473 Comments on “Why The ACA Matters to Me”

1. Living in Britain, my circumstances are very different. But this kind of gambling with people’s lives is horrendous. And it is only 60 years since people here were afraid to call (or see) the Dr because of how much it might cost. Secure access to good basic health care for anyone and everyone is to my mind a vital part of any civilised society.

2. Same here. My friend J got adult onset diabetes, triggered (probably) by a car accident in her early 20s. She went to the doctor, was diagnosed, got medication, got on with her life. The end. Completely agree with Sooz.

3. Succinct discussion of WHY the ACA is necessary. Thank you, John.

4. But I thought that the shutdown WASN’T going to stop the ACA? I’m not really up on it, and I do believe that the ACA is a first step, I’m VERY happy that people who don’t have insurance will now be able to get it. I’m, unfortunately, caught in the middle from the standpoint that I *had* good coverage (I insure myself) which I subsequently lost because according to my provider ‘Obamacare was causing companies to struggle’ (bullshit, I’m aware) and so they upped my premium until I couldn’t afford it. Now I’ve changed plans, but I’ve ended up paying three times as much in co-pays and everything else, and my prescription drugs aren’t covered now. Even under the ACA, at least one of them won’t be. It’s all very frustrating. I just want ACA to be the FIRST STEP in getting to a better place rather than ending up being the final ‘fix’. I want the ACA to start us on a road that ends with the private health care companies actually being held accountable for their actions.

5. My biggest problem (because I have many) with the naysayers is that they’re not offering anything else instead. Yes, the ACA has flaws, but I don’t hear Ted Cruz et al. coming up with a better solution. As usual, it’s a hell of a lot easier to take potshots at the people doing the real work of leading (or at least governing) than it is to do the leading yourself.

6. Artemisgrey:

   The shutdown isn’t stopping the ACA; the people who shut down the government want substantial changes (at the very least; whet they really want is repeal) and decided that inasmuch as they couldn’t get the changes any other way, that using a shutdown as leverage was the way to go.

   Beej:

   Well, that’s not entirely true; their solution is to repeal it, or barring that delay sections of it as long as possible. Their problem is that they can’t sell it — it won’t pass the Senate, and it’ll get vetoed in the unlikely chance it did. The shutdown is the legislative equivalent of the House GOP holding its breath until it gets its way, or passes out.

7. And yet there are many in power in the UK who are desperate to bring in a US style health care system.

8. You avoided using the word that makes the Right dislike the ACA – which word is “Obama”.
   http://gawker.com/kimmel-asks-americans-to-choose-obamacare-or-the-affor-1433866673

   If the Right was against socialized medicine, then obviously they are more against Medicare part D, signed by Bush. But that isn’t an issue worth destroying the country over. Not like the race of the president seems to be.

9. Thanks for this, John. VERY well said. It sums up my own feelings perfectly and I’m going to share it on FB. I’m looking forward to having coverage for the first time in nine years.

10. I have also been fortunate enough to have decent insurance–many times as a nonfiction writer I paid for myself–but I also have many friends who’ve had none and no means of getting it. And some of them have gotten sick and a few have died for the lack of it.

    About half the applicants for Social Security disability every year wouldn’t be there if they’d gotten medical care early–when it was an infected hangnail and not a gangrenous limb, so to speak. I ran the numbers on what that really costs and it came out to about $100B/year in new encumbrances, not to mention that we’d have 125,000 people every year who were functional, working citizens and not people on the dole. (The math and stats are here: http://hedtke.blogspot.com/2009/10/some-hard-numbers-on-health-care-reform.html .)

    But even so, the whole idea that we don’t take care of people and just treat ’em like condoms is beyond disgusting to me. When GOPpers start talking about screwing people out of health care and then in the same breath start talking about how Christian they are, it really just makes me want to massage them with a tire iron and let them talk to God face-to-face.

11. As a person who isn’t from the US; this just gets added to the list of things about the US I clearly can’t wrap my head around. I admire the country but wonder about a portion of the government can’t get behind ideas like the ACA.

12. I too have had friends and family who have been brought to near-or-actual financial ruin due to the cost of healthcare.

    I also know people who have seriously asked, “Why should I buy health insurance when I don’t need it?” My response to them is always, “You, like almost everyone else in this country, is one medical catastrophe away from desperately needing that insurance.”

13. Recent cartoon related to a popular and just concluded TV series…

    http://www.buzzfeed.com/lukelewis/if-breaking-bad-had-been-set-in-the-uk

14. This has been a problem for most self-employed folks, esp. those working in the arts. Singer and songwriter Victoria Williams was diagnosed with MS in 1993, and the Sweet Relief Musicians Fund was started to help her and others who did not have the financial means to properly provide for their medical care.

15. Well said, John. I have friends who haven’t had health insurance for decades because they had “a preexisting condition”…etc. I agree the ACA has flaws, but there are 17 million children out there who can now have health insurance.

16. My wife and I have moved numerous times while being self-employed and getting health insurance was always fraught with peril. For the last two years I’ve been holding on to my Washington State local policy while living in NC and now TN, because trying to apply for BCBS in state has been fraught with peril. I even got rejected in NC and I’ve never had any health issues, don’t smoke, yada yada.

    My wife has been hanging on to her NC BCBS for the past year. Saturday I sat down and did an application for both of us for TN. Sunday we got emailed that we were in underwriting. Monday they came back a new quote (higher of course). We accepted. Today they already withdrew my payment for November. Something is drastically different and it has to be the ACA.

    I know ACA isn’t perfect, but it’s a step in the right direction. We force people to insure their cars. Since when is a car more important than a person’s health?

17. Well it seems to me that the most important part of the ACA is the affordable part.

    And that has yet to be proven.

18. For what it’s worth, the ACA has also greatly impacted my life. I’m under 26, and my husband was in college and I was unemployed when my daughter was born. If I hadn’t been able to be on my parents (really fantastic) insurance, we never would have been able to afford her birth. It’s making a huge difference for lots of young 20-somethings who otherwise wouldn’t have insurance because this is a really transitory phase of life, and not all post-graduation jobs come quickly or with good insurance.

19. Tammy and I didn’t have insurance for years – not until she was able to re-establish herself as a business, and got insurance through the Author’s Guild.

    Our health insurance isn’t great by any means (for a while, they were limiting her to SIX Imitrex migraine prevention tablets a Month because they “cost too much”!), but as somebody who’s getting older and didn’t see a doctor for two decades, I’m grateful for what we’ve got.

    Now, we need to see what our ACA options look like….

20. Living in Ireland, we have the standard European style heavily taxpayer funded healthcare system. It’s not perfect by any stretch, but no one is advocating the US system here, or in most of the EU. Even in Britain, the most economically conservative country in Europe, most conservatives want to tinker with the socialist NHS rather than actually abolish it. Watching Pres Obama, who by many European standards is quite conservative, be accused of being a commie for bringing in the ACA is absolutely surreal. We have communists in most of our national parliaments, and the European Parliament, and sir, Barack Obama is no communist.

21. I’ve always had health insurance, even when I had to pay for it myself. I do things like ride horses, and accidents are just too common there for me to ever risk going without. But I’ve lived in fear for a long time of coming down with some chronic disease that would give my insurance carrier an excuse to boot me, making me uninsured and uninsurable. I no longer have this fear.

    I’m with you. When I hear people slagging the ACA, I want to tell them they are personally punching me in the face, in a manner of speaking.

22. Hi John,

    Thank you for speaking up. I’m also a diabetic (insulin-dependent), and I’ve been in the same exact place you describe. I was laid off one week before Lehman Brothers went under and lost my health insurance because I simply couldn’t afford it, through COBRA or the individual market. My doctors had to scrape and beg on my behalf to get me the insulin and syringes I needed just to survive. Each bottle of insulin costs around $120 without insurance, and I need 2-3 bottles of two different kinds of insulin each month. Those were the scariest two years of my life, and I had numerous visits to the ER to get insulin when the doctors couldn’t find options for me fast enough.

    The ACA already was helping me by putting me in the temporary pre-existing condition plans when it finally got passed two years later. I’m now covered on my girlfriend’s work plan via a domestic partnership, but as I start Geek Bar Chicago, I’m excited by the options that I’ll have to offer my employees next year so that they have better options than were available in the past, using the small business exchange and the tax credits to their fullest effect, because no one should have to worry about the security of their health.

    As always, you rock, good sir.

    All the best,

    David Zoltan
    President and CEO
    Geek Bar Chicago

23. Just wanted to clarify something. ER visits are not free. And I don’t mean in the sense that the costs is borne by taxpayers generally. EMTALA merely required hospitals to treat emergency patients regardless of their insurance status or present ability to pay. The patient is still responsible for the bill. As you might imagine, emergency services are absurdly overpriced, and the bills can be astronomically high. The hospital may then go try to collect the bill as any other charge.

    Full disclosure, I am a debt collection attorney and handle claims on behalf of emergency service providers.

24. Well said.
    My mother in law has chronic Leukemia, and is a California school teacher who was recently laid off. Off insurance, the drug she takes to keep her healthy (and alive, and living something like a normal life) runs somewhere between $7,000 and $9,000 a month. This is a drug she has to take for the rest of her life.

    Right now, she’s on Cobra, and she’s only able to afford that because I am in a position to provide substantial financial support to her, and I’m happy to do it. But I’m trying to imagine a scenario where I was not able to do that, and it sure looks like she would have to go off her meds, go into remission, and ultimately die.

    The ACA could not have come soon enough. Because of it, she can’t be turned away for her pre-existing condition, and she’ll actually be able to afford health insurance. That means she get’s to stay alive. That’s not hyperbole. Under the old system, the end game would have been for her to be refused insurance, go off her medication, and die of a treatable disease, because while I can afford to contribute $500 a month, I don’t even make $9000.

25. I live in California. I am fortunate enough to have a great job and health insurance through that job. (In fact, I’m an ER nurse and believe me, I well know those ER visits aren’t free, by any means!)

    But my concern is with the costs. If you don’t have insurance, and you can’t afford even a basic doctor visit with a prescription, how on earth are you going to pay the premium every month?

    Because those premiums are HUGE!!! And the co-pays are large. I spent a lot of time punching numbers yesterday, and short of being without means so that you are eligible for free Medicaid, the other plans are expensive. The Bronze plans are the cheapest, but have $60 co-pays for visits and $100 copays for brand name drugs (generics are not always available, either.) That ER visit now has a $250 copay. In some ways that is good, but what if you STILL can’t afford it and stay away because of it?

    So, now you are paying your premium AND the high co-pays when you are sick.

    Your state mileage may vary, this was through the Covered CA site.

    I encourage everyone to go the exchange for their state and see what the plan would cost them, even if they have insurance through their employer. You might be stunned. I was.

    I realize this is a long post, but here is something that was posted on my FB page this morning. Here’s what happens when you decide to “opt out” while signing up.

    “This is what you’ll get if you start the obamacare process then opt out: “I actually made it through this morning at 8:00 A.M. I have a preexisting condition (Type 1 Diabetes) and my income base was 45K-55K annually I chose tier 2 “Silver Plan” and my monthly premiums came out to $597.00 with $13,988 yearly deductible!!! There is NO POSSIBLE way that I can afford this so I “opt-out” and chose to continue along with no insurance. I received an email tonight at 5:00 P.M. informing me that my fine would be $4,037 and could be attached to my yearly income tax return. Then you make it to the “REPERCUSSIONS PORTION” for “non-payment” of yearly fine. First, your drivers license will be suspended until paid, and if you go 24 consecutive months with “Non-Payment” and you happen to be a home owner, you will have a federal tax lien placed on your home. You can agree to give your bank information so that they can easy “Automatically withdraw” your “penalties” weekly, bi-weekly or monthly! This by no means is “Free” or even “Affordable.””

    I’m interested to hear what other folks on the board have experienced or come across while signing up.

    Thanks!

26. Just want to correct my above post, that should read “Go OUT of remission.”

27. I agree with the sentiment, but I have to take exception to your implication of Calvinism. If anything, I think a Calvinist would insist that the sufferer had been foreordained to suffer; but this would not preclude pursuing treatment.

28. Okaaay. That makes more sense. Well, as an attempt to ham-handedly get control of the situation, I can now see where the shutdown is supposed to come into play. The whole ‘we’ll fix it later, for right now we don’t want to do anything’ position drives me nuts. Even if the ACA gets refined and tweaked, or eventually put aside in favor of even better and more efficient systems, at least it’s a first step. Love your analogy of a child holding it’s breath until it gets what it wants. But you know what? No child ever died from holding their breath like that. They pass out and then wake up later – without having gotten what they wanted – and life goes on.

29. John Marstall:

    There’s a reason why I put “angry” as a modifier before “Calivinism.”

    Kim McAllister:

    I suspect the person on your Facebook wall has confused Maximum Out of Pocket expenses with the deductible (for a start). Beyond that, I would additionally suggest not relying on Facebook posts as sources of accurate information on the ACA (or much of anything else, for that matter).

30. MobiusSamurai-

    When I read something like what you just wrote, to the effect of “I admire the US, but WTF?!?” I always have the same response:

    What you admire is the story we tell about ourselves. Our narrative. The freedom-loving Pilgrims, the hardy pioneers, the nation-builders, the “we got into two Wars in Europe to save other peoples’ asses,” the “we defend the world from totalitarianism/communism,” the whole Shining City on the Hill mythos.

    And as with every mythos, there is a central thread of truth there, and there are many of us who have internalized the ethos behind the mythos, so to speak, and we do want to be the America that you admire.

    We are, however, somewhat outnumbered at the moment by those who’ve bought the mythos without the ethos. The ones who believe in American Exceptionalism. The ones who think our story, our narrative, entitles us to dictate to others, grab a disproportionate share of the world’s resources, treat those who we think don’t “live up to” our mythos like despised Others.

    Every nation has the issue of “what we’d like to believe we are (and what we’d like others to believe we are)” versus how we actually behave on the world stage.

    Me, I tend to admire the communities who achieve a high level of congruence between the two, as opposed to the ones who have the prettiest mythos.

31. You avoided using the word that makes the Right dislike the ACA – which word is “Obama”.

    I heard a story on the radio last week about Kentucky’s new health insurance exchange KYnect. Outreach efforts have been intense, and they had audio of Kentucky citizens at a KYnect info booth at the KY state fair. These people were very excited about the exchange, raving and saying “This sure as heck beats Obamacare!” and “Now my sister can finally get insurance!” and “Why don’t other states do this instead of Obamacare?!” When the reporter explained that the state exchange was set up because of the Affordable Care Act, i.e. “Obamacare,” these people wouldn’t believe him.

    Jummy Kimmel recently did a man-on-the-street piece asking people which they support, Obamacare or the Affordable Care Act. People don’t understand that they are different names for the same thing.

32. I have to respectfully dissent, and apologize in advance for the length. Your argument falls into the trap that people on the political left in this country are making all the time (along with many on the other side of the aisle): not bothering to understand the real arguments on the other side. Instead of blithely dismissing the counterarguments to the ACA as “angry Calvinism,” it is better to engage them on their own terms. That is why our politics are so horribly broken today: neither side even wants to give a shred of credence to the arguments of the other.

    I oppose the ACA because it fundamentally will not work. There is no magic pixie dust that will give everyone cheap health care by fiat. If you want to increase access to health care, you have to pay for it. Doctors are not slaves that can be compelled to work for free, and unless we want barely-trained and underpaid people making life-and-death decisions, medicine will always be relatively expensive. If you want to reduce the cost of health care on society by fiat, you have to start reducing access. This is how the NHS in the UK and the Canadian system works. You have health INSURANCE, yes. But that’s no guarantee of health CARE. (The Canadian Supreme Court struck down Quebec’s ban on private health insurance for this very reason, calling it a violation of human rights.)

    The ACA assumes that the government can create a Potemkin village of a “market” through the use of government-run exchanges, give everyone access to care (community rating and guaranteed issue), but pay for it by forcing everyone to buy health insurance (the individual mandate). In theory, this would work. The real world and the theory don’t always align, however.

    What will happen is that the government will not be able to get enough money from the individual mandate to both increase access and lower costs. So the government will do the only thing it can: artificially lower the cost. (This is being done already in Medicare.) But doctors don’t work for free: if the costs are too low, they will move elsewhere. (This is why German doctors go to the UK on weekends to make enough money to support their practices.) People will have health insurance, but it’s worthless because there will not be enough providers to meet the demand. This will lead to shortages: which is exactly what happens to everything else when prices are artificially lowered.

    Alternately, the government will artificially constrain supply to try and reduce the costs, as Canada and the NHS does. Again, this has been done before: HMOs were the only agencies that actually “bent the cost curve.” Anyone alive and conscious in the early 1990s knows how well that worked for the American people.

    The problem with the ACA is that it was assumed that 1.) there is a problem; 2.) something must be done; 3.) the ACA is “something.” Unfortunately for the country, it’s exactly the wrong solution. You don’t fix a third-party payor problem by making an even bigger third party more powerful.

    If that makes me an “angry Calvinist,” so be it. But there are better ways of fixing health care that would actually work – but the ACA has made that harder rather than easier.

33. Reading things like this makes me glad I live in Canada. Our system does have some major issues (like super-long waits to see a specialist, doctor shortages, emergency rooms used as a stand-in for long-term care as a few examples) but at least I can go to the doctor for any reason, at any time. If I am feeling sick, I can book an appointment and throw down my government-issued health card, and it costs me nothing to see the doctor. Hospital stays are generally free, along with any drugs and tests given to you while in the hospital.

    Employer plans usually just cover things like prescriptions and physiotherapy. But even the poorest people don’t fear that going to the doctor will cost them the money they will need for other necessities. I’ve had a few medical issues in the past, and I shudder to think what it would have cost me if I had to pay out of pocket for them

34. The best part of all this, of course, is how much the far-right is rejoicing at the shutdown as though it were an unequivocal good thing, as though the government really never did anything beneficial for someone. People on clinical cancer trials have been sent home, and food stamps and WIC programs have been cut off. People may not actually die from the government shutdown (though I’m not ruling that out as a possibility) but they’re certainly going to start suffering, a lot, and fast.

35. A few years back, my wife was hospitalized for several weeks. The same year, a coworker had a heart attack. Fortunately, we had semi-decent health insurance. It wasn’t great, out of pocket expenses were high (I’m still paying some of them off), but we weren’t out on the streets.

    When the fiscal year ended, the insurance company jacked up the rates for the whole company by 70%. The company’s insurance agent said, “basically that means they don’t want to cover you anymore,” and started looking for another policy. He found one, but it was worse, and it cost more.

    Two hospitalizations in a company with nearly 30 employees and about half as many spouses on the policy, and all 40-some-odd of us wind up with less coverage and more costs.

    The idea that any change to the system could possibly make it worse is difficult to accept.

36. Thank Bevan for the NHS! Because I love the country, and because the DH is in the kind of occupation where he could get serious money there, we’ve looked at moving to the US, but the health insurance is killer. That puts all the costs up so much we just can’t do it.
    In the UK, the NHS provides health care, but we have a private system for people who want something else. We have our scandals and our disgraces, but it is reassuring to know that if you’re ill, you will go and get treated for “free” without question.
    You didn’t mention prices – as a self-employed person, I pay £12 a month plus 11% of my taxable income every year for my National Insurance, which is supposed to pay for health and pension. Plus nearly £8 per order for any prescription drugs I might need. How does that compare?

37. And from what I’ve seen it’s even worse for visual artists who are less likely to access white collar jobs that professional writers can often turn to. I found it telling during my first visit to America comparing the In Memorium between the Eisner Awards and the Hugo Awards. The average age seemed much younger at the Eisners.

    Not to underplay the challenges of writers, but just to remember that, on average, we have creative brothers and sisters who may be even more negatively impacted by lack of healthcare.

38. Great post. My story of adult onset diabetes almost mirrors Hurley’s.

    Before that, during a period of unemployment, I tried to get some coverage, but was denied due to “pre-existing conditions” (asthma). I tried to just live with rescue inhalers. I found myself unable to walk around the block without having a mild attack. Luckily, where I live, there are free clinics that are easily accessible, and several teaching hospitals.

    Being uninsured makes you play Russian Roulette with your health.
    Being uninsurable makes you feel like a pariah.

39. @jayredding Exactly. People have no idea what is going to happen.

    I know two physicians who have gotten off the roller coaster, off the grid, and have non-insurance based practices for patients who pay them every month for basic care, with fees unbelievably lower than what the ACA requires.

40. Small clarification: Adult-onset diabetes generally describes Type 2 diabetes. What Kameron has is Type 1 diabetes, a related disease but quite different than Type 2 in some ways, arising from different causes. Type 1 diabetes usually shows up in children and young teens, so it’s commonly referred to as juvenile-onset diabetes, but it does occur in adults, as it did with Kameron and myself. Apologies if I’m derailing here.

41. My family looks like the American Dream from the outside. My husband owns his own business and I work 30+ hours a week at a job that I love. Our kids are healthy and successful in school and sports. And we have been living without health insurance for almost 3 years.
    Between pre-existing conditions and having to pay for our own plan, it would have cost almost $1500 a month for insurance. I have been terrified about medical emergencies for years, trying to make it until the ACA or Obama care will finally start. I have had to have frank discussions with my kids about why they can’t skateboard or go skiing because a broken arm could cause us to lose our home. We are willing to pay for health insurance, but like your examples, who can afford it? I have good friends who argue with me about how our country can’t afford to pay for insurance for all those loafers. Then I get the “joy” of explaining about how the truly poor get coverage (not the best but something) and those of us who work but don’t have affordable employer coverage are the ones that hope those chest pains are just asthma. The regular people who are against Obamacare also tend to be for the Affordable Care Act if it is explained to them. Funny….

42. Back when Minnesota had a Republican governor and legislative majority, they decided that the best way to balance the state budget was to massively cut support services for people with disabilities and the elderly. Since the woman I live with is disabled, I quipped, “I’ll consider voting for a Republican when they stop trying to kill the people I love.”

43. Greg van Eekhout:

    Not derailing at all, and I’ve updated the piece to make that clearer.

44. Even with health insurance, many go bankrupt paying their health care costs.
    60% of bankruptcies in 2009 were due to medical bills. of those, three-quarters of people with a medically-related bankruptcy had health insurance.

    The ACA is a bandaid on a chest wound, but it will save some lives and some from bankruptcy, and I am glad it passed. The pre-existing condition clause that allowed insurers to let you die so they could save money was an atrocity.
    It’s too bad we couldn’t go single payer. But then doctors in the US wouldn’t make 78% more than docs in other countries, on average, and 20% of American doctors wouldn’t be in the top 1% percentile of earners.

45. All three will happen, but hard to predict which will happen first: legal same sex marriage in all 50 states, legal marijuana in all 50 states, one payer universal health care.

    I’m betting universal health care first, same sex marriage second, marijuana last.

46. I had a cancer scare just a little while ago, and though I’m fortunate to still be on my father’s insurance plan for the next month or so, I was terrified about how I was supposed to deal with it on my own. Nothing came of it, but I still remember that fear.

    I understand now that fear is only a fraction of the terror involved for people dealing with this every day.

47. Well said, Mr. Scalzi. Well said! As a fellow resident in this, the ostensibly wealthiest and most technologically advanced nation on Earth, I feel that we, as a collective, need to have health care available. I also found the following link useful: http://www.reddit.com/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/

48. Jay Reding, you’re constructing a specious argument out of hypotheticals and stick figures. No health care system is perfect; but as every other first-world country has demonstrated, having a public health care system yields far better results than not having one.

    Also, the ACA is the law of the land — passed by our elected representatives in Congress, signed into law by the President, and double-checked and approved by the Supreme Court. Shutting down the government and demanding that the ACA now be watered down is a direct attack on democracy and the rule of law.

    IMO, this whole situation would be clearer if we referred to the shutdown as the attempted coup that it is.

49. So, Kim McAllister, I went to CoveredCA and tried to duplicate that Facebook story you posted. Obviously, I didn’t have more details that you laid out, but for a family of 4 (2 adults, 2 kids) with that income range living in San Francisco, the monthly cost was $280 ($884-$606 subsidy), the deductible was $1500, and the standard copay was $40. The maximum out of pocket for the family was $10,400. There was no place to enter the diabetes as a preexisting condition.

    So, no. If it was some other state, then, please, let us know and we can check that state.

50. Jay Reding – Yes, medicine has a cost. The US needs to decide something – Is medicine a market, or is it a right? If it’s a market, people should be turned away from the emergency room if they don’t have money/insurance. Before the ACA, people could get into the emergency room, and if they couldn’t pay, I (as a paying insured person) would pay for their default. Which is wrong.

    If it’s a right, then everyone should have it. And while there is a cost, that cost needs to be regulated so everyone can have it. And yes, that could mean lower quality of care. But that’s how society has always worked. The rich used to go to college and learn french, latin, and calculus. Now we go to college to learn basket weaving. A college education, it could be argued, is of lower quality these days. But more people can have one.

51. that

    *than*

52. A friend’s observation from The Book of Faces:

    If the ACA is such a horrible load of crap, the GOP should let it go into effect, and then reap the rewards of in 2016 when Americans would elect nothing but Republicans to office in order to shut it down. So it’s very, very strange that the GOP is fighting tooth and nail to stop implementation.

    I do not think “horrible load of crap” means what John Boehner thinks it means…

53. Thank you, John. Now that you’ve said that I don’t have to try to. I’m not very articulate when it comes to my passionate belief in doing the right thing. Thankfully you are articulate.

54. Teresa Nielsen Hayden: As noted in my response, many of these things are already happening. We already know what the ACA/Obamacare is going to be like: we can look at the comparable Medicare system to get reliable real-world data. And Medicare has neither “bent the cost curve” nor has it expanded access.

    Your argument is exactly what I described in the first part of my response: it just handwaives away the arguments on the other side rather than engaging them on a substantive level. That’s not how argumentation works, if one side cannot engage the other on their own terms, neither side is really advancing anything.

    As for the “it’s the law” argument, that is utterly unpersuasive. The logical response is that so was slavery, Prohibition, Jim Crow, and “separate but equal.” The fact that something has been put into law (or upheld by the SCOTUS) does not make it a _good_ law, or a _wise_ law or a _just_ law. One can argue whether it’s worth shutting down the government over the issue or not, but the argument that just because something is “the law” it must be immune from criticism or challenge is not a particular wise or cogent argument.

55. I appear to be in the minority here, but my boyfriend is being slammed pretty hard by the individual mandate part of it.

    He’s 30. He was raised a farm boy, which means that last year when he broke a bone in his foot, his solution was to go buy a boot and wear it until it stopped hurting. Same principle when he may have fractured a bone in his wrist. He has terrible lungs from years of tearing down barns with his father (classic ‘dust masks are for wimps’ mentality), but he just gets his flu shot every year and tries to avoid getting those chest colds that seem to last months. Could a doctor help? Probably. Would he go to one, even if he had insurance? Probably not.

    He works two, part-time jobs equaling about 60 hours a week. One is contract work prepping computers for disposal, the other is for a library that only gives full-time status to people with a MLS. Neither offers insurance to part-time employees. His combined income pushes him out of the subsidies, but we really can’t afford the extra ~$300/mo to insure him. So we end up with the choice to have him quit one of his jobs to get him subsidized, probably with the end result of me taking on a third job (currently working a 40hr/wk State job with decent insurance but crap pay, and a 30hr/wk part-time retail job), or eating the first-year tax penalty of $93.

    For the second year…well, we’ll see.

56. Such a complicated issue.

    First, it’s not “health care” that’s the focus, it’s “financing health care,” which is very different but doesn’t so much roll trippingly off the tongue. We all assume that, but it’s good to keep it front-of-mind.

    I too have friends who’ve faced these crazy insurance situations, through no fault of their own. An insurer quoted one of my close friends a premium – I am not making this up – of $5000/month, and only with the provision that she submit to a surgery that 3 specialists told her was unnecessary and even dangerous. Like I said – crazy!

    The whole system is broken, and if it had been easy to fix, the Clintons would have done so back in the 1980s. They had a great team put together, but … well, we know what happened: not much. My feeling at the time was that there were too many fingers in the pie.

    Back then I worked in health care, and I often struggled to keep on the schedule my manager expected because if a patient started crying, I couldn’t just walk away – I sat down and held their hand or talked them through it or whatever was needed. Yet even so, I sometimes pondered why some of our customers (patients) expected to receive our products (health care goods and services) for free, when they didn’t go down to the car dealership and expect to receive their products for free.

    In 1964, my dad was very sick and hospitalized for 6 months with multiple surgeries, ICU, etc. He was a non-union blue collar worker and we had no health insurance at all. My parents went through their (meager) savings, then borrowed from friends and family. The point is that they did _not_ have to go so far as to put a 2nd mortgage on the house, and they paid the hospital and doctor bills in full. It took a few years, but they paid everyone back, on his blue collar wages. This would never be possible today – costs have gone up too much.

    As for Congress … you know that classic definition of insanity, how it’s doing the same thing over and over and expecting a different result? If I was as unproductive in my job as those people are in theirs (and proud of it!), I’d be fired.

    Finally – I totally get what you mean by “angry Calvinism,” John, and I agree with the sentiment, but it’s not a very precise use of that term … maybe consider taking off the capitalization?

57. @ Thomas Pluck

    There was a poll of US doctors a few years back, and a solid majority of them supported the idea of single-payer health care. That backs up the impression I’ve gotten from personal discussions with doctors of my acquaintance. They *hate* insurance companies.

    Sure, they also have complaints about Medicare, including how poorly it pays, but that’s just grumbling. I’ve witnessed doctors *screaming* on the phone with insurance reps.

58. @Jay Reding

    “This is how the NHS in the UK and the Canadian system works. You have health INSURANCE, yes. But that’s no guarantee of health CARE.”

    Yeah, you’ve never actually talked to anybody actually living in the UK or Canada, have you?

    We have better overall health outcomes than the US, we have better overall access to health care than the US, and we pay less per capita to get it, because a national health system can leverage competitive pricing from suppliers so much more effectively. It is cheaper, and it’s accessible to everybody.

    Would I have to wait a bit longer to get an MRI in Canada than in the US? Sure, because in Canada we don’t actually restrict access to the MRI to only the rich people. But of course that’s only true if I’m making the comparison to one of the people in the US lucky enough to have health insurance, because without it the MRI wait time is “forever”, and nobody in Canada waits that long. And when a Canadian gets to the MRI, we don’t have to a write a cheque.

    I stuns me that so many Americans can stand up with a straight face and claim “a national universal health care system cannot possibly work” when there are so many examples, all over the world, of national universal health care systems working just perfectly fine, thank you.

59. I became a type 1 diabetic at age 48. Because I’m in the UK I was tested, diagnosed, and treated free of charge within days. I haven’t had to pay a penny for medicines since. I owe my life to the NHS.

    I suggest that anyone who defends the US system has a look at the figures for healthcare across nations in the CIA’s world factbook. Somehow the USA manages to spend more money (both as an absolute number and as a proportion of GDP) on health than any other nation, but get worse outcomes for its population than most other developed countries.

60. I’m also not from the US – the ACA seems like a band-aid on a lost limb, in that ensuring some actual competition is useful but still prone to market failure, and it doesn’t really address the opaque methods healthcare providers arrive at to determine their charges, which NPR has led me to believe is also a big problem and one that’s apparently solved by insurance providers clubbing the healthcare providers.

    In my country, I go to the doctor and either it’s covered, or I pay the bill and take it to Medicare/my insurer, who covers it just enough that I don’t treat the doctor as a revolving door. I went into hospital last year with a staph infection, and everything was covered. I didn’t need any additional worry after being told they were putting me on an IV to ensure these weird blisters on my feet wouldn’t get into my bloodstream and kill me. Leaving hospital was weird; essentially, they provided me with some at-home medication, let me clean up my stuff, then I toddled over to the ward reception and signed out.

