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PostPosted: Tue Dec 28, 2010 4:29 am 
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This editorial in today's Wall Street Journal taught me a few things about Constitutional Law. I'm wondering if The Law Professor In Chief ever considered any of this, or if he just threw the thing out there hoping nobody would notice.

Or maybe he didn't really read the darned thing. Some (e.g. Pelosi) even admitted the same.

- Bill

WSJ wrote:

DECEMBER 27, 2010
ObamaCare and the General Welfare Clause
The individual mandate is not the only problem with the health law. Its draconian Medicaid mandates on states exceed Congress's spending power.

By RANDY E. BARNETT
AND DAVID G. OEDEL

Remember the Cornhusker Kickback? In a frantic effort to move ObamaCare through the Senate last December, the following provision was added to the bill: Nebraska was given a $100 million exemption to cover the costs of the bill's dramatic expansion of Medicaid. The special exemption was ultimately dropped during reconciliation, but not only because of the public outrage it generated. Many realized it was unconstitutional for a reason that now applies equally to the health-reform law: Both violate the general-welfare clause.

While Congress has no constitutional authority to directly commandeer state legislatures into doing its bidding, it can place conditions on the money it offers them. So in the 1980s, for example, states had to raise their drinking age to 21 or the federal government would hold back 5% of a particular state's highway funds. But Congress's authority to impose conditions is not limitless.

Article I, Section 8 of the Constitution gives Congress the power "to lay and collect taxes, duties, imposts and excises, to pay the debts and provide for the common defense and general welfare of the United States." The problem with the Cornhusker Kickback was that the citizens of 49 states would have had to pay for Nebraska's Medicaid exemption—without getting anything in return. The special exemption exceeded Congress's constitutional authority because it did not serve the "general welfare"—meaning, the welfare of the people of each and every state.

This defect is true of the new health law, the Patient Protection and Affordable Care Act. Although the constitutional objections to its individual insurance mandate—the requirement that any person who isn't provided insurance by his employer buy it on his own—have gotten all the public attention, the law also has a "general welfare" problem. It will pile unspecified new costs on states by requiring them to extend their Medicaid coverage to more people. In Florida, 20 states have challenged these state mandates as exceeding Congress's spending power. Their challenge is based on South Dakota v. Dole (1987).

In Dole, the Supreme Court upheld the congressional mandate that every state raise its drinking age to 21, or lose 5% of its highway funding. But the Court also acknowledged that "in some circumstances, the financial inducement offered by Congress might be so coercive as to pass the point at which 'pressure turns into compulsion'" (quoting a 1937 opinion by Justice Benjamin Cardozo). The Court upheld the drinking age mandate because a state would only "lose a relatively small percentage of certain federal highway funds."

ObamaCare won't alter Medicaid in a relatively small way. It's an "all in or all out" proposition—not a threat of losing just 5% of some transportation funds, but a threat of losing 100% of the single largest federal outlay to the states.

The annual federal spending on Medicaid is now over $250 billion, more than all federal spending on transportation and education combined, and it is climbing quickly. States on average devote about 18% of their tax revenues to Medicaid, typically funding between 40% and 50% of their state's total Medicaid costs. The health law's changes to Medicaid will force them to pay even more of their own funds.

The 20-state challenge to the new law was heard in federal district court in Pensacola, Fla., on Dec. 16. Much of the argument concerned whether the threatened loss of Medicaid funding passes the threshold laid out in Dole, where persuasion becomes compulsion. We think the case also presents a serious "general welfare" problem.

Normal federal spending occurs irregularly throughout the U.S. If Nebraska gets a military base, for example, making the case that it serves the "common defense and general welfare of the United States" is easy, since citizens of other states benefit from the base. The same general-welfare story can be told about virtually all federal spending programs, which is why Chief Justice William Rehnquist said in Dole, "(in) considering whether a particular expenditure is intended to serve general public purposes, courts should defer substantially to the judgment of Congress."

ObamaCare is different. Texas might be allowed to withdraw from Medicaid, but Congress will simply send the Medicaid portion of its citizens' federal tax payments to the 49 other states. Texas citizens would receive nothing in return.

Given the enormous sums involved, sending their tax payments to other states would make it nearly impossible for Texans to fund their own system of medical assistance to the poor: Texas's poor citizens would suffer while the state's tax payments would go to support the poor in other states. Taking from one state to benefit 49 others is as much a violation of the general-welfare clause as the Cornhusker Kickback, which proposed taking from 49 states to benefit one.

