US Supreme Court Upholds Affordable Health Care Act

[smegged]

I love America, it has so much wonderful stuff and it does so many wonderful things. It does tend to be a land of extremes though. I was waiting for a bus outside the LA Disneyland when I was there and started a conversation with a homeless guy who couldn't afford health care to get better from a treatable illness, which prevented him from getting a job. Having spent the day in one of the most opulent places on Earth, it really did make me wonder why America could not afford universal health care.

This was two years ago. As a neutral observer (actually not quite neutral, I lean to the right politically), I can't help but shake my head at the constitutional challenge to the Obamacare package.

Also, while I support lower taxes, particularly for the low and middle classes, I also don't understand why Republican voters tend to get so upset about tax rises on those earning over $250kpa.

I really don't mean to be offensive or say that our system here in Australia is better, or could even work in the USA, but there are some aspects of American political culture which seem so strange. In Australia we tend to have centrist governments which generally respect legislation enacted by previous governments (we had universal healthcare put through in the 70s and despite the opposition to it by many in more recent governments, the legislation largely stands).

In America there tends to be a far greater culture of appealing to the constitution to enact social change instead of changing governments. Roe vs Wade settled a moral issue that the authors of the constitution could never have forseen it being used for. In Australia, that issue has been settled by electoral mandate, but if new information comes to light, or the people of this country decide that they had changed their minds about it, changing the law would be relatively easy compared to what is required to change it in the US. Pretty much everyone in the western world knows what the second amendment is and what it means for Americans.

The long and the short of it - America is a great country, but it has a strange political culture.

[kandrathe]

... did make me wonder why America could not afford universal health care.

We can if "health care" is defined with some boundaries. I can't remember the exact source at this moment (I'm rushing off to a meeting in 5 minutes), but it was essentially that the bulk of our care is given to a small fraction of the population, and that most of that is in the final year of a persons life attempting to buy them a few more months. The sad result is that most often the extra care statistically shortens lifespan. We can easily afford health maintenance, and treatment of common chronic or acute illness. What we can't afford is to keep the mentality that we must "save them at any cost", especially when that persons body is all worn out already.

...I can't help but shake my head at the constitutional challenge to the Obamacare package.

The constitutional question challenged was whether the Federal government can force you to go out and buy something you don't want, or face a fine. The SCOTUS resolution was that it wasn't a fine, it was a tax. So, they ruled that yes, the government can impose a tax on you for whatever reason. The SCOTUS didn't get into the political fray to determine the fairness of a tax on not buying health insurance, that is an issue between the Congress and their electorate. Many states attorney generals challenged (and won) the Federal governments imposition of rules on pushing people onto Medicaid, which is partially funded by the states. Many states were worried that this would be a budget buster at the state level, and wanted control over their own programs. The SCOTUS ruled that the Federal government cannot impose sanctions on states. They can use carrots, but not sticks.

Also, while I support lower taxes, particularly for the low and middle classes, I also don't understand why Republican voters tend to get so upset about tax rises on those earning over $250kpa.

The issue for Republicans is that spending has drastically increased during Obama's tenure (debt has increased 6 trillion since 2008, out of our 15 trillion total public debt), while the recession has been reducing tax revenues. We could take 100% of the income for those earning over $114,000 and still not balance our deficit spending.

Say we take it up to the top 10%, or everyone with income over $114,000, including joint filers. That's five times Mr. Obama's 2% promise. The IRS data are broken down at $100,000, yet taxing all income above that level throws up only $3.4 trillion. And remember, the top 10% already pay 69% of all total income taxes, while the top 5% pay more than all of the other 95%. -- WSJ April 17, 2011

So, do we have a lack of taxes problem, or a spending problem? Mr. Buffet suggest we need to do a little of both, and I tend to agree. Our tax system needs an overhaul -- especially with regards to the disparate rates of income tax derived form work versus investments.