    “As a person who isn’t from the US; this just gets added to the list of things about the US I clearly can’t wrap my head around.”

    I’m more dazzled by the idea that American politicians, in order to score points with the people they’re representing, are perfectly willing to shut down the thing they’re supposedly representing the American people at. Why isn’t their electorate furious that they’ve been disenfranchised? And over THIS? It’s baffling. The troops that Americans keep going on how much they support have all been fired. Tourist sites across the country are shut. All those hoorah things NASA does that say that America can do great things are no longer happening. People don’t seem especially bothered – sure, they’re bothered, but I’d be taking to the streets and calling for early elections. Exactly how badly do your elected representatives have to fail before they’re scared of what you’ll think of them?

    On the other hand, it improves my joke about how the only countries still using the imperial measurement system are ones with no functioning government.

61. Jay-

    I would be very interested in hearing what you believe to be the better solutions for the health care problem than the ACA. If I’m reading you correctly, you believe the following are hard constraints on the problem:

    1) We can not reduce the cost of providing health care, as that will reduce the supply below what is needed.

    2) We can not reduce the supply below what is needed, because that would be intolerably cruel and unjust.

    3) Many people do not have the money to pay for the amount of health care they need.

    Contrary to your post, the way the ACA attempts to navigate this problem is by providing subsidies to purchase health insurance, thus increasing the pool of money available to acquire health care. If you are ruling that out as an option, where will the additional spending come from? Or if no additional spending is forthcoming, what cost savings are there to be had that the ACA has overlooked?

62. @johnscazi “Beyond that, I would additionally suggest not relying on Facebook posts as sources of accurate information on the ACA (or much of anything else, for that matter).”

    Obviously :) Facebook is not where you look for facts, it’s where people share their experiences, where people discuss their actual contact with the system. And even though my friend mixed up her data, she did not mix up her monthly premium.

    That was a chilling email she received. And this is what is going to happen to a person when the reality of those premiums hit, and they find they can’t afford even that, but they make too much money for the free Medicaid system.

63. @ Jay Reding: “And Medicare has neither “bent the cost curve” nor has it expanded access.”

    You are incorrect on both counts.

64. Well, that was freaking embarrassing – I left the “L” out of Scalzi :D Note to self – proofread ALL posts…

65. I fall into the “socially liberal, fiscally conservative” camp. I tell friends (somewhat facetiously) that I want everyone to have everything and be taken care of but just can’t seem to bring myself to pay for it.

    However, on this particular subject of healthcare, I’m pretty much willing to throw away my conservative side. Part of that is personal – I know I’d have died in the 90s without it, plain and simple. A gangrenous gallbladder is a death sentence unless you do something about it *now*. If I wouldn’t have had decent insurance, I wouldn’t have gone to the doctor, the specialist, or the surgeon. At the very least, I would have hesitated. He who hesitates is lost and I’d have been dead in a week. Insurance literally saved my life.

    So, my personal experience and the knowledge that’s given me completely overrides my fiscal conservatism here. I have a deep belief that everyone that wants health insurance should be able to get it and if that means the rest of us need to chip in, I’m OK with that. I may argue the details (the whole individual mandate still feels wrong to me), but I’m willing to live with them and tweak as needed as time goes on.

    Ultimately, I think that the real problem here, and one that neither the Democrats or the Republicans seem to want to touch is our broken civil legal system that has driven up prices, stifled real innovation, and made us a completely risk adverse society is at the root of most of these issues, but that’s a discussion for another day. Today, the ACA is the best answer we’ve got – if the Tea Party Republicans don’t like it, trundle out something better.

66. Muchrejoicing: Health care cannot by definition be a “right” unless you want to re-establish slavery. Nothing can be a right that requires you unfettered access to the labor of others. Free speech can be a right because your right to speak does not depend on the acquiescence of others. Your right to vote does not deprive someone else of their right. But for health care to be a “right” you must be entitled to the labor of someone else. Doctors are not a public resources that can be freely exploited. (If you were an economist, you would note that “rights” are “public goods” that are non-rivalrous and non-excludable.) So no, health care is not a “right,” and never truly can be.

    So the question must be how can health care be allocated in the most efficient way possible that maximizes the good of all? And if we listen to the lessons of the past century, the answer is clear. Markets ain’t perfect, but they produce a hell of a lot more human happiness and better outcomes than centralized planning.

    That’s a quick answer. I’d go into details, but I don’t want to monopolize someone else’s site on what would be a very, very long outline for health care reform. If you want to know what I would support as a general principle, this would be it:
    http://www.theatlantic.com/magazine/archive/2009/09/how-american-health-care-killed-my-father/307617/?single_page=true

67. Jay Reding, please describe the “better ways” of making healthcare work. If you can, you will be a thought leader among opponents of ACA. That’s snarky, but I really do hope someone who opposes ACA has an alternative to suggest.

    Also, is there a shortage of healthcare available in Massachusetts? Seems like RomneyCare is a better comparison to ACA than Medicare. Are physicians spending weekends in New Hampshire to support their Massachusetts practices? RomneyCare hasn’t increased costs OR inpatient usage in Massachusetts, according to the VA Boston Health System, but it has increased the proportion of people with insurance. According to the NBER, people in Massachusetts are also healthier than they were before RomneyCare. Correlation isn’t causation, but it isn’t necessarily insignificant, either.

68. Jay Redding:Medicare certainly has increased access There would be huge numbers of people without health care right now without Medicare.
    The old system (pre-ACA) was broken. If you had a pre-existing condition and lost employer coverage, you were done. As John mentions, ACA is not perfect, but it is quite helpful. If you have thoughts on improvements, please do share.
    Also note that in addition to calling on a “magic pixie dust” argument, you mention things like

    “What will happen is that the government will not be able to get enough money from the individual mandate to both increase access and lower costs.”

    without providing any evidence. Possibly, you need to examine from where the hand waving is coming.

69. Re: my last sentence @ 12:33 – I see that @ John Marstall already said something about that, and you already responded … cross-posted; oops.

    Also, ~ John V. Hedtke @ 11:38 – nice to see you in the Comments here again! I heard you speak several times years ago – you didn’t seem like the tire iron type! :-)

70. Jay Reding:

    “Health care cannot by definition be a ‘right’ unless you want to re-establish slavery.”

    Jay, this is the sort of hyperbole that undermines your argument as credible, and you’ve made a similar argument twice. Make your argument without resorting to such dramatic (and baiting) terms, please. Otherwise you’re going to be written off as someone who is more interested in trolling than making a salient point.

71. I just finished reading The Spirit Level, which is about equality and (among other things) health outcomes, and this struck me: the richest quartile in the US have worse health outcomes than the richest quartile in Scandinavia or Japan. The pre-ACA system in the US isn’t even “good if you’re rich, bad if you’re poor”; it’s just bad.

    ps The authors concede that they don’t have any data on the super rich–the 1%. Presumably, though, that’s not who we should be designing the health-care system for.

72. @David – checking age and state of the person who gave the example. I believe age has something to do with premiums, and have read (don’t quote me) that families are eligible for subsidies – more people for the same income.

73. Okay, I DID go check out the Virginia section of the ACA and right now, I’m looking at $247 a month premium, and a $60 co-pay and something like $9k ‘total’ yearly out of pocket costs. That’s as a single, 32 year old with no pre-existing conditions. I don’t qualify for any of the discounts and so I’m relegated to keeping my current health care (which has a substantially lower premium and co-pay, but still causes a lot of out of pocket expenses) until the premiums are raised beyond my ability to pay.

74. What upsets me on top of everything else that’s been mentioned here is that they are actually working to convince people NOT to buy insurance! This is so irresponsible as to beggar belief. Every healthy young person (the group most likely to not buy insurance due to thinking they don’t need it) is one accident away from hospitalization and bankruptcy.

    As a parent, I’m grateful that I’m now able to insure my son until he’s 26 and (even more important) that he cannot be denied insurance due to his many pre-existing conditions.

75. @Jay Redding: Actually, I have the right to due process, which requires the labour of judges, lawyers, and police investigators. I have the right to physical security, which may require the labour of local or federal law enforcement or even the military. I have the right to vote in elections, which requires the labour of all manner of election officials. The list keeps going.

    Scratch the surface and you’ll find that many of our rights require that other people work to make them happen. That’s not slavery, nor is it wrong; it’s just that the flip-side of every right I have is a responsibility on the part of someone else.

76. The ACA is a good thing. It is far from enough, and it is far from perfect (whose genius idea was it to leave insurance companies open instead of socialized medicine?), but it is a good thing.

    My mother, who used to work as a paralegal, has told me numerous horror stories of insurance company abuse, such as a woman who died of breast cancer following a fight with her insurance company, which had sent her to an incompetent doctor who somehow missed the tumor on a biopsy. In my opinion, the entire health insurance industry needs to crawl up its own ass and die.

    If the Republitards think they can get their way by holding their collective breath until they turn blue, then good for them. I’ll loot their rotting, soulless corpses after they suffocate.

77. The problem with advocating a “pure, market-based” model for health-insurance, let alone health-care, is that its impossible to point to another example of it in the world that works well. Show me a first-world country you’d want to live in, and I’ll show you some version of national health care, or at least, a public option.

78. @TNH: Shutting down the government and demanding that the ACA now be watered down is a direct attack on democracy and the rule of law.

    Exactly. It’s an attempt at an extra-judicial repeal.

    I was uninsured for a thankfully-short period a few years ago. During that time, Scalzi, you had a post up about Athena having a snow day. I just went googling for it, but I can’t recall which it was. I do recall the comment I didn’t post on it:

    “Snow day for me too, sadly. Being uninsured is calling in sick because you can’t afford to slip on the ice.”

    I was a congressional intern at the time. The Affordable Care Act was still at the debate stage. Every day, I’d take phone calls from people telling me that people without insurance were just lazy, and I’d want to tell them, “I’m here, at my desk, listening to you tell me that I’m lazy, because I want a job so badly that I’m working for free.” Then the phone would ring again, and it’d be someone else, begging my boss to do something to save their sick child’s life.

    The Affordable Care Act has already had a huge impact on my life. The day the ‘no rescissions’ policy came into affect was the day I first sought treatment for the pre-existing condition that had cost my brother his insurance. If I didn’t have access to that treatment, I’d be on disability now, probably wondering what this shutdown would do to my benefits. Instead, I’m fully employed and paying taxes–working a job I was able to take because of the provision that allowed people under the age of 26 to stay on their parents’ insurance.

79. To expand on Eric Mills’ point, I have 5 siblings (between blood relatives and in-laws) who’d object to their service in the US military being defined as “slavery.”

80. The ACA is not in any way comparable to Medicare. Medicare is a single-payer system. The ACA is a set of laws regulating for-profit medical insurance companies. Two very different things.

    I do not like the ACA. It is a pitiful, watered-down excuse for a national medical care policy. But I like it better than nothing, which is what we had before. And I am delighted to see that capitalism works, that when insurance companies have to compete for customers their prices come down. Who knew?

    And I really like knowing that if, god forbid, I lose my employer-provided medical insurance, I will not die because I am uninsurable.

81. Floored, et al:

    Let’s go ahead and avoid “Republitard” and other such easy swipes, please. There’s enough to go on regarding substance.

82. to be sure, there are positive aspects to ACA, but not all of it. I hope that it gets re-evaluated (and it will) to remove the stupid parts and keep things that matter. Preventing insurance companies from denying affordable care to people with pre-existing conditions makes sense, that the government has to pay for it does not. Insurance companies should have to figure a way to make it work for them, even at the expense of profit, or they die…

83. Having read Jay Reding’s actual argument, I’m inclined to agree with the bit he said about how the ACA is not a particularly good solution, but no so much about the part where he said that liberals don’t listen. This is because when the ACA was being written, Jay’s argument – that it doesn’t address the actual costs of healthcare, and acts mostly as a band-aid to an undesirable system – was one commonly made by liberals opposed to the bill, who wanted a single-payer system that had the strength to dictate terms to providers. I appreciate the irony of not realising you’re making a liberal argument while claiming there’s a problem with a lack of listening.

    Still, ‘reducing access’ is weasel language – there’s plenty of evidence to suggest that prices for medicine and procedures in America are inflated compared to what they cost comparable countries, and there are alternative treatments that deliver much greater bang for the buck but are less profitable. It’s possible to represent this as ‘reducing access’ if you’re not interested in the distinction between people who require particular apparatus and people who don’t actually need them but might benefit.

84. I don’t know enough about ACA to make an argument about whether it’s good or bad. It doesn’t take a genius to see that the current system is broken. My instinct is that when the government gets involved, things get worse, not better.

    My biggest problem is the whining that we’re seeing in Washington. ACA passed and was signed into law. Get over yourselves, Republicans.

85. @Kim McAllister – Rule of Thumb: The veracity of a Facebook post is inversely proportional to the number of words in caps, exclamation points, and inappropriately-used quotation marks.

    The post’s implication that the Feds will threaten you if you start to sign up but don’t complete the application is a nice touch that’ll discourage some people from even trying. (This is reminiscent of those flyers that get handed out in poor neighborhoods the day before elections, warning that someone at the polls will be checking voters for outstanding parking tickets.) And I don’t know where that huge fine comes from, either: in 2014, the maximum penalty will be 1% of income or $95/person, whichever is greater, with a cap of $285 per family. And which shut-down agency is sending out these e-mails?

    Look, I’m not arguing that the ACA is even close to perfect. I just know that it’s a hell of a lot better than what came before it. I’m self-employed, and calculate that I’m going to save 40% over my current plan and get far better coverage (this is in Silicon Valley, not exactly a cheap place for medical care). And even if I weren’t going to save a dime, I know I’m not going to be rejected for pre-existing conditions, or subjected to ever-decreasing lifetime caps (that happened with my current plan, before ACA stepped in). Feel free to suggest a better system, but keep in mind that you’re going to sneak it past the people who have repeatedly tried to kill the ACA.

86. Merus
    Excellent Point.

87. @ Our Lord Host, May His Name Be Praisèd:

    Yes, sir. Sorry, sir. I’ve been a seething cauldron of burning hatred for the Republican Party ever since the truth about the lack of WMDs in Iraq broke.

88. Okay, I feel like a total idiot. Total. Idiot. The example I initially gave was quoted on a friend’s page. I went back to find out more details about the writer and was given a link –
    it was from an article!

    Ugh!

    Totally red-faced here, as I thought it was a friend of a friend. @John, you were right, don’t believe what you read on Facebook. Or at least get all the facts before reposting.

    So, in the interest of me being totally humiliated – here is the link with that story, complete with the Facebook post at the end. Again, it remains a FB post and I’ve no idea if true.

    http://www.infowars.com/obamacare-fines-to-be-seized-from-bank-accounts/

    @David, there still isn’t enough information in the article to check with Covered CA – we would need this guy’s age and health info (doctor visits, # of meds.)

    I apologize for taking up time/space with this, but felt I needed to clear it up. :(

89. @Jay Reding

    “If you want to reduce the cost of health care on society by fiat, you have to start reducing access. This is how the NHS in the UK and the Canadian system works.”

    You fundamentally misunderstand how single payer universal health care systems work.

    As for “reducing access”, what in the hell do you call “People can’t get healthcare because they can’t afford it”? While single payer universal health care services that are inadequately funded may have waiting lists, that is still a huge improvement over “can’t get care at all”. Not to mention that US medical services still has wait lists even for people who can afford it. They’re called “appointments” and “schedules”, not “show up any time for immediate access” for a reason.

90. @notSMOF: The Republicans don’t want any of it implemented because a) if it’s successful, they’ve already tagged it as Obamacare, b) if it’s bad, it will be next to impossible to shut it down in its entirety, because some bits of it, like the under 26 on the parent’s insurance, and the no pre-existing conditions clause are wildly popular. My biased opinion is that they are now afraid that it will succeed and that their repeated attempts to shut it down will only make it hard for them to attract new followers to the party.

91. Kim, I hate to be the one to tell you this, but “urban myths” are stories that people tell on the internet and the listeners then turn around and tell an exaggerated version of the story and claim it is their own. i’m not going to say they are lying but…
    You can easily look up the numbers on your own. There is no reason to just blindly repost something someone puts up there on faith alone.

    For both Kim and Jay,
    If you really truly think that you somehow have a better handle on the financial and economics aspects of the ACA than the Congressional Budget Office does, then I bow to you. In fact, come and do MY taxes, please. And you could do my best friends statistics homework while you’re at it. Seriously, if you have political objections, I want to hear them, but to refute all the economic and financial information that has already been gone over with a fine-toothed comb based on some hypothetical situations you or some friends dreamed up is RIDICULOUS.
    I know everyone talks about how stupid and incompetant our politicians are but you do realize they aren’t the ones doing all the number crunching, right? The employ many many very qualified people – some from the free market! – to do more rigorous things like that.

    Lastly, about ten years ago I contracted meningitis and had to go to the ER. They did a test to see if it was bacterial or viral, determined it wa viral and after a few days sent me on my way with a bill of over $30K. Which of course I didn’t have since I was a retail clerk and a college student. Since I didn’t have medical coverage or even a doctor, I did nothing to follow up and they didn’t even bother suggesting I do so.
    A year later I got it again. A bil of over $35K Which I couldn’t pay for again.
    A year later I got it again. Another $35K I couldn’t pay.
    Several times, I had what I thought was yet another meningitis attack but I did the “hope it goes away” thing and popped pills. Because I couldn’t see carrying all that bad credit debt for the rest of my life.

    Yes, two more years later and I got it again. But by that time I had medical coverage.
    One more stint and five specialists later (thanks to medical coverage) I now take a prophylactic pill every day so I dont’ get meningitis again.

    Meanwhile that’s about $100K I couldn’t pay. Guess who had to pay for that? Yep, everybody else. Sorry about that. Wasn’t my choice to get Herpes in my spinal fluid. Doctors don’t even know how I got it!
    Had I gotten some extensive testing the first or second time, there wouldn’t have been all those ER trips, lost wages and red-write-offs for the hospitals. Not to mention all the time spent being sick instead of working or studying. That’s 3-4 years “wasted”

    Worst is that because of the progression of my attacks, I ended up with extensive nerve damage and had to go on disability. So now I can’t even work.
    Who pays for that?
    Yeah sorry again.

    All because of lack of insurance.

    So if you want to make an argument about how ACA isn’t “affordable” you need to make sure you include all the hidden costs of NOT having it.

    Or you could just, you know, check the CBO’s numbers. They pretty much covered everything.

    Just like the ACA is going to do.

92. Something that tends to get left out of these discussions is that universal healthcare — however it’s paid for — benefits *everybody*. It is far, far easier to stay healthy if the people around you have good healthcare. That includes your immediate family, your coworkers, your kids’ classmates, the people handling your food, the person driving the tractor-trailer on the highway next to you, and so on, and on.

    “All health is public health.”

93. Those who worry about the costs, or that they “can’t afford it” should look closer. There are means tests to how high the premiums are, there is an expansion to the salary limits Medicaid covers, etc.

    I was uninsured at one point, young family, I was freelance and uninsured, and my appendix went nuts and demanded it leave my body. $30,000 in emergency costs later.. and was LUCKY to barely qualify for emergency medicaid. I could only afford Florida Kid Care (absolutely great program).. and if Obamacare was there at the time, I could have afforded insurance. If I couldn’t get emergency Medicare I’d have been bankrupt.

    Now my youngest son has had 3 surgeries in the last year and a half. I have insurance, but MY PORTION has already balooned to over $10K.

    So with and without insurance, the system is broken. The ACA fixed a LOT of the problems that kept me uninsured for so long, and it will bring down costs further (California has already seen exchange prices fall).

    Plus… No more pre-existing condition refusals. No more dropping of coverage because you’re costing insurance companies too much. No more coverage limits.

    Is it perfect? No. Single Payer is the way to go. Single payer is actually CHEAPER if they tax us. They’d take less in taxes than we’d pay in insurance (Employees who get coverage need to add in their employer’s contribution to see the true cost of their coverage).

    But the ACA is a good first step. It’s a significant improvement to what we had before. All those GOPers who shut down the government, and in a week or two kill our national credit, all in a tantrum to defund Obamacare need to be tossed out of office.

94. I agree with all of your sentiments and principles, and I’ve thought a lot about this issue. Unfortunately, I think we are focused on and trying to solve the wrong problem.

    Modern medical care in this country is extraordinarily expensive due to a variety of reasons, many of which have nothing to do with quality of care.

    We are focused on trying to figure out how to get this extraordinarily expensive to everybody. But, I believe that this incredibly expensive health care system we have, actually sucks and provides a poor level of actual benefits.

    My father recently died of cancer, and his (fully insured) journey through the top levels of our health care system was filled with indifference, incompetence, waste, and a callous insensitivity to his actual needs. He was just moved through the machine, and it was horrific in ways that had nothing to do with his actual illness.

    There is no reason why it has to be that way.

    When my dog got cancer, we saw a vet immediately. He charged a reasonable price that we paid out of pocket, got immediate access to the people, technologies and medicine needed, created a plan designed to benefit my dog, implemented it and followed through. It went humanely and efficiently.

    Today, my dog is still alive. In dog years he was much older than my father and his cancer was more serious.

    Having gone through both processes concurrently, I wish to got that it would have been possible to give my father the same compassionate and holistically approached standard of care that I was able to give my dog.

    My dog’s cancer cost me $1,700. My father’s cost the insurance company over $300,000.

    My dog’s treatment involved a small group of people who cared and were empowered to help my dog.

    My father’s treatment involved multiple huge bureaucracies at cross purpose to one another, who coordinated poorly, and who’s primary interest was involved in following their internal processes.

    I have no interest in any legislation that continuously feeds this wasteful and inhuman machine of lawyers, bureaucracies, and insurance companies.

    Were fixing the wrong problem with this. We are trying to give everybody in this country a broken Ferrari. It’s wasteful, ridiculous, horrendously expensive, and useless from a practical standpoint.

    I just wish that it was reasonable to aspire to a standard of care for this society that we commonly afford our pets.

95. “Or anyone else, for that matter, who doesn’t live in the magical bubble of work that carries benefits.”

    I have a full time job and a good insurance plan but it does not cover everything. Cancer is expensive. Two surgeries this year, follow up treatment and time off work have resulted in my medical bills exceeding my annual income so far this year. Lucky for me I have a husband that also works and wants me to remain upright and breathing or I would be one of the bankruptcies that Thomas Pluck @ 12:11 mentioned.

    The other issue you have not mentioned is that many insurance plans have a cap on how much they will pay for a person then they can stop coverage.

96. Bearpaw: “Something that tends to get left out of these discussions is that universal healthcare — however it’s paid for — benefits *everybody*.”

    If you ask anyone that lives in a country with universal healthcare, it comes up pretty quickly. Even if you don’t get sick, you notice how no-one around you *worries* about getting sick and how different it makes life.

97. Mr. Scalzi: Of course, your house; your rules. But that’s is, IMHO, the best way to make the point about what defines a “right.” The intent is certainly not to accuse anyone of actually wanting to re-enact slavery. My apologies if that’s how it came across. The point being made, I’ll move on.

    Eric Mills: Your argument would be correct, except none of those things are, in fact, rights. You have the right to due process _if you are criminally accused_. (You don’t have the right to an attorney in civil matters – although some states have suggested a “civil Gideon” that would do so.) You don’t have the right to police protection – the Supreme Court has held that on several occasions, IIRC. Nor do you have the right to military protection – we all get the benefits of it, but it’s not a right. That means, as mikes75 objects, soldiers or firefighters are most certainly not anything akin to slaves. (Yes, conscription, but that hasn’t been true since Vietnam…) They are public servants by choice, which is why society rightly values their contributions so much. But we have no right to their services, and nothing in American law gives us such. Those are all services that are granted to us by the government under the social contract. (This is where I’d tell you to read John Locke’s Second Treatise on Government, if you have a great deal of time on your hands.) But they are not “rights” by definition.

    John: That’s a good question: have their been doctor shortages in Massachusetts? Apparently there have been: http://www.massmed.org/News-and-Publications/Vital-Signs-This-Week/Mass–Physician-Shortages;-Monday-is-HIPAA-Deadline/#.UkxUORZxmHk

    It’s somewhat difficult to make an accurate comparison though, because patients in Massachusetts have access to health care resources in other states – that would alleviate some of the problems.

    As for what system I think would work better, the article from The Atlantic I posted earlier gives the general outline of what I feel would work, without having to engage in a very lengthy description on our gracious host’s site.

98. If this bill had been labeled honestly, it would be called the Somewhat Less Outrageously Expensive Health Care Act. I checked CoverOregon.com today and found 28 plans available to my household. After income-based offsets, the cheapest one is nearly $500 per month for the three of us – *before* out of pocket expenses. I am an IT professional who makes a decent living, but there is nothing like that much slack in our budget. I appreciate the intent behind this legislation, but the execution leaves a lot to be desired.

99. This is one of those things where I’ve been on all sides of the spectrum: I’ve had some really great insurance (due to work… got some pretty good stuff at a decent price now), been self insured (and watched my premiums go up by exactly 20% year after year*), and uninsured due to not having a job.

    My solution is that the critters who think keeping me or my fiancée from having insurance should also have to give up theirs, and their job… and try to see what they can get based solely on their medical history.

    *it got to the point where every June I could guess within a dollar or two what my new premium would be. The letter would come… yada yada yada… increasing costs… yada yada yada… raising your premium… financial reports of record profits over all the years before..

100. Beej — the naysayers weren’t listened to. We had lots of ideas, they were just … let’s say that they were ignored by those who know the good intentions of ACA would overwhelm the woe-stories from the Federally run Indian Health Service, military medicine, Tri-Care, and the Veteran’s Administration (and don’t forget Medicare and Medicaid.) I hope the intentions succeed, but I’ve seen those good intentions in action for over half a century and I have no expectation that this time, a miracle will occur.

     John, you paint a wonderful picture of the need, but not how the ACA fills that need and does not damage others. I have pre-existing conditions, and know the woes.

     I’m not inclined to look kindly on the people wishing my friends and family dead. I’m going to remember the ones who did. I am also going to remember the ones who instead chose to help them. Psychological projection is not your friend.

     Should I blame you because the new Medicare formulary has decided that a drug I’ve used for a decade is too expensive and their recommended alternative is likely to cause a return of my seizures? I should go through that twenty years of “Step Therapy” hell again? I wonder if I can get a successful appeal through the system before my emergency supply runs out in January? Oh, committee for appeals hasn’t been formed, there’s not even a appeals process yet. Meet the new federal medicine, same as the old federal medicine.

     It’s very human to blame. I’m blaming those who thought good intentions were more useful than examining the failures of previous good intentions in history.

101. @Kim,

     A good rule of thumb is ‘anything posted on ‘Infowars’ is false’. It’s a conspiracy site, pure and simple.

102. Your argument would be correct, except none of those things are, in fact, rights

     Oh, Jay, so wrong. Among the Bill of Rights which require the services of other people:

     Petition the government for a redress of grievance (requires the labor of government officials taking the petition), right to a Grand Jury (oops! Juror duties), right to due process (despite your handwaving, it is a right that requires labor of others), right to a speedy trial by jury in criminal and civil cases.

     And I haven’t even broached the other Amendments. It’s a specious argument.

     have their been doctor shortages in Massachusetts

     And were they caused by Romneycare? Because it looks like the shortages are countrywide:

     https://www.aamc.org/download/100598/data/

     @Kim: Google “Will Sheehan” and “urban legend” Your Facebook/article is fictitious.

103. My premiums, and we don’t qualify for any subsidies, and to keep what I already have, which is really good insurance, would cost $1980/month, and low-copays. (2 adults, mid-fifties, California) And that’s from my own number crunching, not a link. ;)

104. @David – Thank you!!! I’ll pass that along.

105. Jay, you can’t pull the “Doctor Shortages” flag out and wave it around. The ACA has everyone get INSURANCE FROM INSURANCE COMPANIES. Not the government. So the whole “Communist medicine pays doctors less so they flee” argument is 100% moot.

     Insurance Companies, as you know, negotiate their own rates already, but are nowhere near the levels of Medicare/Medicaid. Those companies aren’t going to suddenly cut their payments and pay doctors so much less. Why? Because they have no motivation to. They suddenly have a lot more money coming in, and since they have to now put 80% of that money to patient care (because of the AMA), they don’t need to lower payouts. If they did, Doctors would stop accepting their coverage and they’d have less places to send their customers.

     Yes, we’ll have a shortage of doctors, but for a different reason. It’s because more people will USE THEM. More customers = increased need for Doctors = More jobs for Doctors = More Doctors.

     Sure, there is some short-term growing pains we’ll all feel. But I couldn’t walk into my doctor if I got sick on the same day before Obamacare passed. I would have to make an appointment a few days out.

106. Because I haven’t looked it up, I’m making an assumption, so take this with the grain of salt it is. But I’ve seen several people talk about a set figure of out of pocket costs that they MUST pay, in addition to copays & deductibles. From the experience I’ve had with insurance policies in the past, usually the figure associated with out of pocket costs is the annual maximum … it’s the point at which OOP are capped. You don’t have to pay $9,000 or $15,000 before insurance kicks in.

     You go to the doctor & pay a co-pay. You get treated. Doctor files your insurance. Insurance pays a certain amount, doctor might write off some amount based on a contractual agreement with the insurance company. If there’s anything left after that, the patient owes it. Sometimes there is, sometimes there isn’t. The doctor bills you for that residual amount. It’s not the entire OOP at one fell swoop.

     You go to the hospital, you pay a copay, or you pay your deductible, or you pay a percentage, however it’s structured. Insurance is filed; payment is made, contractual adjustment is applied. If there’s anything left over, that’s your OOP, for which you are billed. If your hopsital/ER visit was sufficiently expensive, you might have a big OOP that has to be paid off over time, but once you hit the cap or the max for the year, the hospital can’t charge you more than that. So maybe you had a 100,000 visit, and after all is said and done, you have 20,000 left over towards your out-of-pocket expenses. If you have a 9,000 annual cap, I think that’s all you have to pay, & the balance has to be written off.

     Like I said, I *think* this is how it works. If I’m wrong, I apologize here and now for spreading misinformation. But if I’m right, then that Out of Pocket quote might have the potential to SAVE a patient money, rather than IMPOSE additional charges on the patient.

107. Jay, you need to read beyond the headline.

     The shortage is not in generic “physicians”. The actual quote is “showing an eighth consecutive year of shortages of primary care physicians”. PCP shortages are chronic, nationwide, and due almost solely to insurance payments being far lower for primary care than for specialist care.

     To put it more succinctly, when you hear “turn your head and cough”, that’s the invisible hand of the free market on your prostate.

108. Again.. because some others are saying their insurance with an employer is cheaper…

     Make sure you add what YOU pay and what the EMPLOYER pays to get your figure.

     I checked my figure online, and would pay less than what the total cost of my coverage is now if I went to the exchange. But I won’t because my wife’s employer pays a good portion of the overall bill. If her employer would give their part in cash, I’d switch in a minute.

109. My premiums, and we don’t qualify for any subsidies, and to keep what I already have, which is really good insurance

     Well, then, keep the insurance you have. The ACA is not designed to replace every single person’s existing insurance, any more than Social Security is designed to replace everyone’s retirement plan.

110. DAVID:

     “Well, then, keep the insurance you have.”

     Yup. For example, it looks like we’ll be keeping the insurance we have because for us it’s cheaper (after the employer contribution, etc).

