is that the vast majority of healthcare spending in the US is end of life care. It is incredibly expensive to keep people alive who should be dead. The Left is afraid to admit that Sarah Palin was essentially correct. To truly bring America's healthcare costs in line with other nations in a government run system, some higher authority (i.e. death panels) will have to step in and make decisions about what is and is not appropriate end of life care. Left up to families and/or individuals, most people will opt to live as long as possible, especially if insurance is footing the bill.

Now, of course, Palin was trying to invoke an Orwellian emotional reaction for political gain. It would be nice, though, if politicians would acknowledge the essential fact that under a socialized system people's lives would necessarily have to be weighed against a budget instead of acting like the healthcare issue can be solved through the elimination of waste, fraud, and abuse.

[Lemur]

The truth is that the vast majority of healthcare spending in the US is end of life care.

And a really shocking amount is spent on administrative overhead, both with care providers and insurers. A light touch on that subject:

In 1999, health administration costs totaled at least $294.3 billion in the United States, or $1,059 per capita, as compared with $307 per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States [...] The gap between U.S. and Canadian spending on health care administration has grown to $752 per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.

So yeah, between end-of-life care and exploding administrative costs, there you have it. Those are the two big drivers of cost, so far as I can see.

[HoreTore]

Old people has to die, regardless of whether its paid for privately or through taxes.

It might sound cold, but it really isn't. We need to stop thinking about wrenching the last bit of life out of an old and tired body as a positive thing, and instead see a dignified and natural death as a positive.

Keeping terminally ill people alive for a couple of extra months is NOT saving lives. Cancer isn't the deadliest disease, poverty is what kills most people in all countries. Keeping people who are going to die alive costs a heck of a lot of resources, resources which could instead be used on the production economy to create a means of subsistance for a lot more people. Whether healthcare is privately or publicly funded has no meaning on that debate.

All that said, however, we are still doing the same over here with our NHS-thingies, so I believe it's fair to say that public healthcare still saves quite a lot of money. Oh, and of course suing doctors is a candidate for the Dumbest Idea in History-award. Doctors are people, and like all people, they make mistakes in their jobs. Its part of real life, and demanding money when it happens is nonsense.

[Lemur]

Another update, apparently one of the lawyers representing the government's side of the case is doing an unusually awful job. Maybe not as epically bad as the defenders of Prop 8 in California, but bad nonetheless.

Stepping up to the podium, Verrilli stammered as he began his argument. He coughed, he cleared his throat, he took a drink of water. And that was before he even finished the first part of his argument. Sounding less like a world-class lawyer and more like a teenager giving an oral presentation for the first time, Verrilli delivered a rambling, apprehensive legal defense of liberalism's biggest domestic accomplishment since the 1960s—and one that may well have doubled as its eulogy.

"What is left?" Justice Antonin Scalia demanded of Verrilli, "if the government can do this, what can it not do?" Verrilli's response to this basic and most predictable of questions was to rattle off a few legal precedents.

Justice Samuel Alito asked the same question later. "Could you just—before you move on, could you express your limiting principle as succinctly as you possibly can?" Verrilli turned to precedent again. "It's very much like Wickard in that respect, it's very much like Raich in that respect," Verrilli said, pointing to two previous Supreme Court opinions liberals have held up to defend the individual mandate. Where the lawyers challenging the mandate invoked the Federalist Papers and the framers of the Constitution, Verrilli offered jargon and political talking points. [...]

The months leading up to the arguments made it clear that the government would face this obvious question. The law's defenders knew that they had to find a simple way of answering it so that its argument didn't leave the federal government with unlimited power. That is, Obamacare defenders would have to explain to the justices why allowing the government to compel individuals to buy insurance did not mean that the government could make individuals buy anything—(say, broccoli or health club memberships, both of which Scalia mentioned). Verrilli was unable to do so concisely, leaving the Democratic appointees on the court to throw him life lines, all of which a flailing Verrilli failed to grasp.