In short, the real key to the Medicaid challenge by the 20 states is not simply that withholding Medicaid funding is coercive. It is that the taxes paid by citizens of a state that opts out of Medicaid would no longer be spent in support of the general welfare of each and every one of the states—including itself.

The problem is not insurmountable: Congress could simply provide any state that chooses to withdraw from Medicaid a federal block grant equal to the amount that state's taxpayers would otherwise receive for Medicaid. That would make its choice to remain in or opt out of Medicaid truly voluntary and ensure that the Medicaid program serves the general welfare.

A cynic might respond, Congress would never offer such a block grant because then lots of states might withdraw. Exactly right. And this shows how the "coercion" principle of Dole is linked to the general-welfare clause. If the only way to withdraw from Medicaid is for a state to deprive its citizens of the benefit of their tax payments, they are in this sense unconstitutionally coerced into remaining.

The conclusion is clear. So long as Congress insists on threatening the taxpayers of any state that withdraws from Medicaid by sending their tax money to the other states—and, in the process, depriving them of the funds needed to assist their poorest citizens—federal courts should follow Dole and rule that the new Medicaid requirements are unconstitutional.

Mr. Barnett is a professor of constitutional law at the Georgetown University Law Center. Mr. Oedel is a professor of constitutional law at Mercer University Law School and deputy special attorney general for the state of Georgia in the 20-state health-care litigation. He is writing this in a personal capacity, and not as a representative of any party in the case.
- The Wall Street Journal


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PostPosted: Tue Dec 28, 2010 7:03 pm 
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That logic does seem to be sound, although the part where Texas has to pay for everyone else's care is not a fault of the legislation, but a hypothetical. It's merely coercive because Texas doesn't have that option. Is that enough to sink it? Sounds like yes, if the 9 hold by what this Dole ruling was--although, I haven't read that yet. Sometimes these things are overturned. I mean, since we're referring back to a SCOTUS opinion rather than the Constitution itself here (as I'm sure the Dems would say that the general welfare clause is exactly the reason they are expanding healthcare coverage), it's worth pointing out there are plenty of SCOTUS opinions the objecting conservatives / republicans / strict constitutionalists would overturn, eg, Roe v Wade.

Should be interesting.

Two related questions:

1) Is effect ever a measure of degree of coercion? All 50 states took the drinking age to 21. Sounds like effective pressure to me.

2) To what extent should the federal government redistribute the state's money? Before following the link, as yourself what a Texas or Alaskan conservative might say about the following proposition:

"Texas and Alaska should not be forced to subsidize other states that can't pay their own way--we should get back what we put in"

Then read this:
http://www.slate.com/id/2276583/

And then there's the ongoing problem:

If people can get most of the care they need even if they failed to seek insurance, then more sick and needy apply for insurance leaving the fewer healthy responsible people to pay for disproportionate costs. The market is distorted and prices get screwy.

So if we can't have an insurance mandate, and we continue to back up people without insurance who ought to have had it, things will never be well. What's the way around this?

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PostPosted: Wed Dec 29, 2010 12:59 am 
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IJ wrote:

So if we can't have an insurance mandate, and we continue to back up people without insurance who ought to have had it, things will never be well. What's the way around this?

The whole effort was doomed to challenge when the Democrats forced a program through with only Democrat votes. That wasn't the case for instance with Medicare. Now the majority of the nation actually is against the legislation, partially due to the appearance of impropriety. I don't think many Democrats foresaw that, or the subsequent "shellacking" at the voting booth.

And speaking of Medicare... Isn't it interesting that the government-only model is being rolled back, with more and more people opting for Medicare Advantage? (e.g. private insurance)

At the end of the day, the fairest thing very well may be a state by state solution the way this Republic handles a lot of things. That was happening without ObamaCare already. For instance Massachusetts developed its own universal health care model. I don't know why the nation couldn't have waited for that running experiment to go for a while so that the rest of the country could learn from it. (And I could tell you some ugly personal details about that...) The dynamic tension between states and their various approaches to the problem could have resulted in some interesting, region-appropriate models.

- Bill


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PostPosted: Wed Dec 29, 2010 6:21 am 
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Bill Glasheen wrote:
The whole effort was doomed to challenge when the Democrats forced a program through with only Democrat votes. That wasn't the case for instance with Medicare.