111. See, the ultimate issue here has nothing to do with “access to health insurance” or even “health insurance” at all. The ultimate issue is: Why does health care cost so much?

     There has been a great deal of technological innovation in the medical field, as in other fields. Technological innovation, in other fields, tends to drive costs down over time; this is why that new laptop you want costs $1,000 instead of $5,000. Yet this is not the case in the field of health care. Why?

     A large part of it is because the health care industry is allowed, by law, to get away with business practices that, in any other field of business, would result in someone going to jail. And ACA does absolutely nothing to remedy those practices.

     Would you buy a hot dog if the hot dog vendor refused to tell you how much it cost until after you’d already eaten it? Would you buy a TV set if the price you paid for it would differ, and differ wildly, depending on whether you paid cash or used the store’s charge card? Both business practices are common in the health care industry. Cost-hiding and cost-shifting are rampant, meaning that the price of your appendectomy is driven up because you’re also paying for Joe Senior Citizen whose hip replacement costs weren’t fully covered by Medicare, and also for Juanita the illegal alien who jumped the border while pregnant (having had no prenatal care in the country she came from) and delivered her baby prematurely, and, of course, has no way of paying for all the NICU treatment. Again, this is like paying for a tune-up on your car and also being charged for someone else’s bodywork and someone else’s transmission replacement at the same time.

     There are more examples of this. If you want to start a medical imaging business in most states, for instance, you can’t just buy an MRI machine and have at it. You have to acquire a “Certificate of Need” that states that there’s demand for another provider that can’t be supplied by the existing providers…and the people who have to sign off on that certificate are, surprise surprise, the existing providers themselves. Now you know why an MRI costs so much…thanks to a situation that would be deemed “illegal restraint of trade” in any other field of business. But, in the medical field, it’s protected by law.

     Prescription drug costs, another big issue, are primarily the result of drug companies being told by other countries (and their socialized medicine systems), “We want your drug, but we only want to pay this much for it…and if you won’t sell it to us at that price, we’ll break your patents and make it ourselves, and you’ll get nothing.” So the drug companies sell to them at a far lower price than they sell the drug in the United States…and then got Congress to pass a law banning the importation of these drugs, to keep people in the U.S. from going outside the country and getting the lower prices. Thus we wind up with documented examples such as vials of scorpion antivenom being sold by U.S. hospitals at $30,000 a vial, when the antivenom itself is made in Mexico and would cost you only $100 a vial if you bought it there.

     The hell of it is, if you free medicine from the whole concept of “insurance,” it is possible to achieve cost savings of 80% or even 90%. We know this because one group of doctors has done it. The Surgery Center of Oklahoma offers many surgical procedures with prices posted up-front and accepting no insurance billing, just cash at the counterpane…and their prices can be an order of magnitude less than what hospitals will quote you for the same procedures…if you can get an up-front price quote out of the hospitals at all.

     People have been talking in this very comments section as if we have a “free market” in health care. But we don’t, and haven’t for a long time. And, instead of enacting new laws to screw everyone over to perpetuate this system, we could have just repealed the laws granting the medical industry special treatment, and let a real free market work. But, you see, that’s part of the benefit of making so much money when you’re in the health care business…you can afford to pay bribes “campaign contributions” to ensure that the deck keeps getting stacked in your favor.

112. The insurance industry (property, casualty, medical, or any other) is about pooling risk. The theory behind the most talked-about parts of the ACA is that by mandating insurance coverage, you introduce enough healthy people into the pool to offset the cost of the most expensive/risky members of the pool – those previously excluded based on pre-existing conditions. Apart from the “forced into the pool” aspect, this is fairly sound and, in an ideal world, would result in a slight decrease in premiums… very slight, given that the cost of the most expensive can very quickly offset large numbers of the healthy. But at least those with pre-ex can get care. This is a good thing, in and of itself.

     The problem though, is that this does nothing to address the cost of actual health care. The single largest driver of the cost of insurance is the cost of care (procedures and services performed by medical professionals). Most major insurance companies already hit a Medical Loss or Medical Expense ratio above 80%, meaning that between 80 and 85 cents out of every dollar that comes in in premiums is spent paying claims. This becomes mandated under the ACA, but, again, the biggest insurers (and those that insure the majority of the population) are already hitting those numbers. The average profit margins for an insurance company are around 3.5 percent (hospitals are around 7% and pharma companies are around 16%). That leaves around 12 to 16 percent to cover administrative cost. That means that, despite CEO salaries (arguments around which are endemic across all industries) insurance companies are already running pretty lean. They have to take in enough premiums to cover the service costs, and there’s a limit to how low a profit a publicly traded company can accept and continue to be viable. Which means admin costs will continue to be cut. Unfortunately, this has direct, measurable impact on customer satisfaction, as things like call centers are outsourced.

     The only way insurance companies can directly affect the price of care is through negotiating power based on their membership. Company A covers 75% of people in City A and Company B covers 25%. Company A negotiates a better rate with doctors and hospitals in the area based on volume – Company A can send more patients their way, so they get a break on prices… prices which, for the most part, are already based off of a percentage of the Medicare fee schedules (generally lower than the Medicare price, unless you are a rare specialty or the only game in town). The exchanges, while increasing transparency among insurance plans (which I think is hugely important) may actually hurt the negotiating power of some companies. This may help lower premium prices for company B, but will likely raise them for company A as membership becomes more fluid. The average will probably end up somewhere in the middle, but for some it will certainly result in a premium increase.

     There is also a very real potential for access to care to become a problem. As more of the sickest have better ability to finance care (again, I think this is a GOOD thing, but it comes at a price) and more people who have been uninsured decide that now they are paying for insurance they might as well use it, you will have an increase in demand for healthcare with no corresponding increase in supply. Since hospitals that take Federal money can’t close their doors on emergent and urgent care, wait times (already too long in my book) are going to get longer.

     So, what’s to be done? Well, I think the ACA takes some positive steps, but I also think that it is going to ultimately increase the average cost of insurance (though offer it to more people) unless something is done about the supply side of care. We need more doctors and hospitals, particularly given the aging population in this country. If we are going to pump more federal money into healthcare, why not look at grant and loan programs specifically geared toward med school? Maybe make arrangements similar to the military (pay for your med school in exchange for x years of service at a reasonable, but lower than market, salary).

     Sorry this is so long… it kind of got away from me there. :)

113. @ Aloysius:

     First of all, my condolences on your loss.

     The biggest department in any US hospital is the billing department. Given the way things currently are, it has to be.

     Most of the bureaucratic bullshit in US health care can be traced, directly or indirectly, back to the completely fucked-up way that it’s funded. (Most of the rest of it can be traced back to Big Pharma.)

     I work in a hospital. I’m not in billing, but I’m connected enough to it that I might not have a job if the US went to single-payer. And I would be *delighted*.

114. @Aloysius THIS. This is what vexes me to the utmost. It’s the privately owned conglomerate companies providing health care that is the REAL problem. The medical fields face having to provide proof that procedures are actually necessary, or risk having companies reject claims and refuse to pay them, thusly leaving the patients and doctors with the bills. And the companies are large enough to get away with virtually everything they do. I’ve been screwed by the insurance companies more than once. That’s one reason I’m not thrilled with the ACA, because while it will help many people, it won’t do anything to force accountability on the insurance companies, and the people who are self-insured, and single, and make too much money to obtain subsidies like me are going to get caught in the middle. And I know several commenters have said not to jump to conclusion about how much you’ll pay, but I’ve checked into mine and at this juncture, I’ll looking at more than twice what I pay now. So if my premiums DON’T go up, I’ll survive. But if the insurance companies start screaming about how they’re going broke with the ACA, and start increasing premiums, I’m done for.

115. And, instead of enacting new laws to screw everyone over to perpetuate this system, we could have just repealed the laws granting the medical industry special treatment, and let a real free market work

     Sounds great, doesn’t it? Only – as a fair number of scholars have shown – health care doesn’t work like a regular free market because people are willing to pay just about anything for certain types of it. There’s no price sensitivity if you’re going to die without a particular medical treatment.

     Shorter answer: No.

116. As a side note, keeping the insurance you have is only possible if your insurer continues to offer that plan. My current plan will no longer be offered, as it is does not meet the standards required by ACA (a choice I knowingly made, since there were certain mental health riders I felt I didn’t need). I do not qualify for a subsidy, and the current estimate from my insurer is roughly a 200% increase in premium. I’m hoping that will decrease as the market levels out and before I actually have to renew coverage.

117. Hey Kim? I went over the CoveredCa to try and see if I could find a way to make a plan with premiums that cost as much as $1980 a month for two people in their mid fifties. I can’t seem to do it. I see lots of plans between $700, and $1100, and 1 or 2 above that, and I’ll agree that ain’t cheap. But that’s with no subsidy.

     I guess you don’t qualify for any of the subsidies either?

     How are you getting your current insurance? If it’s through an employer then the health exchanges don’t apply to you anyway. Also, and someone can correct me if I’m wrong, but can’t you still purchase normal individual insurance anyway? I don’t believe there’s a requirement forcing anyone to get insurance through the exchanges. You just need to have some kind of insurance.

     Happy to be corrected on that if I’m wrong.

118. As a Northern European it is quite depressing reading about the health care system in the US. Sure, we pay taxes, but weirdly it seems our total income tax is less than federal, state and local tax combined in the US. And our health care is “free” for individuals. Or almost “free” – my medical expenses will not be more than $300 a year regardless of my situation. If I’m sick, I go to the doctor. I get proper medicine. I’m sent to a specialist. I get surgery if I need it. If I’m in an accident the ER will do their utmost no matter the cost and never bill me a cent.

     Of course, elective surgery and such are not free. Reconstructive surgery is.

     As in most systems some mistakes are made, and prioritization of who should be treated first get screwed up, but it mostly works. There are some queues to get treatment.

     If I had been well off, or payed for extra insurance, I could use private clinics to skip the queues in the public health system, but it isn’t really necessary.

     So, looking at the US health care system depresses me a bit. People should not be crippled, literally or figuratively, or even die because they can’t afford proper medical treatment.

     I’m kind of reminded about Mahatma Ghandi’s “A nation’s greatness is measured by how it treats its weakest members.”

119. John,

     Thanks so much for this well-written post. You are open-minded enough to see what DOES happen to those with crappy or no insurance. I was insured, but a couple of recent procedures left me with $60,000 worth of medical bills. Yes, that’s AFTER insurance paid their part. No one I know has $60K sitting around for a rainy day (more like a hurricane, with this type of bill) and so since I was already in a chapter 13 bankruptcy, my lawyer suggested I convert it into a seven and include the new debt. Do I feel bad about not being able to pay? Yes, I feel guilty. But if I’d put this surgery off, in five years (maybe sooner) I would have had cancer. I HAD to have the surgery, even though I was afraid I’d die on the operating table. But yeah, I see a lot of people who need/should go to the doctor, but don’t because they don’t have the money or they are afraid of the cost. I was one of those; I had a couple of bloody bowel movements and a co-worker was furious that I hadn’t gone to the ER. So I might have kept going along until too much pain forced me to do something. And by then, it could have been too late. I thanked my co-worker for saving my life. I guess I should have thanked the surgeon as well. But that’s the way it is in America, and to all those who bitch and moan about socialized medicine, realize that my scenario could happen to you. And what would YOU do?

     Thanks again John. Thanks for having some compassion and knowledge about the challenges of healthcare here in the United States.

120. I read the Atlantic piece Jay linked – it seems barbaric to hit people with a credit bill for major, unpredictable procedures, particularly when, in many cases, the costs are predictable. Surely this can be budgeted for. It doesn’t take into account that healthcare is uniquely unsuitable for market-based solutions – consumers aren’t nearly as informed as doctors, and often believe things like homeopathy actually work; consumers don’t know how much things should cost; and usually people need some form of healthcare and don’t have the option of waiting until the market sorts itself out. Its insight that a regular cost for care aligns incentives nicely is worth noting, but it then takes it on faith that this will happen in the market when the old fee-for-service model has the potential to be much more lucrative, particularly because people love the idea that they’ll save by paying a la carte, even though it’s probably not true.

121. A friend of mine posted this on FB, and I have to say it’s one of the most succinct and accurate pieces I’ve seen on the whole healthcare issue: http://www.upworthy.com/his-first-4-sentences-are-interesting-the-5th-blew-my-mind-and-made-me-a-little-sick-2

     It reinforces what Erbo said in his post about prices.

122. @ htom,

     I can’t speak to the other examples you gave, but VA medical care generally has better results and gets better customer-service ratings than other systems. Are there horror stories? Hell, yes. Is there room for improvement? Hell, yes.

     But arguing against government involvement in healthcare and/or healthcare funding based on the VA depends on a view of the VA that is not fact-based.

123. @Kim

     Kudos for following up with both an apology and a link to the original. I suspect that not a lot of people would have done that.

124. @Jay Redding

     It’s somewhat difficult to make an accurate comparison though, because patients in Massachusetts have access to health care resources in other states – that would alleviate some of the problems.

     Patients in Massachusetts have access to health resources in other states because they carry insurance, bought on a state exchange, which covers them in other states thanks to the commerce clause and the free market. It means I can already use my purchased insurance and see a GP in Rhode Island half an hour’s drive from me, and my visit is covered under my purchased insurance.

     Now if only there was a system to set up state based insurance markets and allow patients to purchase health care coverage…

125. Not to put too fine a point on it. But, technically… health care IS a human right. The U.S. is a signatory to, and helped develop the Universal Declaration of Human Rights. And I specifically refer to article 25:

     Article 25.
     •(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.

     So unless the United States pulls out of the U.N (which I know some people would prefer), we ARE supposed to be providing some form of medical care needed to ensure the health and well being of people.. Because of the crappy system we have in place, we unfortunately need to use the private health insurance companies to do this. But, it’s something. Telling people to go to the ER is not adequate care for health and well being for reasons that have already been touched on.

126. Erbo – you make some valid (if hyperbolic) points. However, defunding the ACA does absolutely nothing to fix those points, and the people who are trying to defund it are (to put it mildly) highly unlikely to make the changes you recommend.

     In short, half a pie is better than no pie.

127. Hi Ben – you have to use the same zip code I do, and the same income level. Platinum Plan, Anthem Blue Cross. You may have been looking at the Bronze plans. There is a button there that you can click for the Gold/Platinum plans.

128. Here in Canada, our system is certainly not perfect but when I was a student, it was for me, literally, a life saver (and that was over 30 years ago). Yes, we do have some problems with long waiting times but the general principle is that for those who most need a particular service or treatment, they get it first. The principle of triage is applied.

     I sincerely hope that your president sticks to his guns on this and that the Tea Party types ultimately become a forgotten footnote in American history. The stupidity of these few obdurate politicians will be their only legacy.

129. @daneyul Thanks. : )

130. Kim – I clicked over to Platinum (I put in $600,000 as income, just so I could see the worst case scenario), I see an Anthem Blue Cross for $1467, the EPO? I have to say I’m surprised that zip code would make a $400+ difference, if that’s the case.

     For comparison, how much do you pay now, for the same plan outside of the exchange?

131. Was just going to lurk today, but wanted to post this handy-dandy link: a subsidy calculator from the Kaiser Foundation. http://kff.org/interactive/subsidy-calculator/

     I am blessed to be covered by my employer, but I do have the choice to go off and use the exchange. My projected annual premium would be a about $2150 a year or $180 a month. Putting this in context, when I was a waitress four years ago, I shopped around for individual health insurance and couldn’t find a plan to cover me that wasn’t $250 or more a month. And I was making half of what I do now. Is the ACA magic for people like me (young, single)? No. But I know what is worse – nothing at all.

132. When I see the Congresspeople who shut down the government as a way to stop the ACA, … I see a group of people who are, essentially, looking at people I know and care about and saying to them, just fucking die, already.

     In other words, the explanation for the behavior of your political opponents that seems most likely to you is that they are evil. This seems uncharitable and unimaginative. It also casts an interesting spin upon all of history unto the present day, times in which there was no ACA (and indeed, no socialized medical care of any stripe until recently).

133. What has always scared me about economics/economists is that denying the basics to people (food, healthcare, housing) isn’t seen as a monstrous thing, it’s called “they no longer are able to afford it, so we remove them from all calculations — they’re no longer want-and-have-means-to-have so they don’t matter”.

     Honestly, the idea that people can stand there, supposed to be representing other people, and say that people do not deserve to live because they somehow don’t make enough money, is terrifying.

     A friend of mine has had to choose between groceries for a month, or watching her 6-year-old suffer with untreated bronchitis. She worked two jobs, but neither offered benefits for part-time employees, and carefully scheduled her to ensure she’d never work more than 39 hours a week, so she would never qualify as full-time.

     Another friend of mine is 7 months pregnant, her husband lost his job, and she was no longer allowed to receive pre-natal care for a very difficult pregnancy because despite him getting a new job, she had a pre-existing condition (pregnancy! But also rheumatoid arthritis).

     Both of them are now finally able to have health insurance.

     In both situations I think it was monstrous for them to have wound up in those situations to begin with, that people can look another human being in the eye and say “Sorry, you don’t deserve to live, because your entire value is based on how much money we can make off you.”

134. Jay, Jay, Jay.
     I wish you could come to Canada and live for a decade or so. You would see that all those right wing articles that you have read about our Health Care system are nothing but lies and fear mongering. They have fooled you my friend.

     However, if you feel like exploring the truth I encourage you to reads this:
     http://delong.typepad.com/sdj/2013/07/the-us-we-are-number-27-in-health.html#more

     I also encourage you to ask yourself why single payer systems are so incredibly popular in the developed countries that have them? Think on it.

135. I work for a large government contractor. All of the companies revenues come from government projects. So basically I get tax payer funded health insurance. I am hardly a liberal (made plenty of posts here criticizing John’s liberal opinions), but I need to point out major hypocrisy with my conservative colleagues.

     This company has a vast number of conservatives. They have lots of TVs in the lounges and the remotes are gone. It is exclusively Foxnews. (when I worked at Dell we had remotes, lots of conservatives and we usually turned on ESPN). Most of them hate obamacare. When I say ‘dude you are getting taxpayer funded healthcare, and your tea party buddies in the midwest probably are not real happy to be paying your medical insurance), I just get a shrug. I got mine. Told a few of them they should go work in the private sector. Technically this is the private sector, but all of the business comes from the government. So its ‘privately selling to the government’. However, its still taxpayer funded. Never ceases to amaze me how many conservatives I have worked with don’t see it this way. They talk about the deficit, but never want to ‘fire themselves’.

     I’m not affected by the government shutdown. My project is funded with previous obligated money. Many others are not. The company furlough policy is ‘you use vacation or you don’t get paid’. The last government contractor I worked at was smaller and was exclusively selling to HHS. The vast majority of their people are furloughed with no pay.

     I am skeptically optimistic that this reform will save money. Anyone who just believes what the president says at face value is a fool. Just copying and pasting someones quote doesn’t make it true. Note that most quotes from the CBO about this are taken out of context. I am hoping the reforms save money in some ways, but I will believe it when I see it.

136. This seems uncharitable and unimaginative

     Doesn’t mean it’s wrong.

137. @Ben Try it with 94541 as the zip and tell me if you see it. Anthem Blue Cross PPO ($1920/mo)

     This is almost exactly what I would be paying via Cobra if I lost my employer’s coverage. Right now. I pay zero, yep zero.

138. John, if you keep maintaining this voice of reasonableness people are going to realize that you live in a district that could really use better representation in Congress. And then they’ll realize there are things like Kickstarter and other crowd-action tools out there and suddenly a “Draft Scalzi” movement will arise. And then everybody will grief you into volunteering two years of your life to sharing your reasonableness in D.C.

     You really need to hang your ass out in a column soon to prove that you’re not as reasonable as we think…

139. for those of you using the exchanges what are you actually paying for insurance? I’m not sure how the subsidies work, its really confusing. I’m not even sure where the tax increases are coming from to pay for the subsidies, that isn’t clear either. A medical device tax sure won’t cover this.

140. @Kim Mcallister: that sounds like its before the taxpayer subsidy. my understanding is that a large portion of that gets subsidized by the taxpayer depending on income level.

141. Couple thoughts:

     The reason we force people to have car insurance isn’t that their cars are valuable. It’s that they need to have coverage in case they damage someone *else’s* car. It’s to keep them from doing huge amounts of damage and not having a mechanism in place to pay for it.

     Are the reasons people oppose the ACA reasonable? Some of them are. Some aren’t. Consider the large gap between people who oppose the ACA and people who oppose Obamacare. Obviously, some people object to the black guy, not to the law.

     Will the ACA work? Depends on what you mean by “work”. I don’t think it will in general make medical care cheaper, but no one expects it to. What it will do is make it so that people who have preexisting conditions can get medical coverage *at all*. And yes, I’m well aware that the insurance model itself is a huge part of the cost, and that another model would be cheaper. We could have had such an “another model”, except that the people complaining about the ACA now weren’t willing to consider the other models that would actually remove the expensive overhead of “insurance” from the system.

     But the real purpose here isn’t to make the costs universally and without exception lower for everyone. It’s to make sure that the people who actually need medical coverage can get it, and so that we will be paying for preventative medicine more often and emergency care less often. And to do that, we need to require that insurance companies take everyone, and for them to do that and continue functioning, they need a promise that healthy people will be in the pool too. It’s flawed, but it’s not totally insane, and it’s a system that came from the conservative side of the fence originally. By most accounts, it even seems to basically work.

     But even if we grant that the objections to it are sound, shutting down the government rather than trying to get a genuine majority and change the law through legitimate channels is sleazy, sleazy, behavior.

142. The ACA is a good thing, a good start. Does it need adjusting and review? Sure it does, it’s brand-spanking-new as a law (since 2010). And, no, not going to do a disservice and address any responses that subscribe to the looney bin of American politics. Not when it is accorded sufficient legitimacy to hold the nation hostage.

143. @Guess

     http://www.healthcare.gov

     It’s a good place to start.

144. Kim – I do see it now. That’s an astonishing difference for a zip-code to make.

145. It is outrageous to try to stop or delay the ACA. It is law. It is needed. People WILL DIE if it is hindered. Exactly how is that good for Americans?

146. @guess Make too much for subsidies. It’s an income based decision. Not sure what the cut off is.

147. @Ben What zip code did you use? And good grief, someone making $600,000 pays the same as I do? :D

148. Awesome video Steve C.

149. @Kim Again, if your current health care plan works, there’s no reason to go off it.

150. Kim – I just grabbed one at random, 90001
     And as far as I can tell, the way the pricing works is, once you’re no longer eligible for a subsidy, the prices don’t change based on income after that.

     So I think the question is, at this point. If you lost your employer-provided insurance, would you be able to get individual insurance at any price (and if so, what would that price be) , in the current market (that is, the market we’ve had for decades, and will have until the rest of ACA takes effect on jan 1st.

151. So, in the interests of following up on this, I went and looked. I used to have health care from an employer, and when I got laid off I could keep it by paying premiums. Premium for two people, early 30s, was about $800-900 a month back in 2003. Premiums have gone up a lot since then. So, would have been about $10k/year, and likely have gone up.

     According to the Kaiser Foundation page, premiums for us now, in our early 40s, would be $4900/year or so. No subsidies, we make too much money to qualify. Just a larger and/or more-efficient market that is expecting to include everybody.

152. Leonard:

     “In other words, the explanation for the behavior of your political opponents that seems most likely to you is that they are evil.”

     You know what, Leonard? Shutting down the whole of the government of the United States in order to force a change (or indeed repeal) in a law offers access to medical insurance to millions that don’t already have it or can’t afford it, because you otherwise don’t have the legislative majority to make changes, thereby putting hundreds of thousands of people out of work and costing the nation millions of dollars each day? That’s not a bad definition of banal evil.

     Now I hear rumblings that these same folks will try to leverage the debt limit in order to get their way on the ACA. If that’s correct, a willingness to destroy the US’ global financial standing, and disrupting the entire planetary economy, would take the action out of “banal” to actual flat out evil.

     I’m sure they see themselves as “freedom fighters” however.

153. @John: Word

154. Jay Reding (@JayReding):

     First, this lays out the economics about the US vs UK health systems. It is fully fact-checked, so please document any flaws you find. But the short version: we are paying roughly twice for less benefit. http://www.upworthy.com/his-first-4-sentences-are-interesting-the-5th-blew-my-mind-and-made-me-a-little-sick-2

     The thing that pisses me off about the whole process to date is the Repubs *refused* to participate. They were very clear: they would do *nothing* that might help Obama *in any manner* to be re-elected. I could rant on that at length, but shall not.

     Making good law goes thru the same basic process as good engineering. One of the fundamentals is intense discussion and debate about the *ideas* of *all* stakeholders. The goal is to examine the ideas and winnow out the bad ones and hone the good ones.

     One of the stakeholders in the health care system is the insurance companies. This automatically creates a serious conflict of interests, because a single-payer plan chooses one of them, because the govt interest is to have a regulated monopoly to handle the gory details. Personally, I would either have a competition or mash them all together. However, that is one of the big problems; I don’t have a good solution.

     So – the Rebubs refused to play. As a result, the ACA has flaws that *would not exist* if there had been proper debate and compromise. Would there still be flaws? Of course, but they would be fewer and of a smaller scale.

     The lack of a good public health system also creates a serious problem that few discuss. We have a large population (last figure is 40 million) without health insurance. Many (not all) are poor and live in substandard housing. This causes a set of problems:

     1. Many have jobs that do not allow for sick days (Olive Garden as one example) so the people serving you might be sick, causing a ripple effect
     2. Their children get sick and miss school or must goto school because the parents cannot take the time off work. This exposes other children and adults, causing a ripple effect.
     2a. The children do not learn properly, which causes a ripple effect in their lives, not allowing them to escape poverty. (We will not get into the reduction of food stamps which means they are hungry, which affects their ability to learn).
     3. If a serious, communicable disease, such as a Spanish or Bird Flu-like disease or Pneumonia, get started in the community, it will not be caught at the early stages, creating a real possibility of a pandemic.

     Keep in mind there are *millions* of folks with jobs that pay squat without any benefits. HALF of all Walmart employees are on public assistance! We pay for those low prices. That is one of the reasons I am a member of Costco and *not* SamsClub.

     For me, the single largest benefit is the ignoring of pre-existing conditions. I have gout and high blood pressure – nothing major and easily controlled. But with premiums of $500..$1000 just for me, I cannot afford that. I do everything out-of-pocket, and managed o get poor-mans insurance for my family thru the UNM hospital system in Albuquerque. I can only really use it for something major.

155. Leonard, not to mention, trying to repeal a law where more people are covered and don’t become homeless or go bankrupt due to medical bills is pretty freaking uncharitable.

156. 1) There IS a problem.
     2) The bastards don’t want to do anything about it, and
     3) actively work AGAINST solutions.
     4) The bastards who say “it just won’t work” don’t offer anything that will, like the proven better track records of the NHS and the Canadian system. Against these systems the offer outliers and anecdotes, and outright lies.

     Fuck ’em.

157. I really prefer the posts where I have some disagreement with Mr. Scalzi. The only negative comments have been people posting fictitious stories from facebook, people providing negative talking points that are easily disproved, and a couple examples of people that would pay more on the exchange if they needed the exchange, which they don’t. Seems like universally a good thing so far.

     Next time, fixing the holes such as medical malpractice reform and getting rid of the regulations against negotiating prescription costs. We’re getting there, America!

158. @ Our Lord Host, May His Name Be Praisèd:

     I personally think that the GOP has been fully evil ever since they let that monster Cheney be vice-president.

159. @Bearpaw at 1:13 – “All health is public health.” – Exactly so. I run into that all the time with the anti-vaccination crowd. My kid might be vaccinated, but if 20% of the parents in my area turn it down, then the population is vulnerable to used-to-be-rare diseases like mumps. And that’s in Massachusetts, where Romney*ptui!*care has been in place for several years.

     To speak from the standpoint of a person with the closest thing the US has to the ACA, my small business pays for healthcare for 21 people and their families. At this year’s renewal, our premium costs went down, with no significant changes in coverage or copays, for the second year in a row. So, certainly my personal experience runs contrary to the panic-prone naysayers. Will everyone’s? It’s unlikely. But again, life has gone on pretty much as usual since Romney*ptui!*care arrived, and businesses have lived or died at about the same rate.

160. @David I plan to keep my insurance as long as possible – it’s a great plan. I am very fortunate. I was looking to see what my options would be were I to lose it, hence my visit to the site yesterday. I was (a) glad to see a comparable plan offered and (B) surprised the premium wasn’t less than what I would pay under Cobra. That’s when I went looking at other scenarios, to see what others would have to pay and for what coverage.

     I think what I am seeing today is both relief that the ACA is here and some sticker shock.

161. Shawn R @ 1:34
     You are misinformed. Many, but not all, plans require annual deductibles to be met before paying. Although they will cover one annual exam, mammogram, etc. non-routine visits and treatments come out of pocket until the deductible has been met. Then there are co-payments for most covered treatments (not all treatments are covered) until another amount has been reached.
     For example: if the deductible is $5,000*, per person on the plan, and has been met, the insurance will then pay a percentage of treatment until the family deductible for co-payments has been met which could be as much as $20,000* or more per household. Therefore a couple with medical needs can pay as much as $30,000* before the insurance will cover 100%. Then on January 1st the cycle begins again. This does not even take into account the amount the employer pays or deducts for the general plan or for non-covered treatments which are 100% out of pocket.
     *Note: not every plan works this way and the numbers I have used are used as an example but are fairly accurate based on personal experience.

162. There are days when I look at my country and am incredibly proud of our achievements and then there are days like the last few when all I can do is shake my head and wonder just what the hell has happened to us.

     ACA isn’t perfect and it will probably take years to work out the various kinks and possibly even go back to a single-payer system, but in the meanwhile, it is certainly better than nothing and none of the so-called “arguments” I’ve seen from the Right have been able to change my mind. Unless the medical profession, Big Pharma and the insurance companies somehow had a massive change of heart and business models to make healthcare more affordable to the masses, ACA is it. Period. Anything less is a cruel joke; something more would be nice, but it’s what we’ve got. However many millions tried to get signed up yesterday and how many more millions are trying today, crashing websites and all, tells you how desperate so many of the uninsured are.

     I count myself lucky, since I’ve had insurance through my job here in Florida for over 29 years; it’ll go up significantly when I retire in a few years before Medicare kicks in, but at least I can afford it. My oldest daughter can’t. My youngest daughter, whose job that was supposed to start tomorrow on a military base is now on hold, thanks to the House GOP, will have limited insurance that she can only use if she REALLY needs it. We’re the richest country on earth and yet we still can’t make sure everyone has some access to decent health care? No wonder our Canadian and European friends wonder about us.

     There are decent folks on the Right who know exactly what’s going on, but who have yet to stand up to the bullies in the midst. It’s time for them to make their voices heard.

163. Not to make a political deal, because this isn’t about politics to me, but you made one statement that isn’t true for everybody. You said that all financial reasons for opposing this don’t hold up to scrutiny.

     I live in a family where we have never depended on anyone else for our health care. We paid for it when we went to the emergency room, paid for it on the rare occasions an allopathic practitioner actually could help instead of hurt, and used payment plans when necessary. On occasion, someone was covered by insurance and on rarer occasions, insurance actually covered or benefited what we needed.

     I can’t afford insurance unless I happen to have a job. I can afford health care though. I go to my chiropractor when necessary, use the regular dental/vision cash or payment plans because insurance for those actually isn’t an improvement on overall cost, eat and drink the foods and teas that take care of common ailments, and can afford the occasional visit to a naturopath that, shockingly, actually helps me get well instead of prescribing me something that DOESN’T help. (I have several horror stories of that parallel in going from one system to the other, but I doubt you want to hear about them right now.)