It's much easier to get elected by giving away free things (at tax payer expense), than to suggest fiscal discipline, and that other dirty A word - Austerity. I've said this before, I'm not against using the fiscal and organizational power of government to make permanent improvements to social infrastructures (e.g. rebuild our antiquated power grid). These types of government projects might only be possible with government involvement, and create long term economic benefits for everyone (e.g. think Roman aqueducts).

The whole argument regarding minimally adjusting taxes on the top x% is a political red herring towards solving our deficit issues (outlays far exceed tax revenue). Being neither in the R camp or the D camp, it seems to me to be pure political maneuvering to obfuscate the issue and give the Democrat base a rally cry. It would be as if we were arguing about obesity in the US, and you suggested I deal with my fat children first (they aren't actually fat, quite the opposite -- I'm having to put them on a bacon for breakfast, and steak/roast beef for dinner diet).

We have a slight correctable issue with Social Security (retirement) due to the number of baby boomers reaching age 65. They either need to adjust the tax rate, the retirement age, or raise the cap from $106K to $250K, or a combination of those three. But, our weak willed politicians are fearful of rocking the senior boat, or should I say vote.

We have a bigger issue with our government health insurance for elderly (Medicare), and slightly less of one with our health insurance for the poor (Medicaid). To me it boils down to an expanding number of possible treatments, and medications with an expanding population of people needing treatments and medications. First, we really need to separate the issues with *Health Insurance* from our issues with *Health Care*.

I claim one of the biggest problems with cost in health care (and education) is inflation (others may disagree). Our CPI masks certain areas of inflation because many areas of our economy have reducing prices, while others are increasing. The bottom line is that whenever you have a fixed expectation of say "a doctor visit", there is no way to use technology to make a 1 hour doctor visit take 5 minutes without jeopardizing the quality of care. We've squeezed about as much efficiency as we can out of doctor visits. We can pick a number (8, 16, 32), but one doctor can only do a fixed amount of patients in a day. As the prices (i.e.labor, technology, insurance, collections), go up, those prices are passed along to the consumer directly. In the US, we have the very best health care money can buy, but most of us can no longer afford it. Since most of us have our employers pay for most of it, we don't see the increases in costs as directly and instead complain about the flatness of wages since 1980. The inflation of health care prices is most certainly due to a lack of supply, and an increase in demand. A good start would be for colleges and universities to increase the output of health care workers to close the demand gap. Currently, the only stop gap we have is to import health care workers through special H1 visa recruitment.

I really don't mean to be offensive or say that our system here in Australia is better, or could even work in the USA, but there are some aspects of American political culture which seem so strange. In Australia we tend to have centrist governments which generally respect legislation enacted by previous governments (we had universal health care put through in the 70s and despite the opposition to it by many in more recent governments, the legislation largely stands).

In America there tends to be a far greater culture of appealing to the constitution to enact social change instead of changing governments.

Case law, and the SCOTUS has been an instrument of dissent over "nullification" in the US since the civil war. What is different is that we are not a true democracy. We are a representative republic unified by the Federal Constitution. Each state in the US should reserve sovereignty, and has it's own constitution that for state concerns supersedes the Federal constitution. Certain things, like the rights of citizens are guaranteed at all levels.

Roe vs Wade settled a moral issue that the authors of the constitution could never have forseen it being used for. In Australia, that issue has been settled by electoral mandate, but if new information comes to light, or the people of this country decide that they had changed their minds about it, changing the law would be relatively easy compared to what is required to change it in the US.

And, if our system were working as intended, the Feds wouldn't be able to tell Utah what to do if they didn't want it. Excepting that the original Roe V Wade case was based upon deception, there is a definite human rights dilemma on whether to support a persons ownership of their body and progeny, versus the rights of the (potential) citizen yet to be born. It's not an easy problem to resolve well either way.

Pretty much everyone in the western world knows what the second amendment is and what it means for Americans.

Really? I've been engaged in numerous debates since the Aurora tragedy, and I find many US citizens don't understand it very well.

The long and the short of it - America is a great country, but it has a strange political culture.

So true. It's designed to be run by part time farmer statesmen, but has been taken over by a political class and special interest lobbyists.