That overlooks that the final product contained the results of a lot of negotiations and demands by Republicans; that the vote split exactly along party lines in the end was merely party politics, not the first time that has happened, and certainly nothing new or extraordinary.

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Now the majority of the nation actually is against the legislation, partially due to the appearance of impropriety. I don't think many Democrats foresaw that, or the subsequent "shellacking" at the voting booth.

Yes and no. The Democrats knew that the majority of the nation was against the legislation because numerous polls said it was. However the majority of those who are against it are so because they don't think it goes far enough. In a January poll 32% said the plan went too far while 35% said it did not go far enough. In a September poll the proportion saying the plan went too far was down to 20% while the proportion saying it did not go far enough was up to 40%. So sure that means that both polls indicate that at least 60% of the nation is not in favor of the legislation, but that does not translate to the majority of the nation being against heath-care reform. What gave the Dems the shellacking at the voting booth is that majority of the legislation's opponents who think the legislation did not go far enough are very discouraged right now, they thought the Dems would be able to deliver a product that would go further than this one does. Their discouragement lead to the near record-low voter turnout nationwide (record lows in some states), which hurt the Dems the most since those that stayed away were more likely to vote Democrat. The Dems did foresee that, it was their biggest concern going into the election.

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PostPosted: Wed Dec 29, 2010 5:14 pm 
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Quote:
That overlooks that the final product contained the results of a lot of negotiations and demands by Republicans; that the vote split exactly along party lines in the end was merely party politics, not the first time that has happened, and certainly nothing new or extraordinary.


That's an interesting claim, Glenn, but I'm not buying it. Yes, Republicans made demands (it's funny how Democrats sticking to their 'guns' on things like keeping insurance - except federally-provided insurance - from crossing state lines isn't 'demanding' anything). Yes, there were negotiations... but pretending that Republican concerns were addressed in that bill is a gross mis-characterization.

A certain few Republicans went along with the Democrats on just about everything this last term. Their reasons are their own, and they're up for re-election in 2012. I think it's fair to say that Obama's fate will likely be theirs, whichever way it goes. But luring a few votes from the Republican side with a mixed goody bag isn't the same as actually working with Republicans. It's no secret Democrats had what they needed, and ignored Republican amendments and requests for debate on bill after bill after bill.

A vote on party lines takes two sides to make it happen.

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PostPosted: Wed Dec 29, 2010 10:23 pm 
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Bill: Ok, yes, it was likely to be challenged, but per your editorial that's on Constitutional grounds and a few favors for Republicans wouldn't have changed that. More importantly, that doesn't have anything to do with the question: what are we going to do about the distorted market if we can't mandate people to have insurance and we don't have the (lack of) heart to tell those who didn't get insurance when they were well to go dangle?

As for the appearance of impropriety, shouldn't we worry more about an actuality than an appearance? Many, many people were whipped up into a frenzy about government takeovers and death panels when in fact people would be keeping their own insurance, the government option got shot down (huge change we're ignoring here), and the death panels were either a deliberate lie from the right or the product of a moron's nightmares. This resembled as much of a Danish cartoon frenzy than an informed revolt.

And again, the Dems took a beating at the polls for a variety of other issues, ranging from an random oil well explosion to the real sinker, which was the economy. People vote against incumbents when the economy *****. Dems were in power. The people didn't feel a direct benefit from the bailouts, and the economy is still sagging. They felt it went to Wall street and not Main street (which is kinda interesting because if anything the republican party is the one known for favoring benefits to the rich to stimulate the economy).

Let's draw a little parallel here. There was an (economic) threat, potentially urgent. The solution was extremely expensive, but was felt necessary at that time to prevent a (financial meltdown). Go and replace those two bits with "WMD" and "terror attack" and you have Bush's plan to invade Iraq. Lots of people on the hawkish or right side feel that was still a good idea, and necessary, but down the road, it appears there wasn't an active WMD program, and the war was mismanaged and resulted in a huge clusterf**k with tons of blood and treasure lost.