     In short, I’m opposed to this law because it forces those who have learned that their health depends on using natural medicine, which isn’t covered by insurance, to choose between getting health insurance OR health care.

     Insurance does not cover the things I need to stay healthy and functional, and paying for it removes my ability to pay for the things that do. Insurance doesn’t cover the things that finally got my tendonitis under control when the work comp doctors found out they couldn’t help me. Insurance doesn’t cover the things that saved my father’s life from CHF and my grandmother’s from cancer, only the “care” that put my uncle in his grave.

     I am not opposed to people getting health insurance. I am opposed to being forced to get insurance at the expense of my health. I had honestly hoped the lawmakers would actually address health care, but instead they made it all about insurance, a wasted opportunity that helps some and hurts very badly many others.

164. @Jay Reding: Here in Canada, with Universal health care, there are no doctors in slavery. Generally, the provincial governments run single-payer insurance plans that negotiate rates with medical associations, and doctors run private businesses that bill the government on a fee-per-procedure basis. Your point about rights leading to slavery seems to be about as useless as possible, easily countered by real-world examples. If it makes you feel better, assume that medical care isn’t a right, but a service that the government wants provided to all citizens. Now we can discuss what’s the best way of accomplishing that—and whether it’s even a good idea—without bringing up such ridiculous notions as health-care professionals in chains.

     And here’s how medical access is rationed in Canada. When a member of my family is sick and needs to see a doctor or enter a hospital, we go to the doctor or hospital, provide our health insurance number, and get treatment. When my son was 1 year old he fell on his head. Worried about a concussion, we rushed him to the hospital at the university, where they have a pediatric emergency ward. He received constant care from 9 at night to 5 in the morning, including a CAT scan to confirm that everything was alright. Total cost to my family: I used up a sick day to sleep in after being up all night.

     Our system isn’t perfect, but it means that people don’t put off going to the doctor because they can’t afford to, and having a single payer in each province means our bureaucratic overhead is a lot lower than in the States. I sure prefer that to rationing healthcare based on who has the most money.

165. Scalzi:

     When I see the Congresspeople who shut down the government as a way to stop the ACA, among all the other problems I have with them is the fact that I see a group of people who are, essentially, looking at people I know and care about and saying to them, just fucking die, already.

     I’ve seen a lot of people blaming ‘congress’ writ large, or Tea Party members of same, saying they’re holding up this CR. In a general sense, you are right to blame a group of people, because a group of people elected your representative Speaker of the House. But it’s important to be clear about something:

     The only person standing between us and a funded federal government right now is John Boehner.

     The Senate’s clean CR has the votes to pass the House. If Speaker Boehner were to schedule a vote right now, furloughed federal workers would be back at their desks tomorrow morning.

     It isn’t the Tea Party caucus refusing to schedule that vote. It’s the Speaker.

     So by all means, let’s remember that the Tea Party would rather watch the world burn than respect the will of the majority and the law of the land. But let’s also remember that while mothers are going without their WIC checks, John Boehner is blaming a mob he has the absolute power to overrule.

166. “Decent folks on the right” are usually happy to throw people on the pyre, unless they happen to know them, then it’s all different.

     They contravene their own principles CONSTANTLY. They are aggressively ignorant, rejecting science and statistics BOTH. “Angry Calvinists”, mad that somebody somewhere is having a good time characterizes them nicely, although throwing children into the furnace of Mammon is low even for them.

167. For what it’s worth, I live in Massachusetts and have not noticed any decline in medical services, nor have I heard of any from anyone else. That’s just my own little bubble of knowledge, but if things were going drastically wrong in the state I’ve lived my whole life I think I’d have heard at least something.

168. With regard to costs of insurance moving forward, a relevant link.

169. One more Canadian here (born in the U.S. and still a citizen, though the latter’s more a case of inertia rather than choice and will probably change as a result of post-9/11 changes in documentation requirements for crossing the border).

     I agree, the Canadian system DOES work, the vast majority of the time … sure, there are some drawbacks already been mentioned, particularly the waits for access to specialists or higher-end technology like MRI or PET-scans (am I the only one who never heard of the latter till I actually needed one?).

     One interesting point doesn’t seem to have been raised here, or else I missed it … Americans DO know the Canadian system works, and numerous times various states have sent delegations up here to study how and why it does work in various provinces, but they don’t seem to have learned a thing in the process. I don’t pay a penny for doctors or hospital care … some fields, like optometry, dentistry, and what the govts. call “quasi-medical” like chiropractic or podiatry, are either not covered or only partly covered. But optometry’s covered if a medical problem is diagnosed or even suspected, and also dentistry is if the work is necessary because of damage from an injury.

     If I have to be taken to the hospital by ambulance, I’m billed $35 — but that’s waived if I wind up being admitted.

     I’m trying to avoid the political angle, but I think that’s almost impossible. I’m seeing almost a return to the McCarthy days of the 50’s, where anything left-of-center (or even left of somewhat right of center) is taboo. My personal guess is that if the Republicans don’t get their act together, we’ll see a major disintegration of the party to the point where it’s only heard of in history books.

170. I took in a homeless friend for 6 months. They didnt have insurance. They were dying. They went and got married and got insurance from their spouse. They got better.

     Their story is not unique.
     Why do these other people want to kill my family and friends?

171. The Senate’s clean CR has the votes to pass the House.

     Maybe. A lot of GOP House folks are saying they’d vote for a clean CR. That’s not the same thing as actually doing it and taking the hit. Only 6 GOP members defected on the last bill.

     As to John Boehner, he can absolutely schedule a vote right now. It’d probably be nearly the last thing he did as Speaker.

172. @ Peter Cibulskis:

     Why do these other people want to kill my family and friends?

     Because they are evil. They see anybody who neither (a) has pots and pots of money nor (b) serves someone with pots and pots of money nor (c) is exploited by someone with pots and pots of money as someone who must be eliminated for the sake of their rich donors.

173. Annalee, I hope that’s right. But it’s mystifying to me how the TPs got so much power when it’s clear that not only can Dems not stand them, even more sane Republicans clearly despise them and have no respect for them. And polls show that Tea Party support is at a low.

174. Hope that’s not too far off point, John.

175. Given all that I have read about the ACA circus, and what I have read here, I can only say I am so, so, glad I’m not American, and live in a country where we have a real healthcare system. Yes, it’s one of those evil, commie, State funded things, and it’s not perfect, but it works. And it’s a lot cheaper, maybe because _our_ system only has to pay for health care, and not also the insane wages and bonuses of insurance company CEOs.

176. @Jay Reding – I don’t know if you’ve actually *experienced* healthcare in other countries.
     I live in the UK, and I’ve also used health care in France, Spain, Sweden, Denmark and the Netherlands. All are some variant of insurance-based cover – even the NHS. The main difference with the NHS is that it’s “free at the point of delivery”. It’s not *quite* as true as it once was; we used to get free prescriptions, optical and dental care as well, which you now get only if you are in full-time education or on state benefits. However, even so the costs are not the full cost (prescriptions are about ten bucks an item, or 150 bucks a year if you have a pre-pay certificate, and are free for some categories like cancer patients and diabetics).

     If you are working, there is a small levy on your salary (called “National Insurance”) and although this is no longer hypothecated, it’s notionally to pay for health and other related benefits.

     You’ve no doubt heard (especially from opponents of the ACA) that the NHS is a terrible system, beset by quotas and running “death panels”. While it’s not perfect, it actually copes pretty well most of the time. No-one is bankrupted by healthcare costs here, unless they go private (which is still an option if you have the money and are in a hurry – and is also cheaper than the US in most cases). We actually have private cover via my partner’s job- it costs about $75 a month for a family of three, and there’s an “excess” (co-pay, I think you call it) of around £300 per condition per year- so obviously you don’t use it for anything small. As I work for myself and don’t get paid if I don’t work, this has been useful to me once or twice, just to be able to pick the time and place. But in most cases, I’d use the NHS.

     And, true, there are sometimes delays – you can’t always get to see someone right away.
     But we have, on the whole, better outcomes than the USA at around half the cost.

     I’ve recently developed tinnitus, and one possible cause is an auditory tumour. So they sent me to the local hospital for an MRI scan. It cost me £3 (about $5). For parking.

177. Earlier I made it clear that I didn’t like ACA, and why.

     However, in no way do I support the government shut down that is occurring.

     I respect that there are rules and processes for deciding how we are going to do things as a society, and that I will not always agree with the end result.

     I look at what the Republicans are doing like this:

     Let’s say five couples decide they want to go out to dinner together but they can’t agree on which restaurant, so the hold a vote, and it’s close, but a winner is decided.

     So, they go out to dinner and they order, the food comes and eventually the bill, and one angry couple loudly announces that since they didn’t want to eat here, they are not going to pay their part of the bill.

     I would look on anybody that pulled that trick with contempt.

     I disagree with Mr. Scalzi’s suggestion that the Republicans are telling a whole bunch of people to go ahead and die. That kind of hyperbole isn’t constructive. People of good will can disagree as to how a problem should be solved.

     But, I do think the Republicans are very wrong in what they are doing now. For better or worse, we have had the debate and collectively agreed to go the ACA route.

     Trying to bitch about or find a back door out, is bad form, a poor precedent, and counter to the spirit of our society.

178. @uleaguehub all countries have a creation myth and people who believe it despite it glossing over some pretty ugly historical behaviors and mindsets.

     I can think of politicians in Canada I’d like to speak to just so I can understand how they can consider doing what I think of as pretty stupid things.

     I admire more than American myths and legends. I see a lot of good people doing a lot of good things. I see a lot of progress being made on important topics in the US.

     But your right. I also see a lot of things that appear out of touch with modern reality and civil society; especially in the politics of the US over the last year.

     It would seem to me that the one place for government is to protect the people who cannot protect themselves.

     That some people would rather see someone die than get affordable care, that some people would follow an ideology rather than see the clear benefits of having children receive dental treatments and standard medical care seems almost beyond belief. It seems depraved.

     The system before the ACA allowed a lot of people to go without any coverage and caused misery to a lot of people. ACA doesn’t seem perfect but seems better than further marginalizing people that are already having a terrible time of things.

     That people elected to serve the interests of US citizens would go to such lengths to fight the ACA, and that they would cause more damage than what they perceive the ACA might do, is basically where I check out mentally and go “WTF??”

179. This is a subject on which I have some opinions, but I’ll try not to go on too long. A few observations.

     First, a minor correction to one of our other commenters: Medicare and Medicaid did bend the cost curve, specifically by implementing prospective (DRG) based payment to hospitals. This changed the hospitals financial incentives, not always in ways that worked out well but in ways that provided incentives to improve care. It’s not a perfect system, by a long shot.

     The arguments against the ACA – and against single payer before that, always stun me.

     It is hard to believe that the industry which invented out-of-network providers, approved pharmacopeia, precertification, preexisting conditions, and lifetime benefit maximums is trying to make us worry that the *government* is going to limit access to healthcare.

     While government run health insurance doesn’t fill me with confidence, having dealt with private insurance companies, the specter of a huge, uncaring bureaucracy does not exactly fill me with the fear of the unknown. Remember, this is the industry that considers a four character code and an 800 number to be an “explanation of benefits.”

     Finally, as a pure thought experiment – we have an industry where they are permitted to skim a certain percentage of money flowing through the healthcare system. First of all, insisting that we retain a stage that does nothing but skim money out of the system does not strike me as “efficient” by any definition I have heard. Second, what, precisely, is their incentive to reduce the total amount of money passing by that they get to skim?

     The ACA is an acceptable first step, but I hope it remains a first step on the way to a more single-payer model. I would prefer a baseline level of care provided by taxation, supplemented by private insurance for optional care levels. I understand this is in use in some nations in Europe, and would like to hear from someone who lives under this system – the analysis I got was pretty academic.

180. @Aloysius What you said. I think the law, if it is to be changed, must be done via constitutional methods, not bullying, and accept that the law is something that we obey even when it’s horrible and wrong, provided it is not sinful. So yes, this.

181. So they sent me to the local hospital for an MRI scan. It cost me £3 (about $5). For parking

     They made you pay for PARKING? The bastards.

182. Bearpaw — Military and VA medicine have probably saved my life a few times. I’m grateful for that (other hospitals in systems and countries not previously mentioned have, too.) That doesn’t prevent me from seeing others’ experiences. My wife’s opinion of the VA medical care I have received is considerably lower than mine. The paperwork snarl that is the VA … some other thread.

     All — Building on hate (whether of the poor or the rich, the left or the right, …) is a plan doomed to fail.

183. Well, when I factor in the fact that I got my hours eviscerated at my job, this is the most expensive healthcare option I could ever imagine…well, other than getting sick and having to pay for it myself I suppose.

     I absolutely support the ACA and I don’t blame the law for thinking that full-time hours should imply full-time benefits, I blame the company that said my life isn’t worth the work I do.

     Is that a bit of an exaggeration? I suppose, but after working 60 hours a week for the last 3 years here with no benefits and now having my hours dropped to 29 hour/week average, I’m more than a little bitter (especially when I find out that they did this over a year before they needed to). But again, I’m not bitter towards the president or the democratic Congress that passed ACA (other than wishing it was more like Hilary Clinton’s original proposal). I’m bitter towards the republican attitude of only good things for the wealthy and let’s live as parasitical an existence as possible that seems to dominate the attitudes of CEOs, boards, and other heads of business.

     You might be saying they can’t afford it? Screw that. They were making close to $200K a year off of the work I was doing after paying me.

     Some people think that poor people are parasites, and yet, their symbiosis is at worst commensalism and frequently mutualism, because helping poor people, providing the bootstraps or the counterweight to help pull them up, helps all of us. Having a well-educated, healthy population means greater economic stability and more scientific advances. Isn’t that something we can all get behind? The parasitical nature of run-away capitalism, the let’s-squeeze-the-public-for-every-drop-of-profit attitude, is not something I can understand.

     I’m looking forward to checking out all of my options and I hope that the healthcare I am able to get for myself and my fiancee will be affordable enough. I am more than thrilled at all of the good the healthcare act already has done. For my fiancee alone, she was able to go on her parents’ insurance for a full year before getting too old. This meant that she avoided being effectively paralyzed when she was having neck and back problems, could afford contacts and glasses, and when she got sick she was able to get antibiotics so that she didn’t stay sick longer and infect more people.

     Now we’re both off healthcare (I couldn’t afford the healthcare I had anymore after my hours dropped) and we both need to go to the doctor. I was lucky to know a friend with access to an x-ray machine when I sprained my ankle the other week, and thank god my ankle wasn’t broke because there was no money to pay for it if it had been. I was told that since I don’t have healthcare I don’t have the luxury of playing sports or exercising. My response was, “So I probably shouldn’t leave the house then either? Or get in a car?” But it’s true. Without healthcare, I shouldn’t do anything other than what I have to do because an injury or an infection could mean losing my house, my car, everything.

184. “Without healthcare, I shouldn’t do anything other than what I have to do because an injury or an infection could mean losing my house, my car, everything.”

     Yes but you are free! Unlike us slaves here in Canada.
     /Back to work in the Maple Syrup mines for me.

185. Regarding the mentions of single payer as a preferable system, it’s worth noting the ACA includes a provision where states can petition the Federal Government to replace the ACA if they can develop a system that covers the same or more state residents for the same or less cost. Vermont and groups in California are already starting to explore ways to use this provision to implement single payer systems in their states. I’d suggest that, much like the Massachusetts system worked well enough to end up as a model for ACA, successful implementation of a single payer system in a state as large as California would pretty much guarantee a national single payer system. If memory serves, Canada’s Health care started in a couple of provinces before expanding nationally, that can certainly happen in the US if some states use this as a jumping off point towards single payer.

186. I confess to not having read every word of every comment. I tend to skip over the details of political arguments, partly because of my own minor anxiety issue. (It’s minor because it doesn’t require medical care, now that I know what it is, and I know how to make a given event pass, not because of the cost. It took two ER visits, a year apart, to get the diagnosis and the copay was, for us, reasonable.)

     That said, I agree with John.

     We have excellent insurance through my husband’s employer. We even have a choice of plans. His employer pays a significant portion of the premium; we pay less than $200 per month. We’ve been happy with what we chose 19 years ago and still have. It cost us roughly $25 to have our daughter, about 18 years ago. (Yes, I know costs have gone up since then.) That included prenatal visits, tests, and the surgery. I think the $25 was for my husband sleeping in the other bed in my room.

     When I add up our current prescription costs–all copays–I come up with almost $2,000 per year. Take away any of those medications and we have a very sick individual. Every now and then I look at the other number on a receipt for one of those prescriptions–what we might be paying if we didn’t have insurance–and come up with almost $3,000 per year for one generic medication.

     Then I look at the copays for office visits, tests, ER visits, out-patient procedures, ambulance rides and come up with well over $1,000. (That figure varies from year to year, of course.)

     That is what we pay with excellent insurance.

     Then I think about what people who have no insurance are being charged.

     My family has gone through enough with only the fear of not knowing what’s wrong with our bodies. Adding the fear of not being able to get the care to treat it would be unbearable.

     No one should have to go through that. I will happily, with no more grumbling at tax time than usual, pay an increased tax bill to keep others from being in that position.

     No, the ACA is not a perfect solution. But you don’t forgo a band-aid because it’s not the stitches that would be a better treatment.

187. Reblogged this on J.R. Johnson.

188. @ Kim McAllister

     You left out the name. Will Sheehan was the person on FB that posted that. It’s been picked up by all the right wing blogs. (and I cannot find it on FB, just pics of it on the right wing blogs.)

     I’m having trouble believing half of what he’s posting, given that the wording of the ACA does not encompass anything like the penalties (drivers license, home lien) that he’s stating.

     The maximum fine has been stated many times in the law. $95 perperson (maximum $295) or 1% of family income. And it is part of your income tax return.

     This looks like a made up story.

189. I apologize in advance – there are a lot of good arguments being made here, and space and time do not permit me to respond individually to everything. (Plus, I don’t want to overstay my welcome on Mr. Scalzi’s site…)

     As for the NHS and Canada, I happen to have experienced both, and both times those experiences have been pleasant. If the people of the UK and Canada are happy with the system they have, good for them. But that doesn’t mean that you could transplant such a system here to the US and have it work.

     Here’s why: the dirty secret is that both the NHS and the Canadian system rations care by fiat. They reduce access by wait times and by deciding what treatments are available. If you look at the statistics about treatment, what you get in Canada or the UK is “free,” but there is a lot that you simply do not get. So much so that the Supreme Court of Canada declared Quebec’s system to be in violation of the legal rights of Canadians and mandated that Canadians be able to get private insurance. (Which technically means that neither the UK nor Canada are truly “single-payer.” Those who can afford private treatments can get private insurance or pay out-of-pocket. And those that can, end up in Rochester rather than Regina…)

     The people of Canada and the UK may put up with that because they have not had a non-nationalized system in recent memory. But Americans would not put up with the trade-offs that Canada and the UK have chosen. Why do I say that? Because all one has to do is look at what happened with HMOs. The one time in recent history when the medical cost curve was “bent” lower was when HMOs were the majority way of getting healthcare. And Americans hated it, because they were told “no, you can’t have that expensive treatment.” What the proponents of the ACA are assuming is that Americans will be more accepting of that answer when it’s the government saying the same. I would not take that bet.

     The NHS and the Canadian system work great if you have minor injuries that don’t require advanced treatment. But that’s the EASY part of health care delivery. Where the NHS and the Canadian system fail is in treating cancer, gerontological issues, and the much harder issues. Americans are used to having the option of getting treatment, even if its expensive. The second the government steps in and tells them “no” is going to be a very bad day for American politicians. The ACA is _already_ unpopular with a majority of Americans (and the more one knows about it, the less popular it tends to be). When it starts taking full effect, what will the results be? Look to the reaction to HMOs to get an idea.

190. @Morgan Actually, most doctors prefer to reduce costs when they don’t have to go through insurance companies, which is why insurers make a big deal of cracking down on that and most hospitals provide discounts and payment plans for those without insurance.

     I’ve done it with and without insurance. With insurance, you get charged a whole LOT more because of the administrative costs of dealing with it.

191. Some personal anecdata:

     I work for the Federal Government and have a good salary ($136,771, to be precise). Under the Federal Employees Health Benefits program, 75% of my health premium is subsidized. I have a large choice of plans under FEHB, and of them I have chosen a pretty good one: GEHA, high option, family. I pay $216.40 every two weeks (about $469 per month).

     Last month Marcia had her right knee replaced. GEHA sent me this week the first in what I expect will be a long series of “Explanation of Benefits” notices. They paid $4,336.33 in room charges, and $20,500.37 in “Hospital miscellaneous inpatient” charges. But with copays, deductibles, and uncovered items, I still owe the hospital $2,537.08. That’s taking into account the fact that the hospital is a Preferred Provider under the United Health Care/GEHA plan, so they cover a larger percentage than for an out-of-network provider.

     And that’s just the hospital, and just for the three days she was there. I haven’t yet got the statement for the surgeon, the anesthesiologist, the titanium joint itself, the radiology, or the ten days she spent in the rehabilitation facility.

     And she’s scheduled for another knee this month.

     In Canada, where we both used to live, we would never see a bill. Oh yes, we might have had to wait a while for that elective surgery to get scheduled, but we probably would have gotten our act together sooner, knowing that we wouldn’t need to get a home equity loan to cover it.

     And we’re the lucky ones. We have good coverage, I get to keep it when I retire (and go on Medicare Part B), and we’re not going to lose our home because of medical debts.

192. Two more comments before I get back to less enjoyable but more remunerative work:

     David – All those “rights” listed are rights _against the government._ That is a subtle but crucial distinction. You do not have the right to a grand jury just because. You have the right to a grand jury _if the government tries to criminally convict you_. Those are what are called “procedural” rather than “substantive” rights because they only come into play in the criminal context.

     Generally, the biggest mistake people make in thinking about health care is that they treat it as sui generis. Yes, everyone will consume health care resources at some point in their life. But that doesn’t mean that health care isn’t subject to the same market forces that everything else is. We all need to consume food, but we don’t have “single payer” food distribution. We all need clothes, but we don’t have “single payer” clothing distribution. We all need shelter, but we don’t all have government housing.

     Well, that’s not quite true. Some countries have tried “single payer” food and clothing distribution – but that idea came crashing down after about 70 years of abject failure and human misery.

     Health care is not special in the sense that it should be treated differently than any other economic good. There’s nothing magical about it other than some people want to treat it that way. If we treated health care the same way we treated food, computers, cars, or clothing we’d see the costs of health care decrease year after year while the quality goes up year after year. Just like we do with just about every consumer good.

     I am somewhat hopeful that the ACA will fail; not because I want people to get hurt, but that when it does it will hopefully lead to the realization that our current thinking on the subject is wrong and we’ll replace it with a system that will produce better outcomes at cheaper prices.*

     (* And for those of you who might think I’m contradicting my first post, you CAN get better outcomes at cheaper prices. But you can’t do it by fiat, you have to let market forces work. The fact that such a point is remotely controversial makes me wonder about the future of this world…)

193. Oh Jay, Jay, Jay.
     If you would just do the reading you would see that pretty much everything you wrote is untrue. People live longer in Canada than the US and, overall, medical outcomes are better. We do this while spending half as much as you do on health care.

     You can whine and you can pout, you can bring up anecdotes and right wing talking points but at the end of the day the facts are what the facts are.

     I ask you again to please read this:
     http://delong.typepad.com/sdj/2013/07/the-us-we-are-number-27-in-health.html#more

194. NB: If my plan weren’t subsidized, that “good coverage” would cost me $22,500 a year. And I’d still have big additional costs.

195. I’m from Belgium. Over here every employer must pay health insurance for every person on the payroll, from himself down to the janitor. Every employee also must pay health insurance. All this money is used to refund medical costs, from a simple visit to the doctor for a persistent headache to brain surgery. Waiting lists are not very common, everyone has a reasonable chance of being treated in a very short time. So for me, coming from a working poor family that worked itself out of the hole through hard work and lots of luck, the situation over there in the USA is mind-boggling. How can any decent society tolerate that millions of its citizens risk falling into the abyss through no fault of their own? Yes, there is a need for individual responsibility. Yes, big government doesn’t deliver half as much as its proponents say it does. No, I don’t think ACA, as far as I can tell from what I read about it, is the perfect answer. But it’s – to say the least – morally and intellectually more in line with what you should expect as a citizen from your own country.

196. Well said, John! Thanks.

197. Jay, market forces are wonderful for determining the price of an iPad or Toyota — not so much for an appendectomy or bypass. Hospitals and doctors aren’t advertising their latest sale on gall bladder surgery, nor will they. The pricing in the US health care system is opaque because the major players benefit from that opacity.

     Treating health care like a consumer good makes as much sense as selling national defense or fire fighting as as if they were TV sets.

198. The scariest thing about the whole situation is that the people that ran for office EXPLICITLY on the platform of “shut it down” are simply doing exactly what they said they’d do. And they are a minority of a minority, and they are threatening our Constitutional system. Because they don’t want people to be able to get health care? I weep for our country.

199. Jay. Bluntly you don’t have a clue what you’re talking about.

     My late father had Osophogial Cancer. It has an insanely low 5 year survival rate even in the US. Within a week of the diagnosis he had a full Osophogectomy a fairly horrific 14 hour procedure. He was in hospital for 10 days and recovering for several months. He lived another 5 years only dying of an unrelated illness years later.

     My family is full of those stories including my appendectomy where from feeling unwell to the OR was 15 hours on a Sunday at a hospital where they had to call in a surgical team.

     On top of all of that everybody in the UK is free to buy additional private insurance.

     You’re yalking bollocks mate with no grounding in fact.

200. @Jay:

     Generally, the biggest mistake people make in thinking about health care is that they treat it as sui generis. Yes, everyone will consume health care resources at some point in their life. But that doesn’t mean that health care isn’t subject to the same market forces that everything else is. . If we treated health care the same way we treated food, computers, cars, or clothing we’d see the costs of health care decrease year after year while the quality goes up year after year. Just like we do with just about every consumer good.

     Actually, health care is sui generis. Demand for the more expensive elements of it is tremendously inelastic. (People in pain or in danger of death turn out to be willing to put up with very high prices.) There’s not a lot of substitutability. (Whereas if I’m hungry and bananas are too expensive, I can usually find an apple or a slice of bread that’s more affordable.) Price information is variable, obscure, and difficult to obtain (Whereas I can find out how much various computers are without leaving my sofa). And people who are making the decisions are ill, kind of by definition. They’re under time constraints and feeling unwell. Neither of those is particularly good for rational evaluations of competing products.

     I live in the Netherlands, where the insurance market is very tightly regulated. But the move from socialized medicine to regulated insurance is generally considered to have been a bad choice, and most Dutch people regret the market woo-woo crap that persuaded them to permit it. I used to live in the UK, where I got excellent care — as did my neighbor the single-parent shop assistant, who would have been comprehensively screwed in the US.

     And one reason I’ve been living in these places instead of my native America is that we couldn’t afford to move back, given the health insurance costs. We considered it a few years ago, and decided that the insecurity and expense were not worth it. (And another reason we didn’t move back was the train-wreck extremist politics from the right.)

201. David – All those “rights” listed are rights _against the government._ That is a subtle but crucial distinction. You do not have the right to a grand jury just because. You have the right to a grand jury _if the government tries to criminally convict you_. Those are what are called “procedural” rather than “substantive” rights because they only come into play in the criminal context.

     Good try, but no. You have a right to a jury trial, even in a civil case (7th Amendment). By your logic, that would be slavery, as I (by suing someone for more than 20 dollars) was forcing my fellow citizens to serve as jurors. SLAVERY!

     And in the criminal context: you’re saying that slavery is okay if I’m accused of a crime? I can enslave people (i.e. force them to serve on a jury) because there’s a crime being discussed? That’s an awful flexible condemnation of slavery you have, there.

202. @ Liana Mir

     First, please know that I’m not disagreeing with you and that I don’t mean to seem argumentative. One of the downsides of online communication is the lack of visual and auditory elements.

     “Actually, most doctors prefer to reduce costs when they don’t have to go through insurance companies, which is why insurers make a big deal of cracking down on that and most hospitals provide discounts and payment plans for those without insurance.

     With insurance, you get charged a whole LOT more because of the administrative costs of dealing with it.”

     I do believe that most doctors prefer to reduce costs. Most doctors (I hope I’m right about this) chose their profession in order to help people. Certainly our own first-class primary care physician did. (He really is a primary care physician. He knows when he can’t manage a specific problem on his own and keeps track of the best specialists. And he doesn’t walk away when he’s referred you–he wants to be kept in the loop. Another thing we’ve had good fortune with.)

     I admit that I haven’t actually compared insurance plans (other than the ones my husband’s employer offers) with each other or with the costs without insurance. I only know that we’d be in huge trouble without insurance, even with the providers’ help on the costs.

     I was non-specific about our copays: prescriptions are $5 for generics, $25 for preferred brands and $45 for non-preferred. Office visits are $20, tests from around $3 to $20, some are free. The $20 copay also applies to appointments with specialists. Even the ambulance copay is maybe $45. There are separate copays for the hospital and for the doctor, but the low copays apply there as well. The reason for our high bottom line is that all three of us have conditions that require a total of of nine maintenance medications and regular visits to various doctors.

203. @Jay Reding.

     Pure market forces don’t work to make the best outcome, they concentrate power: see the early 1900s as an example. The government has a lot of levers that it’s built into basic needs to keep them as accessible as possible for people. Food is subsidized through farmer subsidies to make sure the market isn’t flooded and prices don’t fluctuate that much. Housing prices are partially controlled through federal interest rates. Water and electricity are heavily regulated, even though there’s usually only one local supplier. The ACA is the starting point for building levers into healthcare, so it can adjust as the market bears.

     The US medical system has a lot of entities fighting for money. There are insurance companies, medical device/pharmaceutical manufacturers, the doctors, and probably more I’m forgetting. In the current system, each one tries to maximize it’s own profit to the detriment of the others. The ACA is putting some regulations on the insurers to mitigate some of the cost overrun from this fight. Is it perfect? No, but the more comprehensive laws weren’t allowed to see the light of day, much less go to a vote in Congress.

     Finally, if all ACA does is to make the easily treated diseases easily treated and make the harder treatments a little harder for everyone, that’s the entire point. It’s to get the overall population to become healthier and happier, while costing less.

204. Sir

     Can you point me to some information backing up your claim that those against the ACA make “all sorts of financial and economic reasons, which don’t hold up to scrutiny?”

     Thanks

205. Jay, yes, we all need food, clothing and shelter. The difference between those and medical care is that we can budget for those costs, because we know what and when we need them. If cash is short, we can make do with the clothes we have or go meatless or eat out less. But often medical costs are not predictable and therefore they are hard to budget for. Comparative shopping doesn’t always work. My sister had a large, very hard kidney stone this summer. It required a CT scan, x-rays, multiple ultrasound treatments and surgery. The final cost was in excess of $50,000. Fortunately, for the first time in many years, she had insurance. Her out-of-pocket costs will be less than $5000, which is still a lot, but it isn’t going to bankrupt the family. There is no comparison shopping for her. She lives in a town where there is only one hospital which also owns all of the outpatient treatment facilities. I should note that she also has a hernia which has gone untreated for more than 10 years (fortunately it is not acute), because she hasn’t had insurance. She. Will be having that surgery soon. Without insurance, it would have remained untreated until it became life-threatening.