-edit-

And a good summation of public opinion:

Americans want all the freedom of a market-based health insurance system, all the security of a system heavily regulated by government, and the option to put off purchasing this guaranteed insurance until it's needed. And all for no more than they're paying now. It seems whoever is in power will be doomed to disappoint.

[econ21]

The truth is that the vast majority of healthcare spending in the US is end of life care. It is incredibly expensive to keep people alive who should be dead. The Left is afraid to admit that Sarah Palin was essentially correct. To truly bring America's healthcare costs in line with other nations in a government run system, some higher authority (i.e. death panels) will have to step in and make decisions about what is and is not appropriate end of life care. Left up to families and/or individuals, most people will opt to live as long as possible, especially if insurance is footing the bill.

I don't think that is a truth. End of life care (i.e. care in the last year of life) is maybe 27-30% of medicare spending and there is more to health care spending in the US than medicare. There's not much data on it but one study suggests spending on end of life care takes a similar proportion of total health care spending in the US and some other countries like Holland:

http://stevereads.com/papers_to_read...d_of_life_.pdf

I think your final rider about insurance may be more to the point. The US system may have less incentive to restrain costs across the board, not just at the end of life.

Interestingly studies seem to contest the commonsense view that increasing life expectancy will inevitably inflate health care costs per person per year. Controlling for time to death, extra years of age among the elderly reduce health care costs at the end of life - perhaps because they are less likely to want to be hospitalised. The share of spending on end of life care has not risen markedly over the last two decades. The point seems to be that it's not being old that raises health care costs - it's being close to death (i.e. in the last year of life).

Now, of course, Palin was trying to invoke an Orwellian emotional reaction for political gain. It would be nice, though, if politicians would acknowledge the essential fact that under a socialized system people's lives would necessarily have to be weighed against a budget instead of acting like the healthcare issue can be solved through the elimination of waste, fraud, and abuse.

There's always a budget constraint, whether the budget is private or public. The argument for the socialised system is that it will pay for those whose private budget wouldn't run to it. Those with higher incomes can always use their own private budget (including via private insurance) to get more health care if they choose. If the socialised system is decent enough, they won't. I suspect it's not just "death panels" that see the futility of extending the life of people who "ought to be dead". If the extra bit of time you could eke out is miserable, people may think it's not worth squandering what they have accumulated to pass on to the next generations.

[Xiahou]

Whether it's a good bill or not (I think not) isn't at issue here. Whether we need single-payer or market based healthcare is also not at issue. The issue is does the federal government have the authority to compel people to buy health insurance?

Case law presents us with several twisted and strained abuses of the Commerce Clause (Wickard v. Filburn), but Obamacare, if upheld, would outdo them all. It would not prevent you from taking a certain action- it would compel you to take action under the guise of regulating interstate commerce. To paraphrase Justice Kennedy, it would be forcing you into a market so that the government can regulate you. This is frightening stuff. If the court were to uphold this, what could the government not force you to do under the fig leaf of the commerce clause?

Luckily for us, early indications are that this will be overturned. I welcome such a decision and hope it's just a beginning step in rolling back the power of the commerce clause to that which it was originally intended.

[Lemur]

Whether it's a good bill or not (I think not) isn't at issue here. Whether we need single-payer or market based healthcare is also not at issue. The issue is does the federal government have the authority to compel people to buy health insurance?

I think it's kind of strange to walk into this conversation and tell everyone what the issue is or isn't. Nor do I see how it's illegitimate to discuss the long-term ramifications if the law gets struck down.

The USA's system of healthcare is problematic, as most anyone would agree. The Obama administration tried to apply a fix, which now looks to be nullified. All we're hearing from the GOP is the same small-ball. Surely, beyond the legal question of the Commerce Clause, there is a legitimate conversation to be had about what we do next, yes? I do believe that was posited as the central question of my OP, yes?