The war was supposed to cost 50-60 billion; its probably more like 3 trillion.
http://www.washingtonpost.com/wp-dyn/co ... 02200.html

The bailout was 4.6 trillion, with 2 trillion still outstanding.
http://www.ourfuture.org/blog-entry/201 ... ilout-date

I mention this because the costs were about the same. Except, we'll never know if the bailouts prevented a second great depression, we only know that the war turned out not to have been necessary,* whether it seemed so at the time or not. Also more people died in the war. And I think the administration did a poor job of selling the bailouts and healthcare; they really lost the debates talking when others were shouting. Big expensive programs like these cost votes. And anyone who was forgiving of the war's faults might want to consider extending the same generosity here.**

It's also worth pointing out that there is no reason for the Dems to want to hold on to power rather than get shellacked, if they never intend to use it. But they did use it. They created an enormous program of their liking, in an area which has defied progress for decades of sequential presidents, which if it survives court challenges, is likely to live on, at least in part. Voters will find they like the coverage it provides and other aspects (anti-fraud and others) may prove their worth. If the Dems change America for generations, that was a shellacking well spent.

As for the working with Republicans stuff, let me rereiterate my point that both sides have been really unimpressive in their diplomacy. Know why the president hasn't appointed enough judiciary? Republicans. Which side just held government hostage (including the Zadroga bill for the 9/11 workers) until they got what they wanted on the tax deal? Republicans.

*I'm not saying there haven't been benefits, but by necessary I mean to take WMD away from a psycho. If anyone is up for that I'll see you at the DMZ with a gas mask and a bayonet.

**I always complain about the war so let me rereiterate my point that many of the costs weren't appropriately related to the point of the stimulus. Not pleased about that.

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PostPosted: Thu Dec 30, 2010 2:17 am 
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Jason Rees wrote:
Yes, Republicans made demands (it's funny how Democrats sticking to their 'guns' on things like keeping insurance - except federally-provided insurance - from crossing state lines isn't 'demanding' anything).

I never said it wasn't. Both sides make demands all the time, that's part of the definition of politics.
Quote:
Yes, there were negotiations... but pretending that Republican concerns were addressed in that bill is a gross mis-characterization.

<snip>But luring a few votes from the Republican side with a mixed goody bag isn't the same as actually working with Republicans. It's no secret Democrats had what they needed, and ignored Republican amendments and requests for debate on bill after bill after bill.

A vote on party lines takes two sides to make it happen.

Exactly my point. Bill keeps indicating that what the Dems did was unique, but there was nothing unique about it, it was just party politics as usual. That is the whole purpose of the party whips afterall, to coerce party members to vote the party line under threat of making the next primary very difficult for them.

What the Dems did in passing the health care bill was no different then, for example, what the Republicans did in 2001 in passing the Bush tax cuts without working with the Dems. Both bills have been criticized as only further entrenching the division between the parties. Both parties have played this game, both will continue to play it (and other games), and both will criticize the other when it is done against them.

However, as one Congressman pointed out earlier this year during an interview, the public only hears about the few controversial bills that divide the parties, not about all the times they do work together. During the 111th Congress (2009-2010), 6561 bills were in process in the House and 4058 in the Senate, and for the most part we heard about a grand total of one of those, because it was the only one controversial enough to capture media attention. That media filter definitely influences our perception of how well the parties really work together in Congress.

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PostPosted: Fri Dec 31, 2010 4:48 pm 
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Jason answered Glenn the way I would have.

Discussions among politicians about politics sometimes remind me of discussions I have with my 18-year-old son. Being hard-headed (as he is) and having done all the BS he has done - and yet succeeding anyhow - has given me an amazing BS filter. You know... that ability to translate 90 percent of a conversation to the Charlie Brown Wah wah wah wah... I learned a lot from my graduate school adviser. He set the bar very high and was brutal with his assessments. But the difference between me and the 90 percent (literally) who didn't make it is that I wanted it more. So when my son gives me reasons why his grades aren't good or why he smokes, I remind him of the difference between reasons and excuses. Then I ask him what he wants to accomplish in life.

The Democrats had a window of time to do whatever the heck they wanted to do, and they did it. Pretending they tried to negotiate is BS. They wanted what they wanted and they tried to paint the Republicans as "The party of no!" And Republicans weren't going to go on record supporting an expansion of the size and power of federal government.

And the private sector economy continued to falter. And the unemployment rate remained obscene. And Obama responded by creating temporary GOVERNMENT jobs, more government regulations, and more government programs. Are you kidding me?????

Apparently the voters saw the situation for what it was. People can come on here and talk on about reasons for this, and reasons for that. But I see the results of November 2010, and you know what? You'll have to excuse me for hearing nothing more than Wah wah wah wah... The voters (myself included) have spoken. Not listening? There's always 2012...