Edit: I'll add one more plank to this wall of text. I believe our bigger long term issue is the decreasing number of workers to retirees. A better solution for sustainability through 2050 would be for us to drastically increase legal immigration, and increase tax revenue through broadening the base of tax payers. It's not like we don't have the space for them, and they do want to come here to live and work.

[RiotInferno]

First off, kandrathe, that was awesome and well thought out.

I think that States' Rights has been eroded almost as much as parts as the 4th and 1st Amendments ( Search \ Seizure and Freedom of the Press respectively ). It is rare that states are allowed to make laws that go against the national agenda, and if/when they do, the feds are usually jerks about it.

As far as spending goes, we've been at war for 10+ years, and that has a hefty price tag. I am pretty sure that that money would have been spent elsewhere if it wasn't part of the "defense" budget.

There is a line of thought (that it turns out, is pretty common) that started post-WW2, that Defense spending brought this country out of the great depression, and if Defense spending returned to pre-WW2 levels, that the US economy would crash again.

Our gov't spending (and some other policies) are not sustainable, and 90% of what the political elite (politicians, major media, political media, etc) do is to keep the populace so divided over things that are hot-button topics (Abortion, Climate change, Marriage Discrimination, etc ) that we seem oblivious to the smoke-and-mirrors.

In the 12 years I've been able to vote, I used to think that things would change. Now I'm just a political cynic.

[kandrathe]

There is a line of thought (that it turns out, is pretty common) that started post-WW2, that Defense spending brought this country out of the great depression, and if Defense spending returned to pre-WW2 levels, that the US economy would crash again.

And, I think not just military spending. I'm not sure I like the idea of the government driving or sustaining a huge portion of the economy (GDP). Making war, and defending things not needing defense is not productive unless there is a real risk of them being taken/destroyed by our enemies. Imagine if all those trillions of dollars were spent on productive infrastructure rather than bombs, and the things that deliver them. And, I'm not a pacifist, really.

I can't help but to reflect on the insanity that is IRAQ -- where we shed blood, and spent years and billions of dollars tearing the place apart. Then, only to turn around and shed more blood, and spend more years and billions more dollars putting it back together again. Yes, the Bathists were a pretty evil regime, and so are many others. I just don't think it's our morality to rid the world of evil tyrants (let alone prop them up).

If there is a *real* enemy, and one we can actually target, then we should prosecute war, quickly and with every intent to utterly destroy the threat. If not, we should stand down, and devote ourselves to things that enrich us all. We cannot win a war against concepts like drug use, poverty, or terrorism. What bunker are they in so we can bomb the hell out of them? And, really, our foreign policy of interventionism is a reflection of our domestic policy of interventionism. Our penchant for interference in other governments business is no different than our penchant for interfering in how people live their lives. Our motto should be; "You need to do it my way".

[smegged]

We can if "health care" is defined with some boundaries. I can't remember the exact source at this moment (I'm rushing off to a meeting in 5 minutes), but it was essentially that the bulk of our care is given to a small fraction of the population, and that most of that is in the final year of a persons life attempting to buy them a few more months. The sad result is that most often the extra care statistically shortens lifespan. We can easily afford health maintenance, and treatment of common chronic or acute illness. What we can't afford is to keep the mentality that we must "save them at any cost", especially when that persons body is all worn out already.

The thing that astounded me when I looked into the WHO stats on per capita health spending was just how out of control healthcare is in the USA compared to other countries. When I last looked (a couple of years ago, before Obamacare) the US was publicly spending more on healthcare per capita than what Australians were spending in the public and private systems combined. When you added in private spending on healthcare the figure was pretty much double. Australia and the US are quite similar demographically when it comes to health, wealth and aging population, which to me suggested that the actual system itself was broken and that the problem was not the amount of dollars thrown into the system.