206. Steve C. – Yes, health care pricing is opaque, and horribly so. Yes, that’s a huge problem. But that’s because of the fundamental problem at issue here: you have a third party payor making virtually all the payments. Whenever you have someone else paying the freight for yet another third party, there’s no rational incentive to either get the best quality or to economize. As the article from The Atlantic mentioned, the reason why American health care is broken is because the incentives are all leading to bad results.

     Replacing that system for one that creates a massive third-party payor system isn’t going to make things better. It will be expensive, excessively bureaucratic, inhuman, and annoying. In fact, you don’t have to take my word for that. The United States already has a majority “single payer” system run by the government. North of 60% of medical expenditures are Medicare/Medicaid/VA expenditures. And those systems are not working all that well.

     What I see a ton of here is that the argument is that if you don’t support the ACA, then you must want to deny people health care and you must be an evil, heartless, and cruel person. That is a logical fallacy called a “false choice” and just because our current President uses it more frequently than he does ketchup does not make it a legitimate mode of argument. It’s not a choice between the ACA and nothing, it’s the choice between the ACA and a whole host of other options that could produce better results for everyone at less cost.

207. @Theophylact – all those out of pocket expenses, AFTER insurance? I have Kaiser here in California… shoulder surgery for a torn rotater cuff cost me 15 bucks. But then Kaiser is a non-profit, unlike United Health Care, so none of my premium dollars go to pay a 7 figure salary to a CEO, or to pay dividends to investors who will pay less taxes on them than I’ll get for my ‘earned’ income.

208. @Morgan I used to work insurance and coordinating benefits. I mentioned it only in regard to your line: “That is what we pay with excellent insurance. Then I think about what people who have no insurance are being charged.”

209. @ Jay Redding:

     If we treated health care the same way we treated food, computers, cars, or clothing we’d see the costs of health care decrease year after year while the quality goes up year after year. Just like we do with just about every consumer good.

     Treatment of a heart attack can vary as much as $10K in the same state for hospitals that aren’t terribly far from each other. In the event I have a heart attack, should I check current rates before calling 911, or should the EMT provide me a wine list of ER options? If I opt for cheaper care further away and the EMT can’t keep me alive until I arrive, is my life insurance forfeit because I took an unnecessary risk, or can my kid still have a benefit?

210. Hey, Jay. Much as I suspect I should ignore you as a troll, I’ll give you the tiny benefit of the doubt.

     I’ve lived in both the USA (15 years) and the UK. So I’m completely familiar with both systems, and I figure that gives me real advantage over most other people when it comes to weighing up the pros and cons. You’re pretty much wrong on most of the things you say. But hey, at least you weren’t too frothy about it.

     Also: yay! Well done America.

211. I was uninsured for a while and delayed seeking care for what turned out to be cancer.

     It only cost me the other half of my tongue. Had it been a more virulent cancer, I might well have died.

     I won’t be satisfied until we have a comprehensive single-payer system that covers everyone. Chances are I will never be satisfied.

     I need to find a nice Canadian guy, get married, and move to Toronto.

     And btw this is one case where the “let the free market operate” argument makes me want to rip the arguer’s throat out with my teeth.

     I’m sure they see themselves as “freedom fighters” however.

     The rest of us call them what they are: terrorists. Specifically Teahadi terrorists.

212. @Jay: Another Canadian here to take issue with your claims about our health care system.

     the dirty secret is that both the NHS and the Canadian system rations care by fiat. They reduce access by wait times and by deciding what treatments are available. If you look at the statistics about treatment, what you get in Canada or the UK is “free,” but there is a lot that you simply do not get……The NHS and the Canadian system work great if you have minor injuries that don’t require advanced treatment. But that’s the EASY part of health care delivery. Where the NHS and the Canadian system fail is in treating cancer, gerontological issues, and the much harder issues.

     That is simply nonsense. Yes, one may wait for things for some things somewhat longer in Canada than in the US (given that you could even afford such treatment in the US) but the meat of what you are claiming, that the Canadian system refuses care to those who are old or those with cancer, is simply wrong.

     No one I know, whatever their age, has been refused cancer care. No one has had cancer care delayed. I come from a long lived family with over a half dozen close relatives in their 90s and not once has care been refused, delayed or stinted to any one of them because of their age. My mother’s eyesight was saved by experimental surgery when she was in her 80s. When she died (in her 90s) after being hospitalized after a bowel shutdown it was her decision not to have extensive surgery (they had the room already prepped when she decided not to have it.) When my father (in his 90s) went to hospital with a mysterious bowel inflammation we saw FOUR different specialists all of whom ran rule out tests.

     What I do know about the Canadian health care system is that people don’t make medical decisions driven by the fear that treatment will financially destroy their families.

213. Jay Reding: unless we want barely-trained and underpaid people making life-and-death decisions,

     uh, the scare term you are so vigorously avoiding is death panel. That’s the fear mongering you are channeling, so you might as well use the term.

     Jay: As for the “it’s the law” argument, that is utterly unpersuasive.

     Dude, what she said was Also, the ACA is the law of the land — passed by our elected representatives in Congress, signed into law by the President, and double-checked and approved by the Supreme Court.. That isn’t saying “its the law, we must obey”. It’s pointing to the democratic process that got the ACA passed. The only reason anyone has to listen to the Republicans in the House blather on about death panels or some variation of that is because even though more Americans voted for Democrat congresspeople than Republican, gerrymandering gave more House seats to Republicans.

     If the House were truly representative of the people, this nonsense about death panels and government shutdowns would be dismissed as the conspiracy wingnuttery that it is.

214. I think all this ignores two facts. First, ACA requires others to pay for something you consume. It is just dandy that you can now choose a career without concern for how you can get health care and do it with my paycheck, a thank you note every year would be nice though.

     Second, if this law was just a minimum level of health care afforded to those at some ceiling of income, that would be one thing. The fact that the law is degrading the level of health care I can get is much worse. The law is designed to move people off of what they currently have. It punishes health care that is better than the government offers and eliminates health care that does not meet what the government deems necessary.

     My father was a type 1 diabetic diagnosed in 1950 when he and his whole family were dirt poor. He lost a third of one lung in a public sanitarium from TB. He did not make excuses or look for handouts, he made a life for himself. There was a time when people were expected to do so.

215. Jay, when the ACA was going through the legislative process, where was the “host of other options”? No one in GOP wanted anything to do with the process. They knew that if they did, they would get tarred by primary challengers as collaborators with the Democrats.

216. That’s the thing, Bob v17.40. The facts will never compare to people who just go onto blogs and speak in a didactic tone and either get their facts completely wrong or just make shit up. We have a model for how this actually works, that’s already working (Massachusetts), and several models for how it could work better with more regulation (UK, Canada, etc.) And so far, the naysayers seem to be pretty much wrong on costs, implementation, and… well, pretty much everything. And I’m sorry, but bringing up slavery, Jim Crow laws, and what have you—when the ACA is pretty much the opposite of those laws and quite possibly one of the most humane laws passed in decades—is pretty much the height of B.S.

     And here’s the other thing: the fight to end this law is over. I really wish you naysayers would simply accept defeat and move on—or better, figure out a plan you think would work. Oh wait. Republicans already did that and now they’re trying to repeal what is a model for the plan they originally came up with.

217. I’m sorry, John, but I have to admit, I have not read every single comment in depth. I have to watch my blood pressure these days, and I really should be going to work soon. I have been generally avoiding the comments on ACA-related posts altogether.

     I am in the position of being a “navigator” (not what we call ourselves, but the generic term) in a state that has set up an exchange. Almost all my entire household income comes from my husband, who is a federal employee. Yesterday was a rather mixed day for me.

     A couple of observations: 1) the ACA is not perfect, but it is a damn sight better than the previous status quo. 2) Kim, any story in which any individual claims that they were forced to put in details of pre-existing medical conditions into the “calculator” is most likely fiction. (I only qualify that because I have not looked at every state’s website.)

     How strongly do I feel about the ACA? At the end of last week, I wrote to my Representative, both my Senators, and the White House to tell them to stand firm and not back down, even if it meant the government shut down.

     I still hold to that, even though right now things look scary. (I remember 1996. No fun. This is scarier. Newt Gingrich, et al. were mean (and somewhat stupid because they misread popular opinion). The people behind this shutdown are either crazy or evil.)

218. That story from Kameron Hurley is terrifying. There are times when I am SO grateful for Medicare in Australia, and friends who I would no longer have without it.

219. Not only have I been that freelancer, but my mother – who worked for the state for 34 years and couldn’t afford to keep coverage after retiring, on THAT pension – had to lean on Dad’s retiree health insurance. Had the UAW not assured it for him and her, I don’t know how much sooner she might have died with her leukemia … or suffered with the worst symptoms worse before her death.

220. BTW, Bob v17.40, I hope it was clear that I’m in agreement with you.

221. Jay: If we treated health care the same way we treated food, computers, cars, or clothing we’d see the costs of health care decrease year after year while the quality goes up year after year.

     Wait. What?

     We DO regulate food, computers, cars, and clothing. Food gets massive subsidies to farms. Computers have had a number of anti-trust cases against Microsoft and Intel. Cars have to have seatbelts and get so many miles per gallon. Even clothing has to label what its made out of.

     And yes, prices go down and quality goes up, year after year. In markets with lots of government regulations, prices keep going down.

     You’re channeling laissez-faire fairy tales there I think.

222. First, ACA requires others to pay for something you consume.

     Oh, horrors! Yes, it does. So does: Social Security, Medicare, Medicaid, Transportation funding (the non-drivers subsidize the drivers), public transit, education (people without children subsidize those with), and I’ve gotten tired of coming up with examples.

     This is how society works; we’ve banded together, organized ourselves, and chip in money that frequently goes to someone else entirely. Sometimes it comes to us. Welcome to life.

223. Massachusetts has a shortage of PCPs, but that shortage situation has been gradually improving, not worsening, over the seven years we’ve had Romneycare.

     Meanwhile, we have over 98% of our population insured, and 100% of our child population insured. It has substantially slowed the rate of premium increases, too.

     Oh, and it’s quite popular.

224. it’s the choice between the ACA and a whole host of other options that could produce better results for everyone at less cost.

     And when you can find a majority of Representatives and Senators and the President and at least 5 votes on the US Supreme Court, you can put in place a law that enforces that whole host of other options. Meanwhile, the rest of us who actually live here in reality recognize that the ACA was the only bill that could get over all those hurdles.

     Complete Republican opposition invested enormous power in the most conservative Democrats. The Republican party made their bed; now they get to lie in it.

225. Anecdotes are not data. For every story about some Canadian who got treatment for their cancer, there are several of those who died while on waiting lists. Remember, the Supreme Court of Canada ruled in Chaoulli v. Quebec that the situation was so bad that it was a violation of fundamental human rights to prevent people from getting insurance on the private market. If you want data, look at something that gives an apples-to-apples comparison – such as cancer mortality rates. More Canadians die from treatable cancers than Americans do. If Canada has a superior system of health care, then what factors explain higher cancer mortality figures?

     And I do always find it interesting that whenever I say that people on the left side of the aisle engage in handwaiving away of arguments, a good fraction of the responses do exactly that. Just telling someone that they’re “wrong” without a shred of objective argumentation is not discussion. Thankfully, most of the responses here are smart and substantive.

226. Sorry Rod, but I pay money for lots of things other people consume all the time and I don’t really mind about it.

     I do mind, and so should you, that you’re paying every single day for people to receive primary healthcare through ERs – something I think that old lefty Ronald Reagan demanded?

     Society functions because we’re all in it together.

227. Ok Jay, so where is the data? Canadians and Brits aren’t flocking to the US to escape their situation – all the stories about it are just that. Stories.

     The simple fact is you’re completely wrong about this. Live with it. Please.

     You’ll feel better honestly.

228. Look, the ACA is not about Health Care; it’s about Health Insurance. Just because you have “coverage” doesn’t mean you’ll get treatment or competent treatment. And with most doctors saying they’ll either not treat Obamcare people or considering dropping out of the field, I’d say the likelihood of prompt and competent treatment has gone down under Obamacare.

     The ACA was (falsely) sold to us with a problem that just isn’t a problem. Namely, that the poor using Emergency Services for their healthcare was breaking the system and people needed to be covered. This was false because out of the more than $3 Trillion we spend on Healthcare (private, private insurance and governmental) we spend an average of $62 Billion (that’s 2%) on those people using Emergency Services as their primary provider. Plus you add in that the system will STILL have these costs (or even more with people thinking that the ACA is a magical, unicorn insurance policy that will make everything better. Well, you can’t blame them for thinking that, that’s how it’s been sold to them using their tax dollars and by Authoritarian Puppets of the Establishment like Sarah Silverman), and the people we need to sign up, the young and healthy, will not do so since the penalty is less than the insurance (and they can wait to sign up when they’re dying of a disease or in an accident.

     All in all, Obamacare is a disaster waiting to happen.

     Note: A lot of the facts cited come from Economist and Journalist Megan McArdle who’s an expert in the field.

229. Given that there are over 200 comments already, forgive me if I’ve repeated the jist of someone else’s comment.

     Conservatives in Congress want to undermine Obamacare (ACA) because they wrongly claim that it hurts job growth while simultaneously shutting down the federal gov’t which happens to be a much more effective way of hurting job growth. It’s wrong to claim that the ACA hurts overall job growth due to the simple fact that a large portion of the ACA (i.e. creation of health exchanges) has only just begun coming into place. To claim that the ACA hurts overall job growth amounts to nothing more than an amateur crystal balling attempt that would offend the likes of Ms. Cleo.

230. Jay, just a comment re: “rationed care”. All care is rationed. The way the US does this is by making insurance so expensive/unavailable that those with money can get more timely access while those without money go without. That’s rationing.

     The reason healthcare has to be rationed is the same way any commodity is rationed: there are only so many doctors, machines, technicians, nurses, hospitals, etc. to go around. To deal with the simple and obvious fact that there is simply no way to have sufficient resources in a cost-effective manner the Canadian system is structured around PREVENTION. That means doctors and the overall system attempt to ensure you don’t have to use the system in the first place by trying to keep everyone healthy from the get-go and to keep them there.

     Sure, things aren’t perfect — where are they perfect? — but it does mean if you need to see a doctor urgently you do not wait. You may wait if it’s not urgent, but that’s the price you have to pay for a system that’s universal.

     I can also use myself as an example. A few months ago I wasn’t feeling well. As a stubborn middle-aged man I simply ignored the symptoms. But my daughter demanded I go to the ER, and so I did. When I got there I had the following experience:

     1. At 10am I arrived at the hospital and a Triage nurse examined me in about 10 minutes and sent me to observation.
     2. Observation ordered emergency tests, ultrasounds and CTs.
     3. I was admitted to the hospital and an OR prepped for emergency surgery.
     4. I had 3 doctors and 5 nurses attending to me.
     5. The doctors asked if I was willing to try a new technique that might resolve my condition, I agreed.
     6. I was prepped for emergency surgery while the doctors and nurses monitored me to see if the medication was working.
     7. At midnight the surgeon told me that he felt I might not require the surgery, but would admit me to the surgical ward. I was given a private room
     8. I spent the night under observation by two nurses as they watched my vitals — I got little sleep.
     9. In the AM the surgeon came by and said that I was lucky and the meds did the trick. I had the option of staying in hospital for a week or going home and following instructions and taking more of the same meds for the week. I opted for the second option. The surgeon said it was a good idea because “hospitals are full of sick people”. :-) He said to immediately call 911 or come to the ER if any of a set of symptoms arose. None did.
     10. I saw the surgeon again a couple of weeks after and all is well. Have adjusted my diet changes to ensure I don’t end up back in the hospital but other than that I’m fine.

     Total cost: $0.
     Total doctors seen: 3.
     Total nurses, 8.
     Total technicians: can’t remember.
     Total tests: lots, including cancer screening (just in case).

     And I’m not alone in having that experience. Another friend recently felt unwell and went to the ER. He was diagnosed with pancreatitis which left him in hospital for a week to recover. Another recently had a heart attack and was immediately transported to the Civic Hospital where one of the top cardiac units in the world took care of him; he’s now fine. A friend of ours was recently diagnosed with cancer, she immediately saw an oncologist. We’re hoping things will go well, but it’s cancer.

     I recall a couple of years ago when I was in the hospital suffering from chest pain. It turned out to not be a big deal, but it left me there under supervision for hours until the cardiologist was happy it was truly not a big deal. However, in the unit next to mine I could hear a woman crying and doctors and nurses constantly going in/out of the unit. Finally I saw a couple of men arrive with a gurney and then I heard what was going on: her son had suffered a brain seizure of some kind, the hospital had stabilized the young man but the best neural surgeon in Ottawa was at the Civic and so they had flown in the helicopter to transport him to the OR at the Civic where they would be doing the surgery, they were prepping the OR as they spoke to the distraught woman. They then told her they would take her via ambulance to the hospital and she would see her son once surgery was complete. To me that was pure evidence of how well the system worked. They were transporting the young man to the best surgeon to deal with his problem. There was no concern about whether she had sufficient insurance to get the best, she just got the best. Case closed.

     Perhaps I’ve been fortunate to only see the system function well. But somehow I doubt it. Sure, you do wait for some things such as non-urgent scans, for example. But if you need urgent care there’s no waiting, and that’s when the system works wonderfully. Sure, it can be improved. We could use more doctors and nurses. But no one is turned away because of financial situation. It’s not perfect, it can be improved, but it’s designed with caring in mind not financial gain.

     Finally, universal healthcare, to me and many others I know, is evidence of a civilized society. We take care of those most in need. We do not shunt them aside and say: “Too bad for you, should have worked harder and saved more money so you could handle getting sick.” It’s a disgusting way to treat your fellow citizens. It’s unacceptable. And it’s why nearly every Western nation has universal coverage — save one.

231. It is indeed “just die already.” I’ve heard Tea Party advocates directly say to me that it would be sad and all, but really, survival of the fittest who actually contribute to society, etc. These advocates also assume that people with wealth are contributors, where I see no evidence of this being a given.

232. @Rod Rupert

     “I think all this ignores two facts. First, ACA requires others to pay for something you consume. It is just dandy that you can now choose a career without concern for how you can get health care and do it with my paycheck, a thank you note every year would be nice though.”

     Your paycheck also helps pay for the roads used by people besides you, the state parks visited by people besides you, providing disaster relief for states other than the one you reside in… I could go on, but I’m guessing you’d like a thank you note for all that, too.

     “Second, if this law was just a minimum level of health care afforded to those at some ceiling of income, that would be one thing. The fact that the law is degrading the level of health care I can get is much worse. The law is designed to move people off of what they currently have. It punishes health care that is better than the government offers and eliminates health care that does not meet what the government deems necessary.”

     No one’s required to leave their current insurance plan if it’s working for them. The only requirement is that if you don’t currently have insurance, you need to go to an exchange for a plan (or alternatively, you can see if it’s possible to get a cheaper plan via the exchange versus what you currently have, but switching to a plan obtained from the exchange isn’t required).

     The government is not providing these healthcare policies, private insurance companies still are. They’re just no longer able to turn people away with pre-existing conditions and are required to provide insurance at an affordable* rate.

     (*mileage may vary)

     Apparently what really matters to you is that you’ve got yours, so screw everyone else who happens to not be as fortunate. Pro-tip: It’s not just about you.

     http://www.chicagonow.com/mama-bunny-pip/2013/09/the-affordable-care-act-its-not-just-about-you-sasquatch/

     “My father was a type 1 diabetic diagnosed in 1950 when he and his whole family were dirt poor. He lost a third of one lung in a public sanitarium from TB. He did not make excuses or look for handouts, he made a life for himself. There was a time when people were expected to do so.”

     I’m sorry that happened to your father, but it’s good that he (I’m guessing) was able to manage somehow and that’s commendable. However, not everyone’s as lucky and it sure as hell isn’t because they didn’t try hard enough. I fail to see anywhere where it’s been implied that the government requiring healthcare insurance be provided to all citizens means that no one’s expected to “make a life for themselves” anymore. Offering a helping hand to people who are struggling or who are at greater risk than yourself isn’t “doing it all for them” and when someone asks for help, it doesn’t mean they haven’t already tried to do everything on their own. Implying that people who need assistance are entitled and lazy is getting to be a really worn out strawman and it spits in the face of the countless people who are struggling with healthcare costs and living in fear of the next major health crisis that may break them beyond repair financially – all through no fault of their own.

233. Jay, as for people “dying on waiting lists”, that can happen. You can also die by ignoring symptoms or, in the US, not having insurance.

     The Supreme Court case you and others usually trumpet actually applies only to Quebec. Furthermore, in Ontario if you need healthcare and for whatever reason it can’t be gotten in a timely manner, it can be provided “out of province”. Do note that many Americans come up to Canadian hospitals for care, especially to the Shouldice Hospital for hernia operations. If the US system was so darn awesome why do so many wealthy Americans come to Canada to get their hernias fixed?

     Finally, you claim anecdotal evidence as not being valid and yet all you point to re: the Canadian system is anecdotal evidence and that one Supreme Court case. If you look at actual data you see the Canadian system works much better than the US system in terms of longevity, chronic care, overall health, infant mortality, etc. The only thing the US seems to be best at is spending per individual, which should provide pause. If the US spends, on average, twice what Canada or France or Australia spend on healthcare but have much worse results, you really need to wonder how in the world having a system similar to any of those nations would be WORSE than the current catastrophe of a system? That type of mind bending illogic is simply beyond most of the rest of us on planet Earth.

234. Steve C. – At the time the ACA was being written, the GOP had no majorities in Congress. They were not consulted in the process, and had no opportunity to get legislation so much as out of committee. (Although I suspect that if you looked, you would see plenty of GOP health care bills out that were proposed and died.)

     Back to the argument that health care is sui generis. The arguments here confuse “insurable events” with “things that should not be subject to markets.” I carry insurance on my car partially because my state mandates it, but mainly because if my car is in an accident I can’t bear the financial cost of replacing it. But that doesn’t mean that therefore, I should use insurance to buy gas and change the wipers. Or that there’s no functioning market for cars, therefore the government should provide all transport to everyone as a “single payer.”

     Yes, when you are in a catastrophic situation, you can’t really shop around. But here is the glaring flaw with that argument: only a relatively small percentage of healthcare spending works like that. Most health care spending can be subject to shopping around, especially if you passed a law mandating price transparency. (Which should be done.) Yes, if I keel over from a heart attack, I’m not going to compare prices. But when I go through rehab I certainly can. I can for preventative care. I can for expenses that are predictable like a colonoscopy. Just because part of medical spending is highly inelastic does not mean that we should treat all medical spending the same way.

     One of the biggest reasons why our health care system is broken is that we’re trying to force a one-size-fits-all system on medical spending when not all medical spending should work that way. If your auto insurance had to cover the price of gas and maintenance, the costs for both would go through the roof too. Preventative health spending and catastrophic health care spending should not be financed the same way because they are two different things in terms of what makes sense for spending on them.

235. @jay: Anecdotes are not data. For every story about some Canadian who got treatment for their cancer, there are several of those who died while on waiting lists.

     Please try to wrap your head around this. The VAST majority of Canadians have never, ever experienced these horrors of which you like to speak.

     The case you referred to (Chaoulli v. Quebec) was, first of all, only binding in the province of Quebec. It was about the rights of provinces to use various methods to discourage a secondary tier of health care paid for out by private health insurance. Canadians have not been stampeding to get such care in the wake of the ruling.

     You realize, I hope, that Canadians have come to recognize by name and details these examples that Americans like to dredge up.

236. People here in the U.S. die on wait lists for kidneys, hearts, etc. as well. Let’s not forget that.

237. Jay:Anecdotes are not data. For every story about some Canadian who got treatment for their cancer, there are several of those who died while on waiting lists.

     Wait, so your “data” is that for every 1 canadian treated for cancer, 4 or 5 Canadians die from death panels?

     So, you just get to make stuff up and call it “data” now???
     Is that how this works?

238. Jay, if you find one first world nation in this wide, wide world where health care is practiced like you believe it should be, please let me know. Just one.

239. @Liania Mir Ah. Thank you.

240. While I’m extremely opinionated on this subject, I’ll just confine myself to a few points. First, health care reform is *hard*, and hard to predict; Bob Dole pushed through Medicare’s Prospective Payment System back in ’83 and we’re still trying to figure out what its effects have been. I can guarantee that thirty years from now academics will still be arguing over whether ACA increased or decreased individual insurance costs and overall health spending relative to the pre-ACA baseline.

     The reason reform is so hard is because the health care market isn’t really amenable to traditional economic tools like rat-ex models. In fact, it’s hard to think of many markets that are as weird and spooky as health care; the opacity of the market and downside risk of any transaction means it’s something like finding a mechanic in a world where cars don’t have instrument panels and occasionally blow up after getting an oil change.

     (How bad is it? Read http://www.texasobserver.org/anatomy-tragedy/ and consider if you can imagine the same thing happening in any “normal” services market.)

     “Food, computers, cars, or clothing” all benefit from the usual capital efficiencies of manufacturing apparent in shifts from labor economies. For each of those products, I can, through application of technology, increase *quantity*. In health care, greater capital investments generally increase *quality* of care but do not increase production.

     A “better” CT machine might have finer resolution or lower radiological exposure, but its efficiency benefits (better diagnostic ability for the physician, or fewer cases of cancer down the road) are second-order at best. By contrast, a better fertilizer means more crops or more profit to the farmer; a better die process means faster and more affordable computers; cheap overseas logistics via container ships means $4 t-shirts, and so on.

     The real bottleneck is, and always will be, the labor. And this is where ACA runs its biggest risks. There’s always the possibility that some bright spark is going to figure out the “Wal-Mart for health care” model (living in the medical startup world, I hain’t seen it yet), but we’re not likely to see major innovation in the way health care is delivered. Thus, we’re going to see more people bidding for the services of a largely static labor pool.

     Under a pure free market process, we’d just bid the vast majority of patients right out of health care; under the current (pre- and post-ACA) model, we limit physician reimbursements, so they attempt to maximize the number of patients seen. As we bring more people into the care pool, expect this trend to continue: more time in the waiting room, less time in the exam room.

241. @daveon “I do mind, and so should you, that you’re paying every single day for people to receive primary healthcare through ERs – something I think that old lefty Ronald Reagan demanded?”

     I can vouch for this. Very few of the patients we see are actual emergencies. We see lots of colds, bronchitis, vomiting, headaches, pediatric fevers. Things that a primary doctor would have been able to handle *if* the patient either had a primary doc or actually used the one they have.

     But…people get worried. They can’t get ahold of their doc. It’s after hours and there is nowhere else to go. They hurt, they feel horrible and they don’t know if what they have is serious or not. We are open and ready to take care of them, so the ER is used as a clinic, at a much higher cost than a regular physician would charge.

242. Anecdotes are not data. For every story about some Canadian who got treatment for their cancer, there are several of those who died while on waiting lists.

     Can you give even a single example of these “several [Canadians] who died while on waiting lists”? Because though anecdotes do not equal data, at this time “anecdotes” is more than what you’ve given, which is to say nothing but unmoored assertions.

     Xopher: I think “terrorism” is an apt label for what the House Republicans are doing, and “terrorists” for the role they’re playing and the effect they are having. Indeed, that’s what I’ve been calling it ever since they first threatened it. I don’t think any rhetorical advantage is gained by borrowing the terminology of Islamophobic bigots to create an extra special insult for them, though. That said, I like “Tea Party Terrorists” – it’s a way of talking about it that puts the blame squarely where it should rest, on the party whose primary platforms are to destroy trust in the very institution of collaborative self-government, and to prefer tearing down society and burn the rubble than enduring a black man’s tenure in the White House.

243. @greg: Wait, so your “data” is that for every 1 canadian treated for cancer, 4 or 5 Canadians die from death panels?

     Well put Greg.

     And you know what mystifies me as a Canadian? Where the hell have they been hiding these death panels and why has no one I know ever been called before one? I am mystified that no Canadian doctor I know has ever had to submit a report to one. I am mystified why everyone in my extremely long lived (and medically interesting) family has been overlooked by these panels. I am annoyed that while living in the US my insurance company cared enough about me that medically untrained clerks were able to overrule my doctors as to the course of my care but here in Canadian no bureaucrat cares enough about me to overrule the decisions of my doctors and nurses.

244. Yes, more Canadians travel to the United States for coverage than vice versa. That’s why the Detroit area’s hospital system does so well in cross-border traffic:

     http://www.freep.com/article/20090820/BUSINESS06/908200420/Canadians-visit-U-S-get-health-care

     It is always interesting to me how defensive Canadians are about their healthcare. Again, maybe Canadian health care is better (and I don’t concede that at all) – and even if that is true, you have to prove that that same system would work just as well when applied to the United States – a country that is much bigger, much more geographically spread out, and much more diverse in terms of population and economics. That’s a much, much harder argument to make.

245. @Jay: I’ll see you your study and raise you one:

     http://www.aarp.org/politics-society/government-elections/info-03-2012/myths-canada-health-care.html

     It is always interesting to me how defensive Canadians are about their healthcare

     Yup, it is really interesting that people get defensive about things when you repeatedly tell outright lies about them.

246. I know lots of folks who are self-employed, and they struggle with getting and affording health insurance. I am hoping that the ACA will make it affordable for everyone.

247. All the crap about people dying on waiting lists is largely based on a study done during a period where Canadian healthcare was going through a slower period — and the “lifesaving surgery” they were talking about was hip replacements.

     I have PTSD. Ask me how likely it is that it’ll be treated. If you can find me — check the gutter. Yeah, I’m doing so much better under The Finest Healthcare System in the World (TM). Thanks a lot, Nixon. http://en.wikisource.org/wiki/Transcript_of_taped_conversation_between_President_Richard_Nixon_and_John_D._Ehrlichman_(1971)_that_led_to_the_HMO_act_of_1973

248. USA 9,826,675 km²
     Canada 9,984,670 km²

     I’m a European socialist – I think in metric units.

249. @Pamela D: When I worked in the US many of the people I knew had what might be considered excellent health insurance and yet were plagued with worries about how to afford co-pays and deductibles. I know something is better than nothing but I sincerely hope that those concerns will be addressed as well.

250. Yeah, and according to the article mmy linked, Canadians choose waiting lists (for elective care) in order to save money. They could spend more money and overcome the waiting lists, but have chosen not to. I guess that’s where the “death panel” b.s. comes from.

251. @Jay: a little google-ing will bring up the fact the following list of things in which Canadians are, on average, doing better than Americans: life expectancy, infant mortality, maternal mortality, mental health, and a whole host of others that I won’t link to so as not to bait the spam filter.

     By basically every measure, Canadians have healthier lives than Americans, for far less money per person. If that doesn’t count as having a better health care system, then I don’t know what does.

     Oh, and given that Canada is slightly larger than the US, I find it hard to believe that the US is “much more geographically spread out”.

252. Dear Jay,

     In fact, there are magic pixie dusts that do markedly reduce health care costs without compromising coverage or quality. Several of these were identified in the first go-round 20 years ago. For example, a single-documentation/claims system (NOT single-payer– just uniform, universal paperwork) would reduce total medical costs by 20-35%. The variation is because the cons’ analysis of this went towards the low end and the libs’ towards the high, but they all agreed it was a BIG chunk of totally wasted money. Multiple, incompatible systems of paperwork hoops that doctors’ offices have to jump through is a massive friction in the system.

     So, voila, there’s a magic pixie dust that would cut your costs by 25% (taking the middle ground).

     Also, you might care to look into what emergency room care costs, relative to medical value received. Best guess of the analysts– we’re losing another 10% there in further wastage.

     There are others.

     So, just two known examples of doable things that would cut your medical bills by a third without taking on whit of care away from you or money from a doctor’s pockets.