We are not a centrally-controlled entity, and we are not a democracy. We are a Republic. We are what the EU wants to be but hasn't been able to pull off. Yet...

Imagine if the EU dictated one form of health care for all of Europe. Don't you think there would be World War III? We'd try to stay out of it, but someone would sink one of our ships, and we'd have to go clean house and waste our time rebuilding them.

Cynical? Damn straight I am. The end cannot justify the means.

Just because there is disease doesn't mean that "your cure" is the right thing to do. Primum non nocere.

And Ian... I gave you one simple solution. You're pretending you didn't hear it. You don't like it. Fine... I can live with that. I don't claim to be "The One" but I do have principled ideas and I stand by them. And being principles-based, it's possible for a large group of people with disparate points of view to flesh them out and come up with something that we all could live with. Until we change our minds.

- Bill


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PostPosted: Sat Jan 01, 2011 4:47 am 
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Yes Bill, we are well aware you hear only what you want to hear! :D

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PostPosted: Sat Jan 01, 2011 6:17 pm 
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Glenn wrote:

Yes Bill, we are well aware you hear only what you want to hear! :D

Correction, Glenn. I (regrettably) hear it all. I choose to pay attention to that which matters.

We have a pretty simple matter here. The economy was faltering (you can blame whomever you choose), and the Democrats were given free reign to instill hope and execute some (useful) change. And what did they do?
Ian wrote:

They created an enormous program of their liking,

You argue best when you argue my point, my friend. They squandered it all by spending 100 percent of their political capital on a partisan bill that saddled my children and grandchildren with a trillion dollar program of THEIR dreams. They pi$$ed off half a nation putting this boondoggle together. And no, I don't like it. And I don't want it. And blackmailing the states by threatening to take their tax revenue and redistribute it to the players violates the general welfare clause.

Meanwhile... Unemployment GREW under their watch. Their response? Money for "shovel-ready" GOVERNMENT projects - all while the private sector suffers. You know... that bad, bad private sector economy which create all the federal revenue that progressives love so much. Dumb, dumb, dumb - even in the eyes of a progressive.

But don't take my displeasure as the rantings of a fringe lunatic. Take a look at the election results of 2010. The Democrats lost virtually all of the independents, and a good deal of the soccer mom vote as well. (Check out the stats yourself.)
Obama wrote:

I’m not recommending for every future President that they take a shellacking like they – like I did last night. I’m sure there are easier ways to learn these lessons.

Apparently some are still in denial, and find it great sport to ridicule the messenger. Keep talking!

No, I don't want more federal programs. I want a smaller federal government so there can be lower taxes. PERMANENTLY lowered taxes is the best way for American industry to get back on its feet and compete against the emerging economies of China, India, Korea, and others. Pick the "I hate that" government program or U.S. intervention of your choice and bring it to the table. We're all listening.

This thread is about yet another interesting and frankly legitimate challenge against the Democrat boondoggle. Whether you think that there is "good" in this program is immaterial. Stalin did good. Mao did good. Genghis Khan did good. But I don't want any of them running a country - even if they drive the same car I drive.

My solution? Go back to the drawing board. First do no harm. No (zero, nada, zilch) change is better than this "thing" which is eminently worth fighting against and killing. The fact that the challenges are coming on multiple legitimate fronts is very telling. It speaks to the kind of nation we are, the kind of constitution we have, and the kind of multicultural, multiethnic people who are represented by it.

Expect the following in the future:
  • At least one victory in the Supreme Court which cripples the bill.
  • To the extent that Congress won't undo this harm, a good deal of the rest can be rendered useless via defunding. It's been done before, and can be done again.

Feel free to quote me when it happens. ;)

- Bill


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PostPosted: Sat Jan 01, 2011 6:37 pm 
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IJ wrote:

If people can get most of the care they need even if they failed to seek insurance, then more sick and needy apply for insurance leaving the fewer healthy responsible people to pay for disproportionate costs. The market is distorted and prices get screwy.

So if we can't have an insurance mandate, and we continue to back up people without insurance who ought to have had it, things will never be well. What's the way around this?

Look to nations that are kicking our ass right now on the economic front. Do they have universal health care? Mandated insurance? Are their economies faltering? (Be careful when you quote your stats. I work with people from all over the world. ;))

As time goes on, this SNL skit gets more and more relevant.