On the rest of your points I agree wholeheartedly. The only way that the US will ever return to surplus is to raise taxes on the higher income earners and cut spending across the board. The whole Cheney line of "deficits don't matter" is false. Deficits do matter. Our country was able to avoid going into recession during the Financial crisis simply because we could throw money at the problem because we'd been living with surpluses for the prior decade. We are still close to full employment in part because of the years of surplus.

[kandrathe]

... which to me suggested that the actual system itself was broken and that the problem was not the amount of dollars thrown into the system.

Yes. The system is broken (our care is too expensive), and so I don't understand how the solution is to make us buy into it. More demand and less competition will lower the price?

[smegged]

... which to me suggested that the actual system itself was broken and that the problem was not the amount of dollars thrown into the system.

Yes. The system is broken (our care is too expensive), and so I don't understand how the solution is to make us buy into it. More demand and less competition will lower the price?

The answer is reform. I don't know what reform would work, but obviously the healthcare framework is at least in part to blame. In part it could also be due to societal issues (higher instances of gun crime than in the rest of the western world putting pressure on the demand for surgeons, Hollywood placing upward pressure on the demand for plastic surgeons, poor nutrition placing upward pressure on diabetes and obesity-related illness services etc...).

In Australia we have two systems - a public and a private system. Legally, if you earn over $80 000 p.a. you need to either have private health cover or pay a significant levy at tax time. The public system is much larger than our private one, but the private system is the one to go to if you want to avoid elective surgery waiting lists. I'm not saying that our system is perfect (it's not) but it seems to be more economically efficient than the US system.

[DeeBye]

The answer is reform. I don't know what reform would work, but obviously the healthcare framework is at least in part to blame.

There are lots of countries with publicly-funded universal healthcare systems that spend less than what the US does right now, and provide equal or (more often) better care. The US is in a enviable position by being last on the healthcare train, really. They can examine in minute detail all of the systems already in place and use those blueprints to make a better one.

It won't happen though, because of the political polarization in the US. Every good idea one party comes up with is automatically a bad idea in the eyes of the other party.

[kandrathe]

There are lots of countries with publicly-funded universal healthcare systems that spend less than what the US does right now, and provide equal or (more often) better care.

Boy, that's hard to quantify. You cannot just compare a country with a universal coverage plan to the hodge podge of stuff we have. Our laws make health plans unique by state, so every state is different (which is why we have such a thing as "BCBS of MN" as opposed to "BCBS of WI" across our eastern border. The government has layers of Medicare A, B, C and D covering most of the things the elderly want -- except they missed some stuff so AARP (and others) offer Medicare Advantage (add on premium services for those who want to pay more). And, the poor have multiple programs (SSI, food (Dept of Ag.), Housing(HUD), Health care(Medicaid), etc. none of which coordinate well together.

In our state we have "general assistance" which is temporary (30-60 days) and meant to cover poor people in transition (moving into the state), S-Chip for children (and their families), we have Medicaid, and we have MNCare (like RomneyCare, without the mandate) that *must* cover anyone who is not covered by the former, and who are denied or cannot afford coverage through other insurance. With enough safety nets, you catch most everyone. Maybe you can see why it costs more, when you have this many entities all attempting to perform the same function.

The US is in a enviable position by being last on the healthcare train, really. They can examine in minute detail all of the systems already in place and use those blueprints to make a better one.

Maybe. About 1/2 the population is still desperately clinging to this idea of having "Free Enterprise" in our markets. And, it's not like the ones who've gone before have very affordable models either. They are just more affordable than what we have.

It won't happen though, because of the political polarization in the US. Every good idea one party comes up with is automatically a bad idea in the eyes of the other party.

Smoke screen. They intentionally are trying to divide us so we don't see how messed up it is.

[Jester]

And, it's not like the ones who've gone before have very affordable models either. They are just more affordable than what we have.

What's "affordable"? Most countries spend between 8 and 12% of GDP on health care. That doesn't seem unreasonable to me. Obviously, one wants the most care for the least money, but I don't think spending one dollar in nine on heath is unaffordable. (The US is over 15%, and with an impressively high GDP to boot.)