     Your arguments about the horrors of rationing have simply been utterly disproven in so many countries that I see zero point in engaging them. It’s an entirely logical argument for a flat earth, presented years after it has been circumnavigated numerous times.

     pax / Ctein

253. @Stacy: I sometimes wonder if people are confusing/confounding TRIAGE with DEATH PANELS. In Canada you simply cannot buy your way to the front of the line. If someone else needs a room or a service then your elective surgery/procedure gets bumped. Last time I was in the ER with a family member their care was very clearly divided into two stages: 1) elderly person on blood thinners gets immediate scan after he takes a bad fall and hits his head on the pavement and 2) waiting for the stitches after the scan comes back and shows that there is no worries about internal bleeding. Getting stitches took a while since while he was getting his scan two bad traumas arrived and he was in no pain or distress.

254. Wow, this is a hot topic. Thanks for posting, John, and I would encourage people to discover the facts about the US Health Care System for themselves rather than rely solely on the multiple stories and suppositions here.

     My favorites:

     31% of sicker US citizens “Skipped or did not get a medical test, treatment, or follow-up that was recommended by a doctor” compared to 4-19% of similar patients in other OECD countries (e.g., UK, Germany, Switzerland, Australia, all countries with a national health care system of some kind)
     and similar ratios for did not seek care for a medical condition / did not fill a prescription (US 29-31%; other countries 4-20%).
     (Commonwealth Fund International Health Policy Survey, 2011)

     US ranked #43 on infant mortality for 2005-2010, just above Belarus. (UN Population Division)

     … yet US spends THE MOST on per capita health care per country $8,233.

     Great country to live in, just don’t get sick. ACA has many provisions, including several that are intended to affect costs as well as outcomes. I would generally suggest that we should change our current model and would welcome suggestions.

     In Oregon, the above anecdote would cost $6000 per year ($500 per month in premiums) for a family of 4 earning $50000 with a maximum out of pocket of $4000 for Silver (quality rating 3.5 stars, nice).

255. Kim: The bit that drives my doctor friends insane, especially the Urgent Care physician is how pointless many of the visits they get are, and how upsetting it is when they find somebody who had something relatively minor and treatable that’s now fairly serious and therefore expensive.

     What drives me nuts as a Brit living in the US is just how random it all is. No Jay, you really can’t ‘shop’ around, even for non-urgent stuff – there’s a ton of restrictions on what we can and cannot do with our insurance, and even a visit to an ‘in network’ ER a couple of years ago cost us $900 because the doctor on duty was a locum.

     There is simply no moral case, and yes I reject the usual Libertarian dreck out of hand, that says that access to healthcare isn’t a right. That’s at the crux of this discussion and no amount of mumbling about the market is going to change that.

     It’s 2013 and the US is the richest nation on Earth. I am astounded this is even still an issue.

     The Germans recognized over a century ago that Universal Healthcare access was a conservative and economically sensible thing to do, how on Earth libertarians and republicans can’t see the same thing is utterly beyond me.

256. ” If memory serves, Canada’s Health care started in a couple of provinces before expanding nationally.”

     Yes; it started in Saskatchewan, where my wife’s family is from. And oh, did the medical establishment rail against it, even to the extent of a short-lived “doctor’s strike”.

     But now? At least in the experience of my family, there haven’t been any overlong waits, and more important, no worries of not being able to get or afford healthcare. In particular, my mother-in-law has had various old-age health issues, and has gotten good and prompt treatment for them, including immediate surgery when it looked like there was an acute life-threatening condition. My brother-in-law’s gotten good care as well. Sometimes they have to drive a long ways into the city if they need to see a specialist, but they can see one when they need to.

     We’ve even experienced bit of the system personally, when one of our kids came down with something while we were visiting. The local small-town clinic had us come in the same day we called, the doctor checked them out, and then was very apologetic when they said they had to charge us because we weren’t Canadian residents. (At the exchange rates of the time, the total charge turned out to be just about the same as our insured co-pay would have been back home.)

     Not everyone has the same healthcare experience (and since it’s administered at the provincial level, one’s experience in Quebec may be quite different from one’s experience in Ontario or Saskatchewan). People I know in various provinces still gripe sometimes about various aspects of the system, but all the folks I know up north who’ve visited us have said they’d much rather have the system they’ve got at home than the system we’ve had in the US.

257. Jay: It is always interesting to me how defensive Canadians are about their healthcare.

     It’s always interesting to me how laisez-faire folks get defensive about their free-market nonsense.

     you have to prove that that same system would work just as well when applied to the United States

     Now you’re just being a hypocrite. You most certainly haven’t proven that your “free-market-health-care” hypothetical system would work better than the current one. You just keep talking about death panels as if they’re actually real.

     The majority of personal bankruptcies in America are caused in part by medical bills. Some of those bankruptcies include people who HAD INSURANCE but the insurance company decided to stop paying benefits, or decided to rescind the patient from coverage, or screw them over in some other “let the buyer beware” kind of way. You’re solution to this is simply “more free market”, but you haven’t proven in any way that that would actually solve the problem. What insurance company would give someone diagnosed with cancer a health insurance policy unless the law requires them to do so? The ACA was intended to fix things like rescission and fix things like insurance companies refusing coverage for preexisting conditions. You’re precious Free Market certainly won’t solve that problem. The Free Market is what created the problem.

     You’re clearly subscribed to the myth that “Laissez-Faire Capitalism Solves Every Problem”. You want others ot prove their solutions, but your “proof” for “free market solves eveyrthing” is just assumed. It’s part of your unproven premises upon which you base your arguments.

     Prove to me how the Free Market will solve the problem of insurance corporations rescinding people who get sick. Prove to me how the Free Market will solve the problem of insurance corporations refusing to cover new customers who have preexisitng conditions. The free market creates and reinforces those problems. Prove to me how “more free market” would then solve the problem that “free market” created.

     You can’t prove it because its the opposite of what reality demonstrates. But you keep assuming its true and you keep forwarding “Free Market Solves Everything” as if its proven. All that does is indicate the level to which you believe the laissez faire fairy tale in spite of all the reality to the contrary.

258. I have two friends who have had their hours severely reduced because of the ACA. They didn’t get healthcare from work before, they won’t get it now, but now they’re earning less money than before *and* have to buy health care, whereas before they were covered by Medical.

     How is this a win?

259. Treating health care like a consumer good makes as much sense as selling national defense or fire fighting as as if they were TV sets.

     Let us not forget that the *supply* of healthcare is also not subject to ordinary market pressures. The AMA maintains tight control of the supply of doctors via accreditation, thereby helping ensure that doctors’ salaries remain high. (Of course, the ridiculous student loan sums that doctors-in-training incur make those salaries almost necessary.)

     (Apologies if I’m repeating a point made elsewhere, it’s easy to overlook in a thread this long.)

260. @shakauvm: Yes. Although they shouldn’t have had their hours reduced yet. That’s just the businesses they work for jumping ahead of schedule.

     Also, all of the children that lost their jobs when we weren’t allowed to take advantage of them the way we did during the industrial revolution were a good thing even if it didn’t seem like it at the time for them or their families that relied on their incomes.

261. @Xopher: Good Lord, I didn’t realize your name was based on reality. Just think, if you’d been Canadian, you’d have no neato screen name. Ha.

     As long as we’re slinging anecdata around, among people I know who are in American-Canadian mixed marriages, they all end up living in Canada. Something ridiculous about wanting to be healthy and affording children. Ditto those who marry Brits, Aussies, etc. I thought my pal from Alabama would never survive an Ontario winter, but I guess living in the maple syrup slave mines toughened him up.

     @whoever said it way up there: I think we’re going to see universal gay marriage and 50 state pot before we get single-payer healthcare. There’s no big money industry/lobbying involved in keeping down the gays and the stoners — at least not as much as there is with insurance. Those are also both relatively simple solutions with yes/no answers — you throw the switch and it’s done.

262. NotSMOF: Kaiser is an HMO. You don’t get to pick your doctors or your treatment centers from the universe, only from the plan.

     Kaiser is indeed available to me as an FEHB provider, and my costs would indeed be lower than for GEHA. But we have longtime relations with specific doctors that we’d have to give up, and we have specific referrals as well. I wanted my angioplasty (sixteen years ago) done by a world-class expert in the DC area, not by someone who happened to be available under the plan. It’s not that he cost more, but he wasn’t a plan doctor.

263. @shakaum

     That’s not Obamacare, that’s the greed of the business owners. Hopefully they can find a better employer.

264. They were not consulted in the process, and had no opportunity to get legislation so much as out of committee.

     This, to be polite, is utter BS. More accurate commentary would be deleted by our gentle host. Google Gang of Six health care to start.

265. @shakauvm – maybe they missed the part of the law that states people who fall under a certain income level aren’t required? That part seems to be skipped quite a bit.

     A few years ago, my husband and I tried to have our own business. Of course there wasn’t a way in hell we could afford health insurance flying solo like that. And then, the pain I had in my spine started in earnest. And I lost weight very quickly. We knew something was very wrong, but I couldn’t go to a doctor because we hadn’t any funds to do so. In the end, it turned out that was for the best, because if I HAD gone to a doctor, the CANCER that was found on my spine would have become a very expensive pre-existing condition. Instead, we sold the business, I got a job with health coverage, and THEN went to various doctors trying to figure out what was causing all the pain. It took two years to get to that end, and I was very close to being paralyzed from the neck down by the time I had my first surgery.

     Even with decent health insurance I am still paying off expenses (that annual OOP cost, which varies from year to year) incurred in 2010. And 2011, 2012, 2013…It adds up. If for some reason, I am no longer able to work at my job (which has been very gracious about keeping me on, despite my ongoing illness), I am grateful that I will either be able to still buy affordable coverage on my own, or get it through the next employer and not be denied because I am currently a cancer patient, with the great luck to get one that is very rare, with no known reliable cure, and not much funding for research.

     In the end, if I had no coverage, would I just curl up and die? No, I’d incur a lot of debt and not be able to pay it and then it would still be paid for with taxes. (Look up “uncompensated care”.)

266. “Where the NHS and the Canadian system fail is in treating cancer”

     Wait, what?

     My mother has multiple myeloma, ie incurable cancer. She was diagnosed six or seven years ago. Since that time, she’s had radiotherapy, chemotherapy, numerous other drugs and medications (seriously, you should see our house, it’s like a pharmacy), multiple hospital stays, constant visits to the GP, hospital clinic and palliative care clinic, various types of tests, etc etc etc – all “free at the point of care” via the NHS. She’s even received two free wigs! She’s also stated on numerous occasions that she’s felt cared for and supported by all of the doctors and nurses involved in her treatment.

     Yes, sometimes NICE (the National Institute for Health and Care Excellence) is forced to refuse approval for a particular drug because it costs too much – unfortunately the NHS does not have unlimited cash. But please don’t think that this means that every expensive drug is refused approval. It’s the exception, not the rule. There is also nothing stopping anyone who can afford it from turning to private healthcare and/or private insurance.

     By the way when I say “approval”, I mean general approval for the drug to be available on the NHS, NOT approval for it to be used for a particular patient. It doesn’t work that way. If my mum’s consultant says she needs a new drug and NICE have already approved it for her condition, she gets it.

     Trust me, the NHS does not fail in treating cancer.

267. @Chris: well said. I wrote about it in my blog today as well. I had my hours eviscerated, but when you look at how much money I make my company, it’s almost literally insane that they wouldn’t give me health care, except the fact that it would cut into the almighty margin.

     I made my companies over 1000% of what they pay me (some as low as ~700%, but others much higher (like 1700% higher)), but I’m still not worth healthcare to them. I’ve done the math.

     If they had kept me at full-time, actually started paying a living wage and paid me healthcare, I’d be even better at my job than I am now, but having to work 4 jobs, never knowing if I will be able to afford what happens to me on any given day without health insurance, and spending the time and money traveling between different jobs means that they just get what I can give (which is still a fair shade better than what most other give at my job).

268. Re: Employers reducing hours.

     No employer hires people because writing paychecks makes them feel good. They hire because they need workers to make their business succeed.

     They keep people under 40 hours or off permanent employment wherever possible, and they have done that for over a decade if not longer. Illinois had laws in place regarding that back in 2009 if not earlier, because I’ve contracted to employers who played those games and had to be concerned about how to dodge those laws using contractors. Those laws were not in place because of occasional problems; they were in place because of routine systemic abuse of contractor status by employers.

     Employers might reduce hours to try to press a political point or use politics as an excuse. However, they were either already going to pull hours OR they will have to hire people to make up the difference in labor they inflicted on themselves. Given the current market, I’d bet on the former if I were betting.

     But blaming it on the ACA is an inaccuracy, and it’s one I am tired of hearing.

269. @shakauvm: “How is this a win?”

     That’s a good point, and another reason why single-payer systems are better. That way people aren’t so much at the mercy of their employment status.

270. shakauvm: “I have two friends who have had their hours severely reduced because of the ACA. They didn’t get healthcare from work before, they won’t get it now, but now they’re earning less money than before *and* have to buy health care, whereas before they were covered by Medical.”

     If their hours are now severely reduced and they are earning less money than when they used to be covered by Medi-Cal, how come they no longer qualify for it? In fact, Medi-Cal was supposed to be expanded as part of the ACA, so I would expect the opposite pattern.

     According to this article, if they qualify for Medi-Cal, they can either stay on Medi-Cal or buy on the exchanges, but if they choose the latter, they pay full freight and get no subsidies. Are they looking at the non-subsidized numbers and just assuming they can’t stay on Medi-Cal? From that article I just linked:

     “Medi-Cal is the state’s publicly funded health program for low-income and disabled residents, and currently provides care to more than 8 million Californians. (It is the state’s version of the federal Medicaid program.)

     “Starting in January, Medi-Cal will broaden its eligibility requirements as a result of Obamacare, allowing applicants with higher incomes and those who were previously ineligible, such as childless adults, to get coverage.

     “But whether you’re eligible for Medi-Cal now or become eligible then, that fact alone disqualifies you from tax subsidies on the health insurance marketplace, which is called Covered California.”

271. “Journalist Megan McArdle who’s an expert in the field”

     Hah. Scorpius, your Swiftian satire was almost perfect but you gave it away by citing Megan “Gastritis broke my calculator” McArdle.

     No one would seriously cite the woman who advised that the Newton victims would have survived if only they had rushed the shooter, who thinks someone earning $240+ per year is in poor financial straits, and that unpaid internships are the way poor folk can get jobs.

     Otherwise, your impression of a heartless, fact-cherry-picking right winger is faultless.

272. @JayReding:

     Where the NHS and the Canadian system fail is in treating cancer, gerontological issues, and the much harder issues.

     Whut? So, basically, complex shit requiring large, long term investment in infrastructure, material and a highly-trained specialist workforce can’t be done fast or cheap anywhere? Good to know.

273. For years, I was only employed seasonally and thus not eligible for employer health insurance coverage. I buy my own health insurance and currently I pay over $100 a month for the bare minimum in health insurance, more than I pay for cell phone, car insurance, and student loan payments combined. I make less than the qualifying amount for the subsidies under the ACA, so my insurance costs won’t go down. My state has decided not to expand medicare, so I can’t qualify for that either.

     The whole situation makes me so mad I could spit. I find the childish behavior of the Republicans to be entirely reprehensible in that they are throwing a tantrum when legal means of objection haven’t worked. I recognize that this country has a serious debt problem and the ACA will not help that overmuch. However, the ACA is a quick-fix sort of solution for some of the other problems this country has (which are numerous).

     I think the ACA is a step in the right direction. However, I think there are some serious holes in the legislation. The most glaring of these holes is: requiring everyone to buy health insurance is going to raise prices due to the phenomenon of the captive market. The fact that the law creates an online marketplace is beneficial but (I don’t believe) will do much to lower prices because people who are forced to buy something from a limited number of suppliers will be forced to pay whatever price those suppliers set. However, as many people have pointed out, this is a problem with no easy answers and at least the Democrats have provided an answer.

     Finally, I think there are a lot more brilliant people in the world than the ones on capitol hill and perhaps if our society listened to those people more often we could come up with better (or at least more rational) solutions to our problems.

274. OK Jay, so the NHS and Canada fails so badly in health care, lets see what the CIA has to say…

     Canada: 81.57
     UK life expectancy: 80.29
     Europe: 79.86
     US 78.62

     Ooops, maybe the gerontologists are a bit better outside the US? They have 3 years per person more time to practice in Canada, after all ;)

     Seriously, at least attempt to make sense.

     Or should we just compare rich white Americans with health insurance to the rest of the world, rather than letting all the sick poor people move down the average. I suspect this is the gist of your message.

275. I have lots of American acquaintances who have had cancer. In many cases it has been economically devastating. Retirement funds emptied, second mortgages.

     In Canada, I have a housemate who has had different kinds of cancer over the decades; breast cancer 23 years ago. She works as a freelance editor. She has doctor’s appointments from time to time, had minor surgery last year. No big deal. Cancer treatment is much, much better in Canada than in the US for the simple reason that it is provided when it is needed.

     I worked in the US in 2006-2007. Same job, same salary as in Canada. Taxes in Virginia was less than in Ontario. But after taking off health insurance, my take-home pay in Virginia was a couple hundred less each paycheck in Virginia than it had been in Ontario. Plus, one time I happened to be short on cash. In Ontario, wouldn’t have been an issue. In Virginia, that meant I couldn’t pay the co-pay until I got my next paycheck. Far as I could see, the main difference between my doctor’s office in Virginia and my doctor’s office in Toronto is that in Virginia, the furniture was a little nicer, and the office was laid out so that I had to come to the cashier’s desk before I could exit.

     Something like a quarter of all US healthcare spending doesn’t go to healthcare. It goes to the bureaucracy devoted to keeping track of all the payments, which is vastly more complicated in the US, much of which is about making sure that payments are denied.

     Civilized societies have figured out healthcare is a prerequisite to productivity and that a lot of productivity is lost when healthcare is rationed to the well employed.

     The Affordable Care Act is a flawed compromise to provide healthcare to more Americans. It is flawed mainly because Democrats had to concede to many Republican demands to protect the profits of insurance companies. The simple economic truth is that widening the “customer” base has the effect of increasing insurance company profits while also improving the overall health of the public, which lowers aggregate healthcare costs as expenses shift from urgent care to preventive medicine.

276. I have seen several comments mentioning the levels of fraud and waste in our healthcare industry, and I was reminded of this Time article that came out earlier this year: http://content.time.com/time/magazine/article/0,9171,2136864,00.html

     It seems to be behind a subscriber/pay-wall now (sorry!) but it was an amazing read and I recommend it if you subscribe.

     Slightly different subject, I have always found it funny how one of the first criticisms I hear about the Canadian system or really anything government provided is the ‘wait times’.

     Haven’t multiple comedians done bits on that? You spend an hour in the waiting room next to some obviously sick child who’s drooling on your armrest surrounded by people who don’t cover their mouths when they sneeze then another 45 minutes in the exam room in the ass-less gown, reading and rereading a dogeared pamphlet on family planning with illustrations that haven’t been updated since the ’70s or a People magazine from two years ago with the cover ripped and tooth marks from somebodies teething infant? Just to get sent over to another waiting room for another near hour wait to see a lab tech for a blood test? And that doesn’t even include the time between when you make the appointment and when it actually is. I just set up an appointment today, for a pretty routine thing, and the earliest they can see me is in over a month.

     Only once in my entire life was I able to see a doctor same day for a nonemergency. And that was at my college health center right before a weekend.

     I have always thought this was normal, again probably because of it being a long running joke, just part of why it’s a pain in the ass to go to the doctor. I’d feel sorry for all the Republicans who’ve obviously never been able to appreciate some everyman humor, except for the fact that I just can’t bring myself to be some empathetic toward people actively trying to hurt me because I happen to be not rich.

277. Thanks, John, nice piece and I agree with all of it.

     I recently left a stressful job (in healthcare!) to do what I really want to do, which unfortunately does not come with employer-paid insurance, or for that matter pay. I had waited patiently for Obama to be re-elected and the Supreme Court to make its decision before making the leap. I’m currently on COBRA and plan to go on Obamacare in January. (I have a pre-existing condition – a cancer that will never recur but is still enough to kick me out of the healthy pool.)

     I take it absolutely personally that Boehner has chosen to shut down the entire government for the single aim of not allowing me to pay for my own healthcare insurance next year. It seems so disproportional and so very wrong to be so committed to such a useless, petty and yes, evil goal.

     And for Jay – your polemics aren’t working as there are too many people here who have experience in Canada or the EU. I grew up in the UK and know the NHS well. (I worked in the NHS before I worked in the US system.) It was much easier and less stressful than US healthcare, and per person it’s cheaper – by half – too. My SO’s father recently got leukemia, He unfortunately passed away after he lost remission, but the care he was given by the NHS was excellent. There was no “you’re too old at 76, we have to look after taxpayers instead” decision, no death panels, no waiting lists. Just a very efficient shuttling to the correct specialists and then on to the best treatments available. Since I worked in healthcare, with leukemia a specialty, I specifically asked his son if there had been any delays or attempts to cut costs and there were none. Yes, it is an anecdote, but just as extraordinary claims require extraordinary evidence, boring middle-of-the-road claims like this one don’t require *that* much evidence. (And if you come back and say Medicare would have taken care of him in the US, the question becomes, “Does socialized medicine work for only over-65s, and if so, why?”)

     For comparison, my COBRA (i.e. what work used to pay for my insurance plus my contribution, now paid entirely by me) is $595 for an individual, and “Obamacare” for my age and district is about $510 for a comparable policy. However, my COBRA includes dental and it appears Obamacare doesn’t. (Dental will add $15 a month.) It’s not “affordable” in the “I’ll take ten!” sense of the word, but it’s better than having a heart attack and losing my house, 401K and all my savings. I really feel for those commenters up above who have to tell their kids “No skateboarding as a broken arm means I have to declare bankruptcy”. What a world.

     Oh wait, it’s just “What a US”.

278. I am excited to get care via the ACA in January. At my freelancer’s income level I will get some subsidy, and any insurance definitely beats the current state of none.

     What terrifies me is then taking my two current Scary Things to the doctor to find out whether I either have cancer or am permanently crippled. Or both. Because, yeah, my all-purpose treatment plan for the last ~2 years of uninsuredness has been to take painkillers and cross my fingers. Without insurance, I would run out money for treatment for any major problem, oh, instantly, at which point I would end up homeless and broke and still out of money for treatment because my local hospital (the only game in town) is well known for suing to take people’ s assets if they can’t pay their medical bills. Even if it’s only a few thousand dollars. So I don’t go to the ER. I take painkillers and hope it goes away. It’s scary.

     January 1st can’t come soon enough for me.

     Stand firm, Obama and Reid.

279. It’s the hypocrisy that gets me – these same people claim (loudly and vehemently) to be anti-abortion, pro-life, anti-suicide (assisted or otherwise), anti-euthanasia, and SHOCKED – utterly SHOCKED, I tell you!! – that the ACA made provision for end-of-life discussions with a doctor (which they understood as “Death Squads are coming for Grandma!”). And yet, as you said, the real message the rest of us are getting, loud and clear, is “just fucking die, already.” And then there are those folks who don’t seem to understand that. I’m not going to feel sorry for any of them if they do get their way.

280. Totally late chiming in on this (minding my adorable, 8-month-old time eater), and debating whether it’s worth the time to read comments, but just a “me, too” from the peanut gallery.

     The pre-existing conditions thing is what would literally kill me if I somehow lost access to my husband’s (very good) insurance. The ACA means he’s not tied down to that company, and I’m not tied down to him. Not that he doesn’t like the job or I don’t like him, mind, but having options is keenly important. I can’t imagine how many people stay in abusive or otherwise awful jobs or marriages just because they need health care they wouldn’t get if they left.

     And of course, that’s probably part of the opposition, too. Health insurance is one of the ways companies can retain employees they’re otherwise treating like crap. Taking away that leash gives workers considerably more options–including self-employment–which means companies now have to step up pay and working conditions to keep their workforce from bolting.

281. Sometimes I think back to the days when Dems were gearing up for healthcare reform, and the Very Serious People took single-payer off the table before anyone else was in the room. Sure, single-payer polled really well — when anyone was UnSerious enough to ask. But VSPs knew that it would set off the Repub leadership, energize right wingers, and trigger a tsunami of bullshit.

     So instead, they dug up some old half-hearted Republican suggestions, added a little this-and-that, set the table with the good china, and prepared for a little friendly discussion.

     Gosh, that worked really well, didn’t it?

282. Bravo. well said.

283. I spent my 20s and half my 30s uninsured. I was working miscellaneous jobs, either self-employed or part time, and no one offered insurance. I also have had health problems- asthma, GI issues and severe depression, which were pre-existing when I lost my insurance coverage (1 year into college when Dad lost his job). I tried to find insurance, no one would insure me. Well, one company offered me catastrophic insurance which was $800 a month and didn’t cover preexisting conditions or prescriptions.

     So I became adept at finding ways to survive. Some hospital systems had “free care”, generally teaching hospitals. I travelled about 2 hours at one point to go to the hospital that had decent free care. I often spent half or more of my income on my prescriptions. I remember counting the years until my medication might go generic, and wondering if I could hold on that long. And when I got really sick, I went to emergency rooms. Which I then couldn’t pay the bills for. I would try to set up payment plans but the amount I could pay per month didn’t even cover the interest on it. It has taken me about 10 years of steady employment, working extra hours, and lots of payment plans to fix my credit.

     Now I have great health insurance. But I remember what it was like before. I was joyfully tearful on 10/1 when I realized everyone could sign up for insurance, FINALLY! Our country had a barbaric health system, which just got a bit more civilized. As a nurse, I’m thrilled that more people can get better preventive and ongoing care. The ACA isn’t perfect, but damn, it is better than what we had before.

284. Another defensive Canuck here, and you can add me to the list of Canadians wondering where Jay pulled the ‘many people up there die on waiting lists’ nugget from. I’ve lived in Canada for 44 of my 49 years (the other five were in Britain), and not once heard of family or friends dying on a waiting list while waiting for medical treatment for that issue (or anything else, come to that). Given how people are pretty quick to criticise when things go wrong, you’d think that at least once in my life I’d have known someone who’s had that happen to a person in their life.

     Then there’s ‘The NHS and the Canadian system work great if you have minor injuries that don’t require advanced treatment. But that’s the EASY part of health care delivery. Where the NHS and the Canadian system fail is in treating cancer, gerontological issues, and the much harder issues.’ Again, bzzzzt, wrong, but thanks for playing. Right now a colleague is dealing with her husband’s cancer diagnosis. He was diagnosed in April; he’s been receiving aggressive, continued treatment ever since. I’ve worked with, and known, many other people over the years who’ve had cancer, or dealt with it close to them. Again, I’ve never heard any of them complain about the treatment they got. My grandmother had a bad fall when she was 96; rather than the medical community shrugging and saying ‘too bad’, she got wonderful, prompt treatment including surgery and lived another three pain-free, good years.

     When I moved back to Canada from England after a five year absence, my medical coverage started up again the day I landed; just as well, as I was pregnant. The bill for my pre-natal care, hositalisation, childbirth, and follow-ups was nil.

     When my husband had chest pains a few years ago, I drove him to our local hospital (we live in a small – pop. 1500 – town in the BC interior, but there’s a hospital three minutes’ drive from our house). That was just after 11.30 on a Sunday morning. Within five minutes of getting to the hospital he was being seen by the doctor and hooked up to machines; within 10 minutes he was getting $1000-worth of clot-busting drugs (as the doctor cheerfully informed us); within 90 he was being transported by cardiac ambulance to the nearest major hospital, an hour away. He spent five nights there with round-the-clock care (yes, he’d had a mild heart attack). On the sixth day he was flown by air ambulance to Vancouver for an angiogram; all was fine, and he was able to come home. There was also follow-up care with a cardiac specialist in Kamloops.

     Total cost: five nights of hotel (for me) in Kamloops so I could be close by, and one night of hotel in Vancouver (because it was late when my husband was discharged and we felt a quiet night and some sleep was better than a four hour drive up the Fraser Canyon in the dark). I did get to deduct the cost from my next year’s income tax return, however, as allowable medical expenses (along with all other expenses incurred, such as meals).

     My dad had almost exactly the same experience when he had his heart attack, except that he’s had a lot more follow-up care, being older. He and Mom just had cataract surgery (Mom both eyes, Dad just the one for now). Did they have to wait? Yes, it was about six months between being told they needed the surgery and when they got it. Could they live with that, in exchange for knowing they wouldn’t need to sell the house to pay for it? You betcha.

285. @Kim: “Anthem Blue Cross PPO ($1920/mo) This is almost exactly what I would be paying via Cobra if I lost my employer’s coverage. Right now. I pay zero, yep zero.”

     And here we finally get to the core of the problem. If you would be paying $1920/month under COBRA after losing your employer coverage, that means that the insurance you have right now *already costs $1920/month*. You’re paying zero because your employer picks up the tab as a benefit of employment, but that’s what your insurance is costing your employer.

     Basically, you’re presently lucky because your employer offers you really good benefits in the form of insurance coverage. Not everyone is as fortunate, such as those of us who are self-employed and work for small or less-generous businesses. You’re a winner right now under the current system, but that doesn’t mean that the system as a whole is superior to the ACA. If your life circumstances were to change, you might find that out, and you wouldn’t have had the option of switching to a less-expensive plan, either.

286. I almost died of not having insurance and being poor. I think it isn’t so rare. The victims are poor, so no one hears about them. I got rescued literally at death’s door. Others aren’t so lucky. I can’t believe so many Americans are this mean-spirited and short-sighted. Kind of horrifying really.

287. In Australia we have Medicare. It isn’t perfect, and it’s always under stress, but if you get sick you get looked after (if it’s elective you’re in for wait). I had to explain the U.S. situation to my sons twice because they couldn’t quite believe that a country as wealthy and powerful as the U.S. would deliberately choose to not look after it’s own people, particularly when the rest of the developed world seems to manage without the collapse of capitalism / rise of communism / socialization of whatever..
     I hope it gets through.

288. Since we’re sharing stories, here’s mine: I have been self-employed for over a decade, so I have no employer coverage. For the first several years we were married, my husband worked for a very small business which likewise did not offer insurance. We made a tidy income and were young and healthy, so we bought our insurance on the individual market. Our $5K deductible policy cost about $400 a month for the pair of us, in 2003-2005.

     We decided we wanted to start a family, but our insurance didn’t cover and didn’t offer maternity coverage. We shopped around and found a policy that did, for an extra $500/month. The kicker was that the insurance would not cover any pregnancies conceived in the first 12 months of coverage. Not “wouldn’t pay costs until 12 months” — if you got pregnant with a due date less than 20 months from the start of coverage, you were on the hook for the entire cost of that pregnancy, delivery, childbirth, everything.

     We put off our baby plans for another year, during which we lived in complete terror of an accidental pregnancy. We were wise to be afraid, as it turned out, because when I finally did get pregnant, it clocked in close to $100K. That’s not even with major NICU time, just a complicated pregnancy that required several hospitalizations for preterm labor. If we hadn’t had that expensive coverage, we’d have been literally bankrupted. We’re comfortable financially, but $100K is still a truly monstrous debt. That was the price of live mom and live baby for us because of unforeseeable and unavoidable biology.

     Nowadays, we’re completely uninsurable on the individual market without the preexisting condition mandate — I have asthma and some orthopedic issues, and my husband had cancer a couple years ago. If he lost his job, another pregnancy would ruin us. ACA is a long way from perfect, but it’s better than that.