Obama and Hu Jintao

Just because some people want something doesn't make it right to mandate it.

And no, the insurance market isn't falling apart. I've worked in the field (both on the inside and the outside) for 18 years. It ain't pretty, but it still functions. And the health care bill didn't kill the insurance industry or lower health care costs. It did however make everyone's rates go up faster than the prevailing trend before legislation happened.

And if the federal government won't allow insurers to compete across state lines, then it's only fair for health care solutions to be worked out at the state level.

Here are the solutions, Ian. They've been around for two decades. But Congress won't pass them.
  • Give INDIVIDUALS the tax benefit on purchasing health insurance. There's no good reason why anyone should have to work for a large corporation to get insurance via a pre-tax benefit.
  • Allow for the creation of purchasing cooperatives. Look no farther than Germany to see the concept in play. (I've been there on business, as my former company had the entire country of Germany as a customer for a product I helped upgrade.) That way the concept of pooled risk becomes a reality for individuals and small companies.
  • Let there be a two-tier system. Sorry, John "Scumbag" Edwards, but Two Americas is a very good thing. Philosophically we've always been a land of opportunity and not a land of entitlement. If you buy coverage, you get deluxe. If you don't, then you get deluxe at an ultra-deluxe (non-negotiated) price OR you get economy. There are no do-overs in life.

Problem solved.

- Bill


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PostPosted: Sat Jan 01, 2011 7:40 pm 
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I heard, and am putting aside, your 90% :)

"Give INDIVIDUALS the tax benefit on purchasing health insurance. There's no good reason why anyone should have to work for a large corporation to get insurance via a pre-tax benefit."

Eh, kinda sorta. I've already agreed with you a hundred times that the playing field should be level so that all health insurance costs are deductible, or not; I would propose that they are NOT deductible. Currently, people think that employers pay for healthcare, and they think that their wages are stagnant. In fact, employers have a certain amount of money to compensate you and overall wages have not been that stagnant, they're just being consumed by increasing healthcare costs, from which people are insulated. If people actually had skin in the game, and felt the pain of their monies headed off for various services, then it would be easier to motivate change in behavior. Right now people behave as if more is the only option, more healthcare, more expensive drugs, newer this, bigger that, mri my eyeball. That is because they think we're at one of those large birthday dinners where we all split the bill and trying to reduce costs by ordering less makes hardly any difference to your personal costs.

Anyway, your idea about deducting healthcare insurance at the individual level solves a tiny problem and does nothing about the larger issues.

"Allow for the creation of purchasing cooperatives. Look no farther than Germany to see the concept in play. (I've been there on business, as my former company had the entire country of Germany as a customer for a product I helped upgrade.) That way the concept of pooled risk becomes a reality for individuals and small companies."

Germany, eh? From Wiki:

Germany
Main article: Health care in Germany

"Germany has the world's oldest universal health care system, with origins dating back to Otto von Bismarck's Health Insurance Act of 1883.[68] As mandatory health insurance, it originally applied only to low-income workers and certain government employees, but has gradually expanded to cover the great majority of the population.[69] The system is decentralized with private practice physicians providing ambulatory care, and independent, mostly non-profit hospitals providing the majority of inpatient care. Approximately 92% of the population is covered by a 'Statutory Health Insurance' plan, which provides a standardized level of coverage through any one of approximately 1100 public or private sickness funds. Standard insurance is funded by a combination of employee contributions, employer contributions and government subsidies on a scale determined by income level. Higher income workers sometimes choose to pay a tax and opt out of the standard plan, in favor of 'private' insurance. The latter's premiums are not linked to income level but instead to health status.[70]

Historically, the level of provider reimbursement for specific services is determined through negotiations between regional physician's associations and sickness funds. Since 1976 the government has convened an annual commission, composed of representatives of business, labor, physicians, hospitals, and insurance and pharmaceutical industries.[71] The commission takes into account government policies and makes recommendations to regional associations with respect to overall expenditure targets. In 1986 expenditure caps were implemented and were tied to the age of the local population as well as the overall wage increases. Although reimbursement of providers is on a fee-for-service basis the amount to be reimbursed for each service is determined retrospectively to ensure that spending targets are not exceeded. Capitated care, such as that provided by U.S. health maintenance organizations, has been considered as a cost containment mechanism but would require consent of regional medical associations, and has not materialized.[72] Copayments were introduced in the 1980s in an attempt to prevent overutilization and control costs. The average length of hospital stay in Germany has decreased in recent years from 14 days to 9 days, still considerably longer than average stays in the U.S. (5 to 6 days).[73][74] The difference is partly driven by the fact that hospital reimbursement is chiefly a function of the number of hospital days as opposed to procedures or the patient's diagnosis. Drug costs have increased substantially, rising nearly 60% from 1991 through 2005. Despite attempts to contain costs, overall health care expenditures rose to 10.7% of GDP in 2005, comparable to other western European nations, but substantially less than that spent in the U.S. (nearly 16% of GDP).[75]