-Jester

[RiotInferno]

<Total Sidetrack>

In our state we have ... MNCare ...

MN? Like Minnesota?
If that's the case, I'd just like to say, that although I live less than 30 miles from the MN border, I feel like I'm in a political wasteland compared to them. Also, Minneapolis has some of the best Thai food I've ever had.

</Sidetrack>

[kandrathe]

<Total Sidetrack>

In our state we have ... MNCare ...

MN? Like Minnesota?
If that's the case, I'd just like to say, that although I live less than 30 miles from the MN border, I feel like I'm in a political wasteland compared to them. Also, Minneapolis has some of the best Thai food I've ever had.

</Sidetrack>

::nod:: We get huge diversity here. We are a big destination for refugee's -- since I guess are good at helping them adjust to life in the US. In my lifetime I've witnessed waves of new immigrants and refugee populations from Bosnia, Burma, Cambodia, Cuba, El Salvador, Ethiopia, Guatemala, Hmong/Laos, Liberia, Moldova, Somalia, and Tibet. Then, there is just the normal diversity of people coming here for work. I hired a bunch of people myself from India, South Africa, Britain, China, and Eastern Europe during the exuberant perestroika days.

When I was in college, my wife (then girlfriend) would drag me along to her study group which met at this Polish girls house. Her dad and I would do vodka shots and talk international politics while they studied... He had been on the national boxing team, and defected when they were at a competition outside the USSR.

We do some stuff right here. Way back when we had Gov. Rudy Perpich... He led an effort to build a center for the rehabilitation of torture victims based on the initial one set up in Copenhagen.

[LochnarITB]

<Total Sidetrack>

In our state we have ... MNCare ...

MN? Like Minnesota?
If that's the case, I'd just like to say, that although I live less than 30 miles from the MN border, I feel like I'm in a political wasteland compared to them. Also, Minneapolis has some of the best Thai food I've ever had.

</Sidetrack>

Be careful about admiring Minnesota too much, especially if that might lead to thoughts of moving here someday. It is really an awful awful place. "Minnesota Nice" is a marketing gimmick. Church lady potluck suppers exist in theaters only. Fishing and hunting and general nature observing is locked away in the compounds of billionaires and corporations. Fine dining here is McNuggets and Whoppers. Our transportation system still mainly relies on wagon trails that we scrape down once a year. It is a state full of nothing but frustration and pain and nobody should ever think of joining us here, ever!



Now, if anyone does decide to make the move, and you are from the northwest, could you please bring your cooler rainier summer weather? I doubt I could live anywhere else, but I would love it even more if the summers were cooler and wetter (winter cold is fine, though). It seems that many are realizing our pluses as well and it seems, as our population grows, we are becoming more urban and losing a little of what makes it a great place.

[RiotInferno]

<Total Sidetrack>

In our state we have ... MNCare ...

MN? Like Minnesota?
If that's the case, I'd just like to say, that although I live less than 30 miles from the MN border, I feel like I'm in a political wasteland compared to them. Also, Minneapolis has some of the best Thai food I've ever had.

</Sidetrack>

Be careful about admiring Minnesota too much, especially if that might lead to thoughts of moving here someday. It is really an awful awful place. "Minnesota Nice" is a marketing gimmick. Church lady potluck suppers exist in theaters only. Fishing and hunting and general nature observing is locked away in the compounds of billionaires and corporations. Fine dining here is McNuggets and Whoppers. Our transportation system still mainly relies on wagon trails that we scrape down once a year. It is a state full of nothing but frustration and pain and nobody should ever think of joining us here, ever!

Don't worry too much. I'm a South Dakotan. So it's like Minnesota with less people, and a little more back-woods.

That being said, we do have quite a bit of pot-lucks, but all our real small towns are quietly dying away.

[kandrathe]

It is a state full of nothing but frustration and pain and nobody should ever think of joining us here, ever!

Yes. I forget... Stay away! We've got sickness here. The brutal winters last from October to May, and then our humid hot summers are infested with mosquitoes, bawling children and rabid raccoons.