289. @Eric Mills: Canada is slightly larger, but the population is FAR less spread out — the majority of Canadians live fairly close to the U.S. border, and large areas of the country are effectively unsettled land. Look at this pic: http://worldpopulationreview.com/images/places/canada2.gif

290. Jay Reding,

     I lived in Canada for 15 years, and I’m afraid that you, like many others in the
     States have not a clue how the system works.
     And it does work.

291. I would agree with this if the ACA were affordable. It is not and the health care insurance is not good enough.

292. Jay, is it defensiveness, or just too many people refusing to buy into your “Who are you gonna believe – me, or your lying eyes?” line of reasoning?

     Ann Somerville, for god’s sake, DO NOT ENGAGE!!! :D

293. Doc RocketScience, thank you, but I’m well aware of who and what I am talking in my previous comment.

294. For those who are protesting that the ACA will lead to health-care “rationing” in the USA, could I point out the following reality: you already have health-care rationing in the USA. You’re using money as a rationing mechanism. There are people in this comment thread who have said they quite literally cannot afford to be anything other than untreated and unwell. They can’t afford to get their illness treated. There are people who are working in jobs they loathe, because otherwise they genuinely cannot afford to be unwell. There are people working multiple jobs in order to be able to afford health care cover, because otherwise one accident will bankrupt them.

     Your health care system already has rationing. The rationing is done primarily by the insurance providers. Insurance companies in the US, in the interests of “saving money” or “higher profits/shareholder dividends” will purposefully DENY patients treatment or testing which has been ordered for them by their health care providers. This means said health-care providers have to take time out of THEIR day (in which they could have been providing more health-care for more people) in order to argue with the representatives of a health insurance agency in order to ensure their patients get the treatment they need.

     As an Australian, I live in a system where basic health care is provided by the federal and state governments in tandem. I go to my GP to get treatment for anything that ails me, and I will only be required to pay the Medicare scheduled fee for this visit (if the GPs office asks me to pay more, the difference is covered by Medicare). If I break my ankle going out of a shop in the city, get taken by ambulance to the nearest public hospital emergency department, am given medication, xrayed, have my lower leg put into a cast, and wind up needing crutches, I can deal with knowing the most expensive part of the whole boiling is going to be the cost of the ambulance[1]. If I need urgent surgery, I will be admitted to a public hospital, and it will be performed as soon as possible. If I want elective or non-urgent surgery, I’ll be put on a waiting list, and when my case number comes up, I’ll be able to have the surgery free of cost at a public hospital. Alternatively, if I can afford full private health care (less than $100 per week here for full hospital cover plus ancilliaries like glasses, hearing aids, ambulance travel etc) I can book my surgery in a private hospital, with the surgeon of my choice, and get it done at my convenience.

     Oh, and did I mention that the vast majority of medications which are used by a large number of Australians are covered by the Pharmaceutical Benefits Scheme – so most prescription drugs here cost about $30 – $40 for a month’s supply. Less if, like me, you’re on a social security benefit and have a health care card.

     Our health-care system here in Australia isn’t perfect. If you’re on a low income and can’t afford private health care, you pretty much have to resign yourself to waiting a lot for things like non-essential surgery. If you want treatment for mental illness which isn’t just restricted to drugs, you’re pretty much going to need a solid disposable income, or a local or state system where there’s a lot more concentration on providing services for the mentally ill. But as someone who is on a low income, who has a chronic ailment (hypothyroidism), and who also has a mental illness, I’d much rather deal with our bureaucracy than yours.

     From what I’m reading, the ACA probably isn’t the best solution to the problems the US health care system has (in the same way that band-aids aren’t really a solution for large burns). But it’s a better solution than nothing, and at least it’ll do something to reduce the worst of the problems. It’ll mean you have the chance to get better.

     [1] The ambulances here in Australia are supplied and provided by a private charity. Medicare therefore doesn’t cover ambulance travel, and a journey of approximately four city blocks by ambulance (from the shop to the RPH emergency entrance) cost me about $500. Fortunately, at that time I was on private health cover with full ancilliaries and ambulance cover as well. Well worth the $35 per week it was costing me.

295. I wish my mother were alive today to see ACA take affect. Her medical issues bankrupted my family unfortunately. It wasn’t until she was able to get Social Security Disability was she able to deal with all her medical problems. If she had better insurance (the one she was on at the time managed to boot her off), she probably would have been in better health and wouldn’t have stopped working. We lived in poverty for several years after that. Not fun being a teenager and being dirt poor.

     I have learned so much today reading everyone’s posts. Most everyone on here is well-informed individuals who have done their research. The ones that haven’t, I’m sorry that we’re raining on your parade. People are ending up on the streets because of their health and the non-ability to pay for it. People are getting sicker because they cannot afford to even walk into a clinic, much less their doctor’s office. Now, with ACA, people will be healthier. Isn’t that a win-win? In California, it’s opened with much fanfare, many are finding that their premiums are going to be much lower than they have been paying.

     Now if the idiots in Congress would quit acting like two year olds, we can get back to business. I swear, my seven year old is more mature than they are!

296. If you’re on a low income … resign yourself to waiting a lot for things like non-essential surgery

     Just like America! Minus the having to wait a lot, versus having to wait forever.

297. I’m British, but lived in the US for ten years or so – fortunately my medical care was covered by the Veterans Administration, which struck me as being very like the British NHS. However, the US spends about twice as much per head as the UK on healthcare, to cover 70% of the population, and gets about the same results – cancer survival time are longer in the US, and infant mortality rather higher. On the whole, the US is apparently slightly less healthy, but none of these differences in outcomes are significant.

     In the end, the current US system just isn’t affordable, so let’s hope that the current changes are an improvement.

     Will

298. @megpie71

     “For those who are protesting that the ACA will lead to health-care “rationing” in the USA, could I point out the following reality: you already have health-care rationing in the USA. You’re using money as a rationing mechanism. ”

     THANK YOU!

     Much of my family has been rationed out of healthcare due to being unable to afford it. Others don’t always have enough to pay for the medication that they need. I know multiple people who regularly ignore pretty serious symptoms because they can’t afford to see a doctor. And that’s just in my personal life.Thousands of people die every year in this country because they can’t get care. Compared to that, the “OMG, someone in Canada had to go on a waiting list!” really isn’t that frightening.

299. Thanks John. That’s a great piece and expresses my own thoughts far more eloquently than I could put them!
     @C W Rose: You make a great point, but I wanted to comment on the cancer survival times: Does it really make sense that a country where many people are not covered really could have a better rate than one where everyone is covered, without something else going on? Also the fact that overall life expectancy is lower in the US should suggest that there’s something wrong with that particular statistic.I’ve looked at comparing international statistics on other subjects and often found that different countries use different definitions and that can account for most of the variation. In this case, the problem is likely to be that in the US there is a lot more screening of healthy people with good insurance, which picks up asymptomatic issues that are not life threatening. I’ve seen this statistic used a lot by the right, but it’s basically misleading because the compared groups are not controlled for other factors.

300. So, my best friend had Crohn’s Disease. Well educated, hard working, uninsurable. Never a substantial period he wasn’t working,, above minimum wage. Ended up with $40,000 in hospital bills, and went through bankruptcy. Now no employer would put him on their plans, and he lost his then current job because of excessive absences due to his health. Depression. He could not afford his meds for depression. So, he bought a gun, which he could afford.. And threatened to kill himself in front of his girlfriend. She talked him out of it, he was arrested and put in jail for 20 years, where he died from lack of adequate health care.

     I care about the ACA. I don’t like it, it didn’t do enough, but it would have covered my friend, it would have stopped a tragic chain reaction that effected the lives of everyone he knew. I also take names of those who sneer at the thought that the lack of health care is always someone’s fault or a choice they made.

301. I think ACA is either going to be replaced by single payer or repealed entirely. If insurance companies and exchanges are barred from turning down new customers because of pre-existing conditions, and if the tax penelty for going without insurance is lower than the cost of premiums, then a lot of currently healthy people will have a strong incentive to choose to go without health insurance. I don’t doubt its good intentions, but I don’t think it’s a sustainable model as it currently stands.

302. This is what Boehner says about the ACA (and what he means):
     http://www.theonion.com/articles/the-republican-party-cannot-stand-by-and-let-obama,34074/

303. So, I have to admit that with all of the Jay’s blather about Canada failing in cancer care and the like, I went looking for stats to prove the opposite (as mentioned above, he reason we’re defensive about our system is that it works, we like it, and people keep LYING ABOUT IT.) I was hoping for a slam-dunk, but after a little bit of googling cancer survival rates in Canada vs the US, I found that the results were inconclusive—which I find interesting, since the United States spends almost twice as much per head on healthcare than Canada does. In fact, even with private health insurance, per capita government spending on healthcare is higher in the US than in Canada. For results that are roughly the same. That doesn’t sound like a triumph of the market—in fact for a theoretical “free-er” market system to do a better job than single-payer health insurance, you would have to demonstrate savings of over 50% compared to current US spending.

304. @Andrew Hackard “Canada is slightly larger, but the population is FAR less spread out — the majority of Canadians live fairly close to the U.S. border, and large areas of the country are effectively unsettled land.”

     Um, look again at that map you linked to. Se all those red dots in the top 90% of the country? That represents a small population spread out over a very large area. The area near the US border has a population density comparable to the US, but as you go north the density drops dramatically. The fact is that Canada’s population is more spread out than that of the US, and that presents a challenge for providing adequate healthcare.

305. Lurkertype. You simply underestimate the healing and recuperative powers of maple syrup. Especially the awesome stuff mined in Quebec. I mean, it’s unbelievable. I’m sure a lot of us Canadians are already dead but haven’t realized it courtesy of the bliss imparted onto our bodies courtesy of our maple syrup. Damn, now I’m hankering for maple syrup.

     As for the boneheaded comment re: people in Canada dying waiting for cancer treatment I have never met someone who had such an experience. One of the top cancer hospitals in the world is Princess Margaret in Toronto. Here in Ottawa, the Ottawa Hospital specializes in stem cell-related cancer and cardiac therapies — I’ve had friends go through these new treatments with great success. My dad had cancer and was treated, had his surgery, etc. all within the span of a few weeks followed by years of additional screening to ensure it didn’t recur. It hasn’t. My wife has had skin cancer and thyroid cancer. She had both taken care of quickly — well, immediately — and has been undergoing constant supplementary cancer screenings every 6 months for years (it was every 6 weeks after her thyroid cancer surgery, but due to no evidence of new cancer it’s now every 6 months). Another friend of ours who had the horrible luck of getting ovarian cancer was treated for years undergoing countless new and even experimental treatments only to ultimately succumb to the disease after 15 years.

     The implied notion that for every successful case a half dozen perish waiting for cancer therapy or surgery is an outright lie. If it were true, based on the number of friends and family who have had cancer, a vast number of them would have died before being treated yet NOT ONE died waiting for treatment. All who have since passed on passed on years and years after undergoing necessary surgeries, therapies and experimental drugs. It’s highly insulting to claim otherwise.

     As for “death panels” the only death panels I’m aware of are in the US where insurance firms and idiots in Washington decide who deserves medical coverage and who doesn’t. Up here, your doctor decides. Case in point, I had a visit with my doctor and he’s ordered more tests to follow-up on the 4 major scans (2 CT, 1 MRI, 1 US) I’ve had since May. Gee. How can that be. According to the expert talking heads in the US I’d have to wait months, years to get all the scans I’ve had.

     Finally, if I was in the US I wouldn’t easily be able to change jobs, let alone start the various companies I have. I would never get coverage now for “pre-existing conditions” — code for “death panels have decided you’re too risky, and we prefer low risk, money making clients, thank you very much.” Same with my wife, who has started a couple of companies. Or countless others I know who’ve done the same. Each knew they could go off and start a company and any health issues that may arise are covered. That stressor is simply non-existant. You don’t have to worry that “If I start a company my family won’t be covered.” Simply doesn’t happen.

     In my view, and that of many studies that have been recently published, universal healthcare is actually a profound way of encouraging entrepreneurship since it removes one of the largest stumbling blocks for people to start a firm. But God forbid the GOP do anything for the economy, they’re too busy lining the pockets of sponsors and the rich to give a crap about the economy.

306. Note that in my long missive above, only the first paragraph is for Lurkertype. The rest is commentary on statements made by others. I just want to ensure Lurkertype doesn’t feel I put words into his/her mouth. Apologies if it read that way (there’s no edit option that I can see).

307. I think a point that many people miss is that the opposition to the ACA/obamacare isn’t about the weaknesses of the ACA (and there are plenty); or the strengths of a single payer (or free market or some other alternate health care strategy) this is politics. This is Kabuki theatre. Sure a single payer system would be better (and destroy a multi billion dollar insurance industry and drastically reduce the profits of big pharma and the corporations that run hospitals etc.) The current republican talking point is that the Dem’s are refusing to come to the table and compromise- the ACA IS a compromise, the insurance companies and other corporations will still make (most) of their billion$ but not as much and not as easily. And businesses (employers) got an extra year to figure out how to comply. It is bullshit that “it’s not fair” that businesses get that year to comply but individuals don’t – that year for businesses WAS a compromise and the republicans aren’t holding up their end. This fight is no longer (if it ever was) about healthcare costs, quality of healthcare, burdens on employers or anything else but attempting to deny a victory to the other side. To the teabaggers politics is war, casualties are expected, and the public are (expendable) pawns to further the Koch Bros’ agenda. Gerrymandering has made them (the republicans in the House) all but invincible in the coming 2014 elections. I don’t know how – but fuck them, they need to GO. Subverting the public good, costing hundreds of million$ a DAY, jeopardizing the economic stability of the USA (and maybe the WORLD) is treasonous and fucking EVIL – they need to GO!

308. Jay’s problem is that he’s actually making two arguments:

     1) As a matter of principle, health care/insurance should be left to the free market.
     2) Health care/insurance works best when it is left to the free market.

     …..but is conflating the two, which is leading to some bizarre arguments and goalpost-shifting, because they really are not automatically compatible. “Even if it does not result in the most people receiving health care, it is wrong to force people to socialize health care” – certainly one can disagree with that argument, but it is based on the idea that a morally sound system is inherently better than an immoral one. (This isn’t all that bizarre even if you disagree with it. Certainly, if it were proven beyond a shadow of a doubt that all humans could have free health care if only we tortured one out of ten children through their entire lives, a la Omelas, there’s a VERY good argument that we would nonetheless reject such a system.)

     But Jay is not willing to state that #1 is true even if #2 is false, and is jumping from example to example – quickly discarding them when it is shown that they don’t quite support his premise and jumping to the next. That’s why the arguments are a little weird.

     Jay, if you’re still around, I would offer some advice from a very wise and experienced trial lawyer I know: “Never let anyone out-truth you.” Maybe the other side is more numerous, or has better resources, or is sleazy, or whatever, but you have to be unimpeachable, or the first time you get caught out, nobody will trust you. You can’t simply parrot talking points from Reason columnists. You can’t cite to a court case and hope nobody else will read it, thus noticing it doesn’t say what you claim. You can’t argue from anecdote or generalization and expect that people will discard their own anecdotes or generalizations in favor of yours. (I mean, you can. You just won’t get anywhere.)

309. That final sentiment of the piece is one reason why I’ve become a serious liberal curmudgeon in many ways. I could’ve died during a time in my life when I had no healthcare because I had serious health problems and no means of dealing with them. Instead, I took on a mountain of debt that followed me for the better part of a decade. The Calvanistic thing that I had done to deserve my bad breaks at health? Being born, mostly, because the stuff that keeps whacking me upside the bad-health tree are all mostly congenital conditions that mostly manifest later in life. When people I know have opposed Health Care Reform and said so to me, I’ve tried to gently remind them that in doing so they’re basically wishing me dead. None have ever taken well to my pointing that out…

310. @Gene: “I’m sure a lot of us Canadians are already dead but haven’t realized it courtesy of the bliss imparted onto our bodies courtesy of our maple syrup.”

     Syrup zombies? (Looks through Rolodex for Roger Corman’s number…)

     Gene, I applaud your valiant efforts to defend the Canadian healthcare system, but we Americans prefer to get our information from people who don’t know their tush from a hot rock. It’s just the way we roll.

311. Nicole:

     I don’t think any rhetorical advantage is gained by borrowing the terminology of Islamophobic bigots to create an extra special insult for them, though.

     I see your point. I was trying to force a direct comparison between them and something they (at least profess to) hate. I also call the Christian Dominionists “American Taliban.”

     But the true jihad, I’m told, is the struggle within a person to be the best person they can be. So maybe I shouldn’t use the term in that way. Just as in the West the word ‘crusader’ doesn’t mean “someone who comes and slaughters women and children and burns our towns” (pretty much its reputation in the Islamic world), the word ‘jihadi’ doesn’t mean “terrorist” in the Islamic world. It’s like the word ‘family’, which isn’t a bad word, but which in the name of an organization almost always means it’s a sexist homophobic hate group.*

     I need to think about this some more.

     Lurkertype:

     Good Lord, I didn’t realize your name was based on reality.

     Yeah, it was my way of middle-fingering at the loss.

     Just think, if you’d been Canadian, you’d have no neato screen name. Ha.

     Hmm, would I take that tradeoff? Sacrificing my neato screen name for a whole tongue?

     In a New York minute.

     Greg:

     You’re channeling laissez-faire fairy tales there I think.

     Awww, why didn’t you call them laissez-fairey tales?!?!? I’m going to use that from now on, inspired by you, even though you didn’t actually say it.

     Jay Reding (October 2, 2013 at 6:08 pm): Wait, you’re citing FREEP as if it were a serious source?!?! You do know that ‘freeper’ is a shorthand for “troll who parrots right-wing babble as if it were fact,” right?

     They’re not above outright making shit up. I won’t quote the Daily Worker if you won’t quote freep, and if I do you should laugh at me, as I am now laughing at you.

     I haven’t decided yet whether you are personally a liar, or if you’ve just been in the Fox News bubble or equivalent and have just believed the lies you’ve heard there.

     Also, mythago is speaking wisdom to you. Listen to the mythago.

     Eric:

     Oh, and given that Canada is slightly larger than the US, I find it hard to believe that the US is “much more geographically spread out”.

     Canada has a much, much smaller population than the US, but 90% of them live within 100 miles of the US border.

     *Examples include the Family Research Council and many others. The only exception I can think of is the Working Families Party, whose name antedates that particular dogwhistle.

312. “Tea Party Terrorists”

     It’s nice to see the mindless, unAmerican, thuggish bullying Fascism of the left has asserted itself.

313. Oh, Scorpy, you are so adorable when you gnash your little teeth! That read like a laundry list of the John Birch Society’s usual complaints.

     Go to a gay bar and meet some nice men. It shouldn’t be too hard to cure you of your conservatism and inane silliness.

314. Also:

     http://www.washingtonpost.com/blogs/wonkblog/wp/2013/10/02/grover-norquist-ted-cruz-pushed-house-republicans-into-traffic-and-wandered-away/?hpid=z1

     ZOMG THE WORLD IS ENDING!!!!! The Norquist is calling his thralls insane!

315. @Floored,

     At least he didn’t take America Hostage in a temper-tantrum and then go play golf at Andrews Air Force base while closing that same base’s grocery stores like Obama did.

316. I pay for an annual travel insurance policy – it covers various things, e.g. it will repay any travel booking I cancel if I have a good reason to do so (long list in the policy).

     The policy also covers healthcare if I get sick while outside the UK (the only “pre-existing conditions” exclusion is that I can’t claim if I travel abroad in order to get treatment).

     There are three price levels for this policy, one for Europe, because I’m entitled to an EHIC which gets me government-issue health care everywhere within the EU, and the policy only covers the difference (also because a cancelled flight to Europe is likely to be cheaper). The second price level is a world policy, which covers everywhere in the world except for a list of countries that there are sanctions against (e.g. North Korea, Iran) and the USA.
     The third price level is coverage for the USA. The entire difference is that the cost of healthcare in the USA is much higher than private healthcare elsewhere in the world. Travel insurance for a holiday in Japan is less than half the cost of going to the USA – and that’s entirely healthcare; an emergency flight home from Japan will cost a lot more than one from the USA.

     This isn’t government-run healthcare. I don’t have access on holiday to Japan’s government insurance scheme.

     This is just the fact that private healthcare in the USA is much more expensive than anywhere else in the world. Every MRI, every night in hospital, every operation is charged at a vastly higher cost than the same care in another country.

317. And are you comfortable with Obama hiring guards in a shutdown to specifically close down the WWII memorial (which is always open, guards or no) in a temper tantrum just because the Peoples’ representatives are enforcing the peoples’ will and not funding the crappy ACA?

318. Someday Scorpius will encounter a bit of reality. I’d worry that the shock would do him grave harm, but it seems likely that he’d dismiss it.

319. Xopher, the Free Republic is a most odious site, but http://www.freep.com is the Detroit Free Press. A different thing entirely.

320. A factual clarification. Jay said that the NHS in the UK works on a principle of “reduced access”. I don’t know where he gets that notion. Here in the UK the NHS is free and available to all, at the point of demand. You roll up to the doctor or the hospital and you get treated; and in my experience, well treated.

321. Oh, come on. The fucking Mall is shut down, including the Washington Monument, the Lincoln Memorial, and both the Vietnam and Korean War Memorials. The Air and Space Museum (with all the historic warplanes, including the Enola Gay). Rock Creek Park (the largest urban National park) is shut down. The National Gallery, The Museum of Natural History, the Museum of American History, the National Portrait Gallery, the Museum of American Art, The Museum of the American Indian, the Renwick Museum of American Crafts, the Hirschhorn Gallery, The National Zoo, the National Arboretum, the National Botanical Garden — all shut. Guards are there too; they’re among the Federal employees who haven’t been furloughed.

     Who’s throwing a temper tantrum?

     You forgot Benghazi!!11ELEVEN!!OMFG!!!

322. @Theophylact,

     And most of those operate without guards. Most of those are open-air parks which anyone can wander onto at any time. Obama specifically closed them down needlessly to make a point in a tantrum-throwing way.

     He’s simply taking us hostage to shove his crappy ACA down our throats even though we (the American people) have said repeatedly that we don’t want it.

323. scorpius, there’s a difference between you and Jay Reding. He’s a Libertarian, and his ideology however unrealistic it may be, has a certain consistency to it. It leads him (as another has pointed out) to prefer ideological purity over practical consequences, and makes him tend to disbelieve in the factuality of those consequences.

     You, on the other hand, are a moonbat, and if you object to something it’s mainly because Obama is for it.

324. So I mentioned the size of Canada in the context of an argument that Canadian-style health care wouldn’t work in the States because the US is more geographically spread out.

     This was apparently a poor decision on my part as people now seem to be taking issue with my use of area as a substitute for geographically-spread-outedness.

     Rather than debate the appropriate measure of geographicspreadness, I’ll get back to the main point: geographic separation per se is of little consequence in the context of health care delivery. If we look at urban centres, since each city can typically support the full complement of hospitals, clinics, primary care givers, etc, it doesn’t really matter how far apart they are.

     Rural, sparsely populated areas are a challenge; this is true regardless of how large a country is. Yet given that Canada has, as has been pointed out, a larger area than the US and a much smaller population (which is concentrated in the southern part), it follows that Canada has a much larger area of sparse population. But somehow Canada (along with Norway, Sweden, Finland, and Australia) is dealing with that challenge without bringing down the whole system or bankrupting the government.

     Ultimately what I was arguing against was this idea that, “that works in multiple other places, but it would never work here because America is Special”. It’s an argument I’m a little sick of hearing.

325. Damn it, Theo, beat me to the punch again!

326. @Theophylact,

     Thank you for proving my point about “bullying” leftists by offering a fact-free, but insult-heavy response.

     You have anything but your crazed moonbat ideology to offer in response to my facts?

327. @scorpius, Obama ran on health care in 2008, and won. The Democrats as a whole made it a large part of their platform and won majorities in the house and senate. The ACA was voted on in congress, passed, signed, and upheld by the Supreme Court. Obama won again in 2012, when the American people knew that the law was due to come into force and a Republican administration was likely to repeal it. So please stop saying the American people don’t want the ACA. They voted for it. Twice.

     @floored, theophylact, “go to a gay bar, you moonbat”? Seriously?

328. My mother was uninsured for 10 years. And then we started paying her insurance, but then she would barely use her insurance because it went up every time she used it. And she would have been sunk by her medical bills as is if we hadn’t been paying for her insurance to the tune of $200-300k.

     She just got onto Medicare last year. She’s finally let me drag her to the all the doctors she should have seen, kicking and screaming. She’s finally almost caught up on two decades of medical neglect. And her health is poorer now than it need be because she didn’t receive medical care sooner for fear of medical debt and/or bankruptcy.

     The ACA is step in the right direction, and everyone going forward should be thankful. The past was a nightmare.

329. scorpius: Obama specifically closed them down needlessly to make a point in a tantrum-throwing way. He’s simply taking us hostage

     Dude, it’s your life and I’m not going to tell you how to live it. But I just want to point out that the thing you’re barking at is a mirror .

     It’s funny/entertaining when its done for a laugh. But when its done seriously, like you’re doing there, it’s kind of sad.

330. @acorpius
     “we (the American people) have said repeatedly that we don’t want it.”

     Who is this “we” you are talking about? I’m a tax-paying US citizen. I think the ACA is imperfect, but desirable over the past.

     Don’t you dare try to speak for me.

331. @Scorpius:

     And are you comfortable with Obama hiring guards in a shutdown to specifically close down the WWII memorial (which is always open, guards or no) in a temper tantrum just because the Peoples’ representatives are enforcing the peoples’ will and not funding the crappy ACA?

     If any of that was true, (and it’s not), thank God Texas Rep. Randy Neugebauer (R-TX) has the time to verbally abuse a park ranger for the entirely predictable consequences of what he voted her, instead of passing a budget. Yeah, it’s Obama having the tantrum…

332. Scorpius, et al:

     Lower the temperature, please.

333. @ aetherize: Just trying to mock the homophobic love for “gay conversion therapy” abuse.

     @ cranapia: Damn, but I love your posts. Do you write professionally?

334. @ Our Lord Host, may His name be praisèd:

     Aargh, sorry, sir, crosspost. Dunking my head in some ice water.

335. Honestly, I don’t think that article on the Freep indicates what Jay thinks it does. Let’s look at some choice quotes, shall we?

     “I go to the hospital in Windsor and two hours later, I’m done having angioplasty in Detroit,” he said. His $38,000 bill was covered by the Ontario health ministry.”

     “He said doctors told him money was limited for transplants, particularly ones using unmatched donors, which are riskier.

     After his family’s doctor wrote the Ontario ministry, the agency agreed to pay $200,000 for the operation.

     “They include Canadians such as Mercado, whose care is reimbursed by Canada’s health system, as well as people who pay out of pocket to avoid waiting in Canada.”

     Multiple times in the article, it’s made clear: Canadian patients are sent to the US and Canada’s system pays for the services. They are sent to Detroit because that city has capacity (what with half the city being abandoned and all that) and is willing to take money for the services. At one point it’s specifically mentioned that some people pay out of their own pocket to get services quicker…but those services were things like stomach-stapling.

     If anything, this article seems to highlight that the Canadian system will go further than the US system and still not bankrupt the patients.

336. @Floored by Scalzi’s awesomeness: Aw… too kind. I do, but not as often as I’d like – the perils of freelancing! You may have noticed I also help keep food on the tables of proofreaders and sub-editors, though not as many as I’d like. :)

     But seriously, I’m wondering how President Obama has the time to commit all the acts of unhinged malevolence the usual suspects attribute to him every hour of every day. I guess quitting smoking freed up a lot of time. Or something.

     But back on-topic (or at least topic-adjacent) before our host decides to use my skull as a mallet cradle. :)

     I’m sorry but I just don’t get it — and on the political spectrum down here in New Zealand, I’m firmly on the right. I’ve not followed the ACA that closely, but closely enough to know it’s very far from flawless. (What human work, including legislation, ever is?) Nor would I insult anyone’s intelligence by pretending the public health system in New Zealand – or anywhere else – is perfect. But it strikes me as a no-brainer that millions of people without access to basic health care isn’t only morally wrong, it’s an entirely avoidable drain on the nation’s economic and social wellbeing. You don’t have to be a raging Marxist to think that should be slightly more important than the profits of insurance companies and Big Pharma.

     Oh, yeah… and down here in New Zealand if you can’t defeat a bill in Parliament (or get it overturned by the judiciary) you amend or repeal it when your team is in a position to do so. What the Opposition can’t do is either shut down the public sector, or threaten to make this nation welch on its debts, out of pique. That’s silly, as well as profoundly irresponsible.

337. @ cranapia:

     Oh, yeah… and down here in New Zealand if you can’t defeat a bill in Parliament (or get it overturned by the judiciary) you amend or repeal it when your team is in a position to do so. What the Opposition can’t do is either shut down the public sector, or threaten to make this nation welch on its debts, out of pique. That’s silly, as well as profoundly irresponsible.

     Wooowwwwww…..what’s it like to have a functioning government?

338. I had health insurance under my ex’s policy, and it was a good thing as I ended up hospitalized for a time. Then he lost his job and the insurance went with it, and I lost the ability to cover my heart medication, my asthma inhaler, and the hormones that were keeping me from bleeding all the time. I spread out what I had left and lucked out on the latter that the problem is no longer a problem once I ran out of medication. The only time since then that we’ve had to opportunity for insurance it was too expensive to use. Hub’s current job only offers insurance to salaried managers, so I’ve had dangerously high, uncontrolled blood pressure for 2 or 3 years now and no emergency inhaler for at least as long. I’ve had to use tax returns to cover glasses for 4 people (nearly $2k because my eyes are so bad, and not going to get any better) and a root canal (and another one is needed and isn’t getting done any time soon), and next year’s return will probably go to more of the same. Maybe. Paying off the car as quickly as possible so we’re not robbing Peter to pay Paul may end up being more important. With the ACA, we qualify for Medicaid, which means at the very least, I can get my basic medications. I’m sure my husband has things to be looked at too since he’s not seen a doctor in 15 years (and has been damn lucky that anything he’s needed has been covered under workman’s comp).

     I have an autistic son who needs me to be around for as long as possible, but the Tea Party in particular seems determined to make sure that doesn’t happen. I guess they’d rather have to pay for him to be institutionalized than for me to be healthy enough to keep him home at a far cheaper cost.

     And seriously, if all their cries about how much the ACA would cost were REALLY a problem, a government shutdown that’s costing $300 million per DAY hardly seems to support their “but it’s too much money!” whine.

339. @DenyseLoeb My friend just did this for his root canal: some/many dental schools do free dental work. It’s a long wait, and the dentist is a supervised student, and procedures can take 2x as long. But it’s good and it’s free/low cost.

340. The current republican talking point is that the Dem’s are refusing to come to the table and compromise- the ACA IS a compromise

     As is the amount of the budget in the CR, which continues at the current paltry levels of the sequester.

     By agreeing to pass the “clean CR,” the Democrats in Congress are agreeing to (at least for the moment) the Republicans’ spending demands.

341. Thank you! This is one of the most reasonable and well-written descriptions of why the ACA is extremely important I’ve read so far. I have a pre-existing condition. One that costs quite a bit to manage. I have been very aware that I’m highly fortunate thus far. I worked for a health insurance company for a while and learned a lot about the industry, which helped me navigate it and also gave me a good idea of how fortunate I’ve been.

     I bring in a very good salary, well above the median, and I get excellent health care that’s mostly paid for by work. But I’ve seen how quickly things can change, too. I had a great job where the company went suddenly downhill (turns out the execs were hiding lots of stuff) and we were almost all laid off without warning. It took 6 months to find another job, during which I had to find a way to pay for COBRA. We’d saved up 6 months worth of expenses, like you’re supposed to, but It nearly wiped us out. To not have health insurance would have been far worse. It was worrying to see just how quickly things could change. The individual health care market wasn’t really an option for me, either. I can hardly imagine how people less fortunate than me are managing (and many aren’t).