Well, at least it's decentralized. But otherwise it fits pretty well into your disaster model, with opting out by paying a tax, mandatory insurance for most, and public options. Hey, even though you cleverly (didn't!!!) say that Obamacare was like having Pol Pot and Stalin in charge, here you get to have Nazis!

"Let there be a two-tier system. Philosophically we've always been a land of opportunity and not a land of entitlement. If you buy coverage, you get deluxe. If you don't, then you get deluxe at a deluxe price OR you get economy."

I'm sorry--wait, come again? If you don't buy coverage, you get economy. If I am reading this right, and maybe this is another mine laid to be misread because it seems way out of character for you, if you don't buy insurance you get economy. You get the lower tiered insurance. You get FREE HEALTHCARE INSURANCE AND MEDICAL CARE. Which is like Obamacare except you didn't have to pay that tax to exempt.

Are you serious?? I mean, I know functionally that everyone supports this in practice as we don't think it's right for hospitals to kick leukemia patients to the curb regardless of ability to pay, but in principle, this is what happened during the Reagan years: tax cuts, without service cuts = exploding deficits. This is California, voting for prop 13, reduction in property taxes without service reductions = insolvent state. And in contrast to your simul-claim, that's quite an "entitlement."

I actually agree though. I think there should be some basic level of care that's guaranteed and we simply aren't going to be able to deny care as a country to people to poor to pay for healthcare, which is a great many. Have a heart attack? That's crushingly expensive to treat these days. Cancer? Hugely expensive drugs and hospitalizations. There is not an "economy" option that's sufficient, sadly; there is only deluxe and ultra-deuxe. If you want to save money on economy class insurance you just increase copays for visits and meds, and people don't consume them anymore. They're too pricey. Or you can reduce reimbursement and doctors stop taking that insurance. UCSD will not self refer new patients with Medi-Cal to our own clinics anymore for these reasons.

Anyway, if we're going to provide an insurance guarantee to individuals, they should also get to pay for it (=Massachusetts, = Obamacare). If we're going to insure AIG against crises, which apparently we are, there should also be quid pro quo there, too. Regulations or payment. Or we can make an upfront promise that AIG will die, or the patient will die, if they don't take precautions early enough. As I've said many times, we seem not to be able to let that happen in our culture.

Incidentally, let's dispense with that silliness about how the growing economies don't provide universal healthcare. Of course they don't. They're still poor as heck. They're growing because they have basically unlimited labor at low cost, and they're industrializing. How can a fully industrialized nation match the growth of a country going through that change?

China has crazy growth because it's industrializing. China has crazy growth because it's obliterating it's environment. China has crazy growth because it's stealing copyrighted materials and producing poisoned heparin, poisoned toys, and poisoned dog and infant food. And they crush dissidents. If you want to imply there's something to their not having universal healthcare, coolio, but then you open yourself to others who point out they have a more state controlled economy and a single party system (no gridlock--if they want to flood a valley to make a dam, they just do it), as well as inevitable confusion as to why you just advocated guaranteed economy healthcare (provided by whom, if not the government?).

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PostPosted: Sat Jan 01, 2011 10:12 pm 
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Ian

I stopped reading about halfway through. Oy!!!!

I'm an a la carte kind of guy. I generally don't eat at restaurants because they won't make things the way I want them made. I like sashimi because it's unadulterated, and I know they can't slip in the butter, salt, and sugar.

Just because I learned from Mr. Dong how to use a Sanchin posture to block a spinning hook kick doesn't mean I have to sign one of his taequondo contracts, does it? I see something I like, I use it.

Just because we copy the idea of purchasing cooperatives from Germany doesn't mean we have to join the Nazi party, does it? It also means we don't have to accept a US FEDERAL GOVERNMENT MANDATE to purchase insurance.

Nice try...

By the way, keep dissing China. A third of the people I work with were born in China. Why? They (like yours truly) weren't afraid to work hard and get an advanced degree in science and/or math. Many are Yale or Harvard grads. Meanwhile... I'm one of the few "native Americans" hired for our growing unit. We can't seem to keep it fully staffed; there aren't enough like us to hire. China the country keeps buying more and more of the U.S. China the country is becoming more and more influential, and is beginning to flex its muscle on occasion - as they should.

Communism and totalitarianism aside, we could learn a thing or two from them as well. Or not... Personally I like my friends from various parts of China, and what they contribute to my world.

- Bill


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PostPosted: Sun Jan 02, 2011 9:17 pm 
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Sometimes I respond directly to you and you tell me I haven't read your posts; you're telling me you only read half of mine?

Anyhoo.

Your points are limited to saying we don't have to take all of Germany's ideas, just one. True. Sometimes, however, things work in concert. Like vitamins. And there is something to be said for considering all of the ideas a country employs along with one you like.

You did not comment on:

1) my point about how disguising employment contributions that go to healthcare as essentially free distorts the market for healthcare.

2) the big issue that you seem to be endorsing a guarantee of healthcare, but without the requirement to get insurance or pay a tax.

As for China, I'm not dissing your Chinese coworkers. Those are individuals. As you are probably aware UCSD and much of academia is chock full of bright and hard working Asians and I don't begrudge them their success in the slightest, nor does their race or origin cross my mind. The only time it does is when I am chatting with my VERY ESL Chinese friend who is here on a student visa.

I specifically critiqued China's well known environmental issues, its well known copyright abuses, its well known product safety issues, and its well known suppression of dissent (and human rights abuses). I forgot to mention that it sponsors cyber attacks, particularly on the West. I am right to critique all of these things (as you put it, "communism and totalitarianism aside...", but I have trouble putting those things aside).

It's also a fact that having a ton of cheap labor and being in the process of industrializing should yield plenty of economic growth. Americans simply won't do some of the lower paid work they're raking in money doing. We're too well off / spoiled. That's just how things work--production shifts to consumption. Right now we're at odds with our hungry-enough-to-do-it workforce because they're largely illegal immigrants.

Anyway, none of this suggests in the slightest that I would think we don't have things to learn from the Chinese. In the future don't worry that if I critique a totalitarian state that I'm against your Chinese friends or don't recognize China's influence (see numerous posts to that effect for details).

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PostPosted: Mon Jan 03, 2011 4:50 pm 
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IJ wrote:

You did not comment on:

1) my point about how disguising employment contributions that go to healthcare as essentially free distorts the market for healthcare.

Why should I comment on something that you present as fact when it isn't? Fercryinoutloud, Ian. Don't you ever fill out your forms every year which itemize the a-la-carte benefits you choose for your pre-tax compensation? Or does the little lady do it for you? (jk) Do you do your own income taxes, or do you just turn it all over to H&R Blockhead?

Much has been written about the effects of third-party reimbursement. But nobody in health services research characterizes employment-based insurance this way.

If you supported my position of giving the pre-tax benefit to the individual, then all of this world would go away. But no... you blew it off as being "Eh, kinda sorta." Then you pretend you are misunderstood. What-ever....

In your spare time, I suggest you attend some classes in any MBA program. They might learn you a few things about what's relevant for pre vs. post tax expenditures. Better yet, run your own business some time. (Been there, done that BTW.)
IJ wrote:

You did not comment on:

****

2) the big issue that you seem to be endorsing a guarantee of healthcare, but without the requirement to get insurance or pay a tax.

Why should I comment on a misrepresentation of my position?

There are no guarantees in life, and nothing is free. As I've said over and over again, I live in the land of opportunity, and NOT the land of entitlement. Hunger and pain are wonderful motivators. Without them, most people won't get out of bed in the morning. Greed/passion (the carrot) and pain (the stick) are what make our system work. The difference between you and I is I don't do the BS warm and fuzzy dance.

Can I be any more clear? Your debating style is a non-starter. I can't communicate with you when you do this. You say things that aren't true, and then launch off of your false foundation. I don't bother to follow the flight of said verbal excursions.

Nice try though... You get points for creativity. I enjoy debating with you - even when it appears frustrating to you.

- Bill


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