     The ACA is changing the game for everyone, and it’s making care more accessible and affordable. It’s definitely not perfect, but the alternative is so much worse.

342. @Gene, no worries, I got that. I’ll think of you and your zombie Canadian pals this weekend when I pour some of Quebec’s finest on my pancakes. Stay strong, Commie slave homies.

     @Foreigners: you should probably stop talking about your awesome health care. It sets off the wingnuts, and makes the rest of us jealous that you don’t have to choose between food and medicine.

343. @ Foreigners:

     Please keep talking about your awesome health care. It gives me ideas for how to fix this hell-hole when I’m old enough to vote and run for office.

344. @Gregory: In this case, it’s really important to mentally Auto-Correct “compromise” to “abject and degrading submission seldom seen outside BDSM porn” every damn time. I would be impressed by the sheer chutzpah of Boehner etc. saying the other c-word with straight faces, if only this wasn’t so far beyond a joke.

345. Where to begin…

     First, thank you for addressing this issue, Mr. Scalzi. As is often the case, I greatly enjoy your commentary and also appreciate the venue for discussion.

     The free-market health care system in our country is disastrous. The United States pays more in taxes per capita for health care than the U.K., Canada, Australia, New Zealand, etc. and for that money, we receive less care. Individually, despite paying our taxes, most of us receive nothing.

     Health care, like so many other aspects of life in the United States in the last couple of decades, has been twisted into a for-profit commodity. It’s main purpose now is to make money, not to save lives.

     While the ACA isn’t perfect, it is a desperately needed first step towards health care reform. Since the passage of the ACA, President Obama has repeatedly offered to meet with the Republican opposition to continue the process of reform and has always been rebuffed. The conservatives have instead chosen to waste incredible amounts of time and energy on repealing the law, which is a tactic that has failed over forty times. They initiated a Constitutional challenge to the ACA, which they also lost. Now they’ve degenerated into this farcical but all too harmfully real shutdown stance.

     Perhaps if we had all insisted that our representatives act like legislators instead of ideologically-obsessed children, we’d have been able to refine the ACA by now. Nonetheless, the imperfections in the ACA are reasons to put further work into reform, not to scrap it entirely. I can’t help but think and feel that those who are so hell-bent on repeal or nothing aren’t remotely concerned with the well-being of anyone but themselves.

     On a much more personal note, I am 100% in favor of health care reform, and by extension, the ACA. I myself have not had health care insurance for almost five years now, despite working a full time job during this period. While I will appreciate being able to obtain health care for myself (and preventative, not just palliative… what a concept!), a stronger motivation to support the ACA is so that other families won’t suffered needless and tragic loss as mine did.

     My mother died from a massive, sudden heart attack recently. She worked full time as a skilled paralegal, paid her taxes, and owned her own home. But her employer, the all-mighty small business owner/attorney, valued buying beachfront property and weekly shopping trips to Macy’s more than her sole employee’s welfare, claiming an inability to afford health insurance.

     My mom knew she had heart problems. She regularly went to a nurse practitioner to monitor and control her blood pressure and cholesterol. The nurse practitioner was compassionate and caring, doing what she could to make the medication and certain tests affordable. They both would have loved for my mother to have more complicated tests and more involved care, but there was simply no money for it. As mom was employed, she couldn’t qualify for Medicaid. She had no insurance through her employer, and will pre-existing conditions, any insurance company that might consider insuring her would have charged sky-high premiums rivaling her mortgage payments.

     No one should EVER have to make the decision between being able to pay for food, insurance, and shelter or being able to obtain the health care needed to live. That we have the ability to better the health of so much of our population and yet it’s unobtainable for many of them should be something about which we are deeply ashamed.

     (https://www.youtube.com/watch?v=qSjGouBmo0M is the video link with the statistic I quoted in the beginning. It’s interesting viewing.)

346. @Bob. I’m utterly confused. I thought all the individuals in DC who are ass-finding-impaired are out of work at the moment. Or have I been watching the wrong news? :-)

     @Lurkertype. So glad you read it properly. Enjoy the pancakes. Now I’m hungry again. Dammit. Good thing they pay us in syrup …

     Note to all: We foreigners will not give up our right to blather on aimlessly and pronounce truths that, when converted from metric to imperial measurements for US consumption, become half-truths … or sometimes outright lies. Mileage may vary. Check instructions prior to use. Yada yada yada.

     BTW, for those out there who are having difficulty swallowing that our system mostly works I will remind you that our Canadian flag is half white and half red and when you mix them you get pink. It’s a big secret up here, but I just had to let you guys in on it because some other thoughtless folks have gone and destroyed so many of anti-Canadian tirades in this thread that I just wanted to provide those requiring fresh ammo with something that is simply impossible to deny. If you doubt me I hear certain members of Congress have crayons at the ready to verify my claims since they aren’t using them to write with at the moment.

347. I am absolutely for the provisions of ACA that remove pre-existing conditions (hey, I am insurable again), cover children to 26 and remove lifetime limits. However, since the exchange policies do not begin until 1/1/2014, I am unsure exactly how anyone knows these policies will be “affordable.” Even the insurance people are not sure yet what the rates will do. If you look at all the people who are “exempt” from the provisions of ACA, you will see that they are most of the people who do not have and can not get insurance now. How will this help them? Finally, if the government is counting on the individual mandate to fund these “affordable” policies, there is a major problem. There is absolutely NO WAY the government can collect those imposed taxes/penalties unless they are paid voluntarily.

348. However, since the exchange policies do not begin until 1/1/2014, I am unsure exactly how anyone knows these policies will be “affordable.”

     You do know that it’s possible to check the prices now, right? At your state web site if available, at the healthcare.gov site if not (subject to technical disruptions).

     There is absolutely NO WAY the government can collect those imposed taxes/penalties unless they are paid voluntarily.

     The IRS says hello.

349. @Gene:

     I’m utterly confused. I thought all the individuals in DC who are ass-finding-impaired are out of work at the moment. Or have I been watching the wrong news?

     No, Congress is in session. It’s those of who can find our asses without a pair of full-length mirrors who are out of work.

350. Thank you, John!

     I’m a freelance illustrator who struggles to find insurance, and for me the ACA is a godsend. I currently get health insurance by delaying my master’s thesis defense and using the student health plan at my alma mater — which requires me to pay both tuition and insurance premiums. But with my health history, it’s the only insurance I can get.

     It also means that health insurance is the largest single expense in my budget. I currently pay more for health insurance than I pay for my car (including insurance and gas) and my lodging combined.

     If everything else stays the same, the ACA will allow me to do all kinds of crazy things, like finish my degree, pay for an apartment with its own bathroom, and set some money aside for retirement and future emergencies.

     So I take the GOP’s current behavior very personally. It’s like they’re deliberately trying to hurt me, and no matter what they do in the future, their actions today will always affect my opinion.

351. A couple of decades ago, DH needed emergency surgery. At the time, Aetna was the insurance provider of choice, however after a somewhat risky brain/aneurysm thing, they dropped DH like a hot rock. Until I was able to add DH to my own insurance, we had to hope for nothing catastrophic to hit our household. Since then, we have had 3 bouts of necessary and unrelated hospital visits, which would have cost us 5 digits each were it not for insurance. Couple that with various prescriptions, and medical insurance becomes a functional necessity. If any of that had hit while we were uninsured, we would be living in a cardboard box right now. How can anyone think that needing urgent medical care and being unable to get it without mortgaging your soul is a good thing?

352. @DenyseLoeb

     You can get glasses online for really cheap – as in as low as $8/pair last I looked (plus shipping). That’s everything – frames and lenses. The titanium frames I got a year back were $80 total, but that included air overnight shipping, as I needed them fast. Unless you have a really oddball prescription, it’s definitely the way to go.

     A decent place to start is glassyeyes.com – there’s a lot of ranting about Lenscrafters, but also good info, reviews, and discounts at several different vendors. I’ve had good luck with eyebuydirect and 39dollarglasses personally.

353. Just trying to mock the homophobic love for “gay conversion therapy” abuse.

     Do you understand *why* your remark was offensive, Floored? You found Scorpius’s remarks odious, and then you implied rather strongly that he was a closet homosexual. The logic is thus “Person thinks bad things/is a ad person –>must be gay –> because gayness is a bad thing too/makes you a bad person”.

     It’s exactly the same logic that leads to “gay” being used as a synonym for “bad”, “crappy”, “substandard”.

     It’s really, really not on. And in no way is it a proper responses or mockery of the “gay conversion therapy” abuse. (I think you mean ‘aversion therapy’, but the point is the same.)

     Mock Scorpius for the risibility of his stance, because it is truly risible. Mocking someone for what you think their sexuality is or is not, is revolting.

354. It’s a shame that the President and Harry Reid are putting children with cancer at risk by refusing to pass a CR specifically for the NIH and by refusing to negotiate on the ACA. The House has already passed legislation to repeal this horrible law over 40 times, it’s time for the Senate and President to recognize the will of the people and make the compromises to end the shutdown and raise the debt limit.

355. Steve C.:

     Xopher, the Free Republic is a most odious site, but http://www.freep.com is the Detroit Free Press. A different thing entirely.

     Whoops. Dammit. Mea culpa, Jay Reding.

356. The House has already passed legislation to repeal this horrible law over 40 times, it’s time for the Senate and President to recognize the will of the people and make the compromises to end the shutdown and raise the debt limit.

     The correct way to deal with a temper tantrum is to walk away and ignore it until the person calms down. Not give in.

     Obama was re-elected twice on a platform which contained the ACA. Mitt Romney was defeated on a platform planning to abolish it. The Supreme court has stated the act is constitutional.

     The people have spoken. 30 or 40 teabaggers in the House trying to push their will onto the nation deserved to be ignored.

357. Ann, do you think Bruce was satirizing the idiots, or…do we have a Poe’s Law problem here?

     If the latter…Bruce, if the House decides to disregard the will of the people, their disregard becomes the will of the people? That’s perfectly idiotic. I do hope you were being sarcastic.

358. do you think Bruce was satirizing the idiots, or…do we have a Poe’s Law problem here?

     I’ve seen similar statements made in all seriousness by rightwingers from your country so many times in the last few days, I’m afraid he’s speaking from the heart.

     Or whatever wizened, dysfunctional organ substitutes for one in people who think that letting the poor die because of lack of healthcare is a just and proper thing to happen in the world’s wealthiest democracy.

359. Theophylact: Ah. I know much of the government was shut down but I thought the congress critters would have had the decency to go without, too. Probably too much to ask.

     Man, I (and many folks I know) just don’t get what’s going on down there. What’s up with that one oddball that somehow got all those Republicans to sign a document that he claims is somehow more binding than the constitution?

     I feel for the normal Americans who just want to get on with their lives, have decent medical coverage, and work. You know, that Life, Liberty and the Pursuit of Happiness thing that seems to have suddenly gotten lost in the noise from the Tea Baggers. I guess the “Life” part is immaterial since it was stated by some old farts 200+ years ago. It’s probably immaterial now.

     Here’s a choice quote for those who figure this is just some new desire and not a platform from one of the US’s most famous and loved Presidents.

     “The supreme duty of the Nation is the conservation of human resources through an enlightened measure of social and industrial justice. We pledge ourselves to work unceasingly in State and Nation for … the protection of home life against the hazards of sickness, irregular employment and old age through the adoption of a system of social insurance adapted to American use.” — Teddy Roosevelt.

     Obviously just a damn communist.

360. Well, Fox pundits have no problem denouncing the President for “hurting the kids” by cancelling White House tours, then turning around and saying that cancelling WIC/SNAP payments doesn’t matter, because kids going hungry just isn’t important.

     See, it’s a class thing. Poor kids starving isn’t as important as upper-middle-class kids being deprived of a treat, because to them only people of their own class are really people.

     I hate them with a deep, burning hatred.

     I’m guessing that if Bruce was serious he’s also a driveby. If not…we throw down, within the rules of conduct Scalzi has laid down.

361. Bruce’s comment so nonplussed me that I reread it at least 4x, and still couldn’t comprehend that it might not be satire or irony, but serious. The president et.al. should toss the ACA ‘for the sake of the children’. I haz a cognitive dissonance.

362. I thought the congress critters would have had the decency to go without, too

     You’re talking about the kind of people who, while refusing to do their job while being paid handsomely, are happy to scream abuse at a man not being paid for doing *his* job, over the fact that the first group of people have created a situation where the second man is not getting paid while working, and therefore services which depend on people who aren’t being paid, are being limited:

     http://www.rawstory.com/rs/2013/10/03/republican-who-voted-to-shut-down-government-asks-park-ranger-why-part-of-government-shut-down/

     They have no shame or decency whatsoever.

363. @Bruce:

     It’s a shame that the President [… is] putting children with cancer at risk by refusing to pass a CR specifically

     OK, let’s take a pause. You are aware the President can’t “refuse” to pass anything in either House of Congress, because he doesn’t actually get to vote? I’m not even an American citizen, and I appear to have a firmer grasp on the constitutional separation of powers (or more scruples about pulling blatant lies out of my arse) than a good chunk of America’s political class.

     And, seriously, it’s time for the American right to grow up. I’m a small c-conservative, and it’s frankly embarrasing watching the Republican Party behave like a pack of delinquent toddlers on a crying jag because it’s just mean they can’t have candy for every meal, stay up all night and have ALL THE TOYS.

     I’m really sorry you guys couldn’t get the numbers to defeat the Affordable Care Act. I’m sorry the Supreme Court (which we all know is little better than a branch of the Communist Party) didn’t agree that the ACA is unconstitutional. In general, I’m sure it really sucks that Barack Obama won not one, but two, free, fair and credible elections.

     But the awful reality is that the Republican caucus in Congress is causing real and lasting harm to people, and are threatening to escalate this into the United States defaulting on its obligations for the first time in its history with potentially cataclysmic consequences not only for the US but the whole global economy.

     Enough.

364. Well said, sir. My husband had a kidney transplant ten years ago. He’s required to have doctor visits and blood tests on a consistent basis to make sure his meds are at the right levels and so they can monitor side-effects from his meds among other things.

     His new job considers his condition ‘pre-existing’ and won’t cover any kidney-related visits. Because he has a job, medicare no longer covers him.

     The ACA makes sure his insurance will cover him completely. I may have issues with the ACA, and I may have issues with how it was put into law, but now my husband can get the care he needs to make sure he stays healthy, and for that I am grateful.

     The fact that the legislators are throwing a fit and basically saying they don’t care about my kids having a healthy dad, really pisses me off. I will remember this when I vote.

365. @ Ann Somerville:

     You found Scorpius’s remarks odious, and then you implied rather strongly that he was a closet homosexual.

     I apologize–that was not my intention at all. I have seen him make homophobic remarks in the past, and so I decided to say something that would offend his tiny mind. I was anticipating some homophobic vitriol in return, to which I would have responded with a tongue-in-cheek attempt at chatting him up.

     Essentially, I was trying to expand his mind by showing him what it is like to be one of the people he hates. I was also trying to satirize some aspects of conservative social thought. Obviously, I failed. I apologize. Next time, I will try a different tactic.

     @ Xopher:

     I hate them with a deep, burning hatred.

     I hate them, too. I have daydreams of seeing Rush Limbaugh ridden out on a rail and dumped into a river. To blatantly steal a quote from Judge Sn, I hate the entirety of Faux Lies with a passion that smolders like a trash fire on top of a vein of pure anthracite coal.

     Maybe we should just take a leaf from Sergeant Scholck’s book and end Fox News in any way we can. And CNN, because they suck and they are craven bastards. And MSNBC, because echo chambers are bad for your brain, whether they are for or against you.

366. The current bugaboo has very little to do with the ACA. The Republicans care about the ACA in the same way that they care about the deficit — as a tool for leveraging increased diversions of money to business, including the businesses of which the Congressmen are still a part of while serving office and which they plan to be part of after serving office, to increase their personal fortunes. The goals are the same as they’ve always been: break open the piggy bank of Social Security for the finance industry (they’re going after the CPI,) gut social aid and education (this one is related most to the ACA and the expansion of Medicaid that comes with it,) to create a pool of unskilled and skilled labor that is absolutely desperate and will let them do anything (plus privatize the schools for cash,) and tax cuts, subsidies and fire sales for corporate entities, (R Utah is pushing a selling off of large tracts of public lands in the western states to “reduce the deficit” — and cough up mineral rights, oil, timber, etc. while the shutdown is on-going.) They haven’t stopped working — they’re working on getting concessions, same as they have for the past five years, at federal and state levels.

367. Late to the party, but I do have a quick comment for @JayReding.

     In your first comment: “Your argument falls into the trap that people on the political left in this country are making all the time (along with many on the other side of the aisle): not bothering to understand the real arguments on the other side.”

     In your second comment: “That’s not how argumentation works, if one side cannot engage the other on their own terms, neither side is really advancing anything.”

     Have you bothered to understand the real arguments on the other side? Have you been able to engage with the other side on their own terms?

     It honestly doesn’t appear so based on your comments. (Though you have certainly stimulated activity in the thread, which (also honestly) I’ve enjoyed reading.)

     Something to think on, perhaps.

368. Floored:

     I apologize. Next time, I will try a different tactic.

     Thank you. As a gay man who was rather put off by that tactic, I’m glad to see you learn from your mistake and take criticism with such good grace. You have a good heart, ISTM, but that comment to scorpius left me with a bad taste in my mouth, which is now gone. So thanks for that.

     …smolders like a trash fire on top of a vein of pure anthracite coal.

     You’ve heard of Centralia, PA? If not, look it up. It’s a horrible, fascinating story of how a few careless people can cause a problem that lasts for decades (and isn’t over even now).

     Maybe we should just take a leaf from Sergeant Scholck’s book and end Fox News in any way we can.

     Assuming “any way we can” is constrained by legality, constitutionality, and morality…which pretty much leaves boycotting their sponsors and other forms of civilized persuasion.

369. I have heard of Centralia. That’s why I used the analogy, in fact–I still have vivid memories of that chapter of “A Walk in the Woods”.

     Also, mercenaries’ only moral code is living long enough to get paid. And mercenaries don’t care about laws. *evil grin*

     Civil persuasion hasn’t worked so far. If there’s money in lying to people, then bad people will do it.

370. There’s this thing, Floored, called “becoming what you hate.”

371. They are rather panicked at the state level, though:

     http://www.news-sentinel.com/apps/pbcs.dll/article?AID=/20131001/NEWS/131009962/1006

372. @Kim McAllister
     @Ben Try it with 94541 as the zip and tell me if you see it. Anthem Blue Cross PPO ($1920/mo)

     This is almost exactly what I would be paying via Cobra if I lost my employer’s coverage. Right now. I pay zero, yep zero.
     
     I hate to be too pedatic, but you are not paying zero. You are actually paying about $1900 a month for health insurance already. Even if is hidden, you are really paying “the employer contribution” portion of your health insurance. It is part of your salary. The employer does not pay it out of charity, it is as much your pay (and hense your money) as the rest of your pay check.

     COBRA payments based off the sum of the “employee contribution” and the “employer contribution” plus something like a couple of percent for administrative costs.

     So in fairness, it sounds like under the ACA, you would be able to get the same type of insurance plan in the individual market at the same rate that your current employer is getting in the group market. This is would actually be an endorsement of the ACA.

373. So, I’m late to this game, but I’ll just add my $.02.

     I’m an American. I write full-time for a living, and before I decided to do this, I was self-employed in the tech industry for almost twenty years. I’ve had insurance for a total of six months in about seventeen years.

     My wife is a public school teacher. She has excellent BCBS insurance, and the school district pays for it. To put me on the plan (no children or other dependents, just me), would cost $508/month. So for the seven years she’s been a public school teacher (History/Government/Human Geography at the AP level, btw), I’ve had only dental/eyecare insurance.

     There have been at least five times I’ve needed to see a doctor or go to the hospital for an issue with my back/spine. I’ve never been able to go to the hospital because of the cost, and the two times I visited a doctor ($100/125 per visit, out of pocket), I was immediately referred to a specialist, because a GP cannot really do a lot about spinal/back problems other than…send me to a specialist.

     My goal for the last two decades has been to NOT GET SICK. That’s it. That’s my healthcare insurance plan. Don’t get sick.

     As of this afternoon, a ‘gold’ plan through the Healthcare.gov exchange, one that basically matches my wife’s excellent BCBS plan, would be $162/month. And because of our combined income, I will only have to pay $104/month for it with subsidies/tax credits.

     Anecdotal evidence for Jay: I’ve spoken to probably 2,000+ Canadians, Brits, Germans, etc. over the last decade or so because of my job(s), and one thing I always ask them is ‘would there be anything that would get you to give up your healthcare system?’. And the answer, 2000:0, is universal: no. Not a single ‘foreigner’ that has nationalized/socialized healthcare would give it up for any reason. I would estimate that 1,975 of the 2,000 would definitely agree that their system is not perfect by any means. Improvements could be made in all areas. But not a single one of them would allow you or anyone else to take away their healthcare system.

     And yes, I ALWAYS ask others about their healthcare system. Mostly because I’m fascinated by our (American) resistance to it.

     Now that the Gov’t is shut down, my wife is extremely worried. For almost a year, she and ten other students have planned and then booked their trip to D.C. to see everything from the Capitol to Williamsburg and everything in between. It’s going to be a very expensive $2000/per student waste of money if the gov’t is still shut down during the trip.

     The ACA will never be repealed. It will never be defunded. For this to happen, one of the following scenarios would have to be true:

     1. Republicans win majority of House, Senate, and win the presidency (good luck)
     2. Republicans win 2/3 majority in the House and Senate with a Dem president to override any veto. (good luck)
     3. Democrats vote to defund or repeal the ACA (best of luck)

     None of those three things will ever happen. Sure, never say never, but I’m saying never.

     Thank you ACA. I can finally visit a doctor soon, and have my ‘pre-existing condition’ covered.

374. I actually blame the Republicans for this mess, but I was paraphrasing the comments I heard on NPR today describing the “reporting” and commentary on the shutdown from Fox News, Rush Limbaugh, and other conservatives. It’s clear to me that people who only get their news from these sources, including my father-in-law, do believe that the House Republicans have been bending over backwards trying to compromise with Obama and the Senate Democrats, only to be rebuffed time after time because this is the message they are repeatedly hearing. The cynical House Republicans are attempting to create outrage against the Senate Democrats by trying to pass funding bills for individual programs with high emotional content, like programs for the armed forces and/or veterans, and pediatric cancer projects at the NIH because they know that the Democrats are refusing to consider any of these funding bills unless it’s to fund all of the government agency that are currently shut down, just as they know the Senate Democrats are refusing to accept any attempts to defund or delay implementation of the ACA as part of the funding continuing resolution. And every time Boehner comes out of a meeting with the Democrats, he includes a comment like “All we are asking for here is a discussion and fairness for the American people on Obamacare.” as though making it easier for the uninsured to get insurance despite existing conditions and abolishing lifetime maximums is somehow unfair.

375. I met someone who paid more than $10k out of pocket for his dog this last year. He really loves his dog. I pay for insurance for my dog, and I saved $10k this last year. He wished he had insurance for his dog.

     Turned out he himself didn’t have insurance, and deferred some of his own medical care because of all the money he put in for the care of his dog. When I said I hoped he could get affordable insurance when the exchanges opened, he said he was against Obamacare and that he wasn’t going to get insurance. (And he said that he knew many doctors who were quitting because of Obamacare. This makes me suspect he watches too much Fox as doctors aren’t doing this.)

     I hope he changes his mind and gets insurance.

376. Honestly, this is one of the reasons I don’t want to move back to the US. I’ve been in the UK doing postgraduate work for the last five years and now am absolutely desperate to find a job in Britain that can sponsor me for residency. Some of it’s that I just like it here; it’s where my friends and professional networks are. But a lot of it is that going back to the health insurance nightmare that is the US is terrifying. Even when I was insured (and in fact worked for the hospital that insured and care for me) I couldn’t get things like my horrible excema taken care of, because it’s ‘just cosmetic’ and the copay for the medicine was like $90. Where are the working poor supposed to get $90? So I spent three years with the skin flaking off my feet. It took less than a month to sort out once I got to the UK and had the NHS look at it.

     I’m happy to pay taxes the way I pay for electricity, or water, or internet. Because in theory it gives me a society to live in, and one of the facets of that society is that if I get sick, I can go to the doctor and get what I need to feel better. Even if I managed to get a tenure-track job in the US, the level of care and access to medicine is unlikely to be better than what I’ve had here, and I’d rather just not have it be another complication in my life. It doesn’t have to be. Practically every other civilised country on the planet has a way to take care of their citizenry. The doctors where I live don’t say ‘I wish I moved to the US because I’d make more money,’ they say ‘what a barbaric system.’

377. @scorpius, what peter k said.

     and to just beat it in, the MAJORITY of the country voted in President Obama based upon his platform. I, my wife, my son have experienced periods of no coverage and it scares the crap out of me. Don’t you get that? You and your teabagger terrorist-like-substitute friends don’t GET to tell me what I and my family need or don’t need.

     @Floored by Scalzi’s awesomeness, please forgive me my friend and know that I (mostly) dig your comments but seriously, “@ Our Lord Host, May His Name Be Praisèd:” is way creepy.

378. @ Ambivalent in Tokyo: I just think that Mr. Scalzi deserves some proper respect for his awesomeness…;)

379. I agree with John’s analysis of the state of health care in the US. But I think many people are getting upset about the Republican congress for doing what essentially is their job. The constitution clearly gives the House to right to fund or defund anything it wishes, spending bills MUST originate in the House. If Democrats controlled congress and didn’t like an expensive weapons platform that was passed in years past, it is well within their purview to defund it, effectively killing it even if the Senate and President wanted it continuted. If the House is so organized and motivated that they deny all other funding based upon this one item, it is their right and responsibility to hold out as long as possible. This is by design.

     While I disagree with the Republicans here on this issue, I must support the right of the House to make such a stance on principle. They control the House. It is up to the Senate and the President to compromise with the House until a majority of House members can pass something they will agree with. It isn’t the House’s responsibility to give the Senate and the President what they wish. The Senate and President must compromise with the House. The reciprocal of this is the President’s Veto; but that can be overruled. The President cannot overrule congress, and the Senate cannot dictate to the House.

     We need something like the ACA. The better way to pass an ACA type bill is with a constitutional amendment. The Enumerated powers should make the current bill unconstitutional, but the last eighty years of court rulings (or lack there of) make this stance on my part dubious. An amendment is harder to pass, but would give a needed mandate to such sweeping legislation. I also believe this should have been required of Social Security before FDR could implement it. Once such legislation is passed, it then becomes the constitutional duty of the House to fund it in a logical manner. What we have now is horrible legislation (which I agree with John is better than none) being bickered over by political infighting. Here is my proposed ammendment:

     Amendment to the CONUS: “Congress will legislate and provide for a) universal heath care, b) retirement and c) disability benefits for all citizens and residents of the US of A. There will be no provided exemptions for governmental or special groups.”

     Then we would concentrate on a better way of doing things and it would be Constitutional. Congress (House and Senate) would be tasked with coming up with a good system beneficial to all. The last sentence makes it fair for all and disallows a two-tear system. Pity it will never happen (in my lifetime).

380. I’m late to the party but I am in total, metaphysical agreement with Scalzi here.

     And another thing: If you don’t want a single-payer system (which I favor – there’s a reason why the rest of the industrialized world does this another way), you should be pulling for the ACA to work. The old way of doing things had us on a fast track to total system meltdown. The implosion of our current healthcare model would force America to adopt true socialized medicine, like everybody else.The ACA has a chance to at least delay that.

381. If Democrats controlled congress and didn’t like an expensive weapons platform that was passed in years past, it is well within their purview to defund it, effectively killing it even if the Senate and President wanted it continuted.

     Yeah, I remember all those times that Nancy Pelosi shut down the government over things like the Bush tax cuts, the Medicare expansion, the war in Iraq. Amazing how common it was.

     Hint: that someone has the ability to drive a car off the cliff doesn’t mean they should. The GOP’s responsibility is to govern, not destroy the government. And there was lots of compromising *during* the passage of the ACA itself. The GOP is trying to take two bites of the same apple.

     They control the House. It is up to the Senate and the President to compromise with the House until a majority of House members can pass something they will agree with

     Well, a majority of representatives would, in fact, pass a clean continuing resolution, but Boehner won’t let it come to a vote because a majority of Republicans wouldn’t. So that compromise already exists, but the GOP leadership won’t allow the House to vote on it. So now who’s upholding the Constitution, exactly?

     Second, why is it the Senate’s responsibility to compromise and not the House’s, as well?

382. WRT Boehner’s determination not to allow a vote until a majority of Republicans support it. Is it possible he is trying to bring the Tea-Party under control with this? If he lets a resolution pass without breaking the back of the TeaPs then this will keep on happening again and again and again, and he’ll just have to deal with continual internecine rage which might turn out to be a recruiting banner for more TeaPs. If he insists on waiting for the party to get consensus then he effectively forces the TeaPs to acknowledge they are not the be all and end all of the GOP. They either have to get on board and get with the program or accept that they are just one group in tent.

     I kinda hope this is what he is playing at, its dangerous and stupid, but I think that the GOP and its members have long since crossed what Tvtropes insists on calling “The Godzilla Threshold” and something drastic needs done. Of course if this isn’t him trying that, then everyone is screwed because this is just going to keep happening until the TeaPs eventually implode under the weight of their own crazy.

383. Second, why is it the Senate’s responsibility to compromise and not the House’s, as well?

     Because the Senate isn’t controlled by the correct party, silly.

384. crypticmrror: I suspect you are correct – Boehner can’t allow a vote until either a majority of republicans are on board or enough high profile repubs are (McCain, et al). do. To do so would not only ask for this to happen again, but would most likely lead to a coup within the house GOP caucus and he’d lose the speaker position- he may be fighting for his career here.
     that being said, I hope this is a wake up call to some career politicians – the tea party is poison

385. @Brad:

     The Enumerated powers should make the current bill unconstitutional, but the last eighty years of court rulings (or lack there of) make this stance on my part dubious.

     Why review eighty years when we can just go back to June 28, 2012? The Supreme Court upheld the ACA after all.

     Also, regarding an Amendment to empower the Federal Government, again, why write an Amendment to do what’s already enumerated in Article 1?

     “The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence [sic] and general Welfare of the United States; but all Duties, Imposts and Excises shall be uniform throughout the United States”

386. @Brad: The Constitution says bills for raising revenue must come out of the House, this is a spending bill. Also, there is nothing requiring that a bill coming out of the House be brought to the floor only if the majority party has enough votes to pass it without any votes from the minority. It sounds like the House might be able to pass a CR to fund the government and a debt limit bill (which might need to originate in the House) without the Tea Party contingent, but Boehner isn’t willing to allow a vote on them.

387. @Floored by Scalzi’s awesomeness. Respect, sure. It’s the over and beyond part that has me shivering in my keds…..

     no worries, I think highly of our host as well though perhaps just short of the worshipfulness implied in your statements.

     Be good.

388. Floored (from yesterday), I know the Onion is all satire, all the time, but what might be the thoughts scuttling though Boehner’s subconscious actually made me sniffle a bit. if only…!

389. Kim McAllister: Both the driver’s license suspension and the fine amount are totally false.
     http://www.snopes.com/politics/medical/penalty.asp

     There is *no* suspension of anyone’s driver’s license; the limit on individual yearly out-of-pocket expenses is $6,350. The IRS is not allowed to withdraw money from your bank account.