
House Passes Health Care Reform - Xichekolas
http://www.latimes.com/features/health/la-na-healthcare-passage22-2010mar22,0,2788293.story
======
grandalf
One thing that bothers me about taxes is that they are around 20-30% of
profits. If you take on a business partner and give him/her 20%, you expect
something in return.

What do we get for our taxes? Wars and social programs that will be bankrupt
long before we can benefit from them. (roads, etc., are < 1%).

I would be OK with paying the taxes for social programs if I thought those
programs would be sustainable into my old age, but they aren't and nobody
seems to care, even though this is widely known.

So when you write the IRS a big check, you are paying for old people, and when
you are old you will not receive the same treatment.

By the way, most of the cost of healthcare is in areas where the money has
very little yield, such as end of life care for the elderly, bypass
operations, stents, and statins. If people actually had the opportunity to
consider the value of healthcare, reform would be nothing like what it is now.

Next time you see an old person eating bacon and eggs in a restaurant, picture
that person's bypass operation, years of statins, and excessive end of life
care that you are paying for... and think to yourself how perverse "reform"
is.

Meanwhile, there are millions of so-called "illegal immigrants" who can't even
call the police if they are assaulted or abused (for fear of deportation)
being left out of the reform.

Most of your income taxes go to wars and medicare, and most of the healthcare
reform goes to the practitioners who practice useless surgeries and
interventions on a vulnerable population of elderly.

The "reform" bills don't change anything, they just transfer even more of the
wealth of young people to the elderly and their exploiters.

~~~
MartinCron
I like driving too, but don't focus too narrowly on roads. I think you're
getting benefit from more than < 1% of taxation. Public education helps
everyone. Research helps everyone. Having a criminal justice system helps
everyone (well, the non-violent drug offenders would disagree). Having a
strong civil legal system helps everyone. Meat inspectors help everyone.
Financial regulators help everyone.

You could even say that knowing that we don't have senior citizens starving
and dying in the streets as helping everyone. I _like_ knowing that I live in
a society that takes care of many of the less fortunate.

I'm not saying that government is good at solving every problem, but focusing
on just roads, wars, and old people is very narrow.

~~~
muhfuhkuh
I always have and always will take umbrage with how people downplay the
government's role in ameliorating the lives of people.

Case in point, can anyone really deny that the overwhelming majority of the
cures and vaccines for deadly afflictions that have plagued the US (and the
planet, for that matter) have been developed in a university or non-profit lab
under the funding, technology transfer, and/or support of governments (in the
US case, the NIH)? Polio (Salk), TB vaccine (Calmette), the list goes on.
Hell, even Norman Borlaug helped eradicate famine in several parts of the 3rd
world under the encouragement (and part-funding) of the Roosevelt
administration.

You're right that it's not just about socialized interstates and bunker bombs.
It's truly about doing those things that just _cannot_ fit on any sane balance
sheet trading on Wall Street (or if they tried, investors would truly revolt).

~~~
grandalf
Ok so you've successfully argued for 1% of the Federal budget and 5% of state
budgets. I hope you're not going to stop your thought process there.

~~~
muhfuhkuh
Manned space missions that go more than "just passed the exosphere", making
sure people with the pre-existing condition called "old" and "dirt poor" and
the extra-duper fun combination "old and dirt poor" are actually not left to
die on the streets with a simple infection, networks of massive national
laboratories whose prime mission is to secure technologies and advance science
for one of the most technologically advanced and by far most innovative
countries on earth (perhaps not in the adoption of personal electronics, but
we surely laid the foundation for all innovation, not the least of which was
von Neumann and his work with Eckert and Mauchly's ENIAC, the first programmed
computer). Those labs take several billion a year each to operate, and have
arguably single-handedly placed and kept the US at the forefront of technology
for decades.

I'm not going to pussy-foot around it, we spend 50% of our tax dollar on
defense, and most of that into personnel and pure weapons r&d and
manufacturing. It's a shame, but it's the truth. Just imagine if we could
refocus those dollars elsewhere (in an ideal world, anyway), where would we be
now?

More importantly, why hasn't private industry come and done it for us?

------
kgrin
For all of the talk about the impact of higher cap gains taxes on startups,
the far more important impact is likely to be that potential founders will
have a (slightly) easier time leaving their jobs and purchasing insurance on a
less-broken individual market.

~~~
gte910h
The day pre-existing conditions don't matter is the day the us _explodes_ with
small businesses.

~~~
jacoblyles
As a counterpoint, countries that already have this are far behind the US in
small business creation. Despite this supposed handicap, the United States has
the most dynamic large economy in the world. It turns out that the government
soaking up a large portion of the GDP to pay for expensive public benefits
diverts capital away from financing private ventures, and this has a
detrimental effect on entrepreneurship.

If universal health care were really that important to entrepreneurship, why
isn't Silicon Valley in Europe?

~~~
credo
>>As a counterpoint, countries that already have this are far behind the US in
small business creation.

Do you have any data to back up your assertion ?

According to [http://www.cepr.net/documents/publications/small-
business-20...](http://www.cepr.net/documents/publications/small-
business-2009-08.pdf) "By every measure of small-business employment, the
United States has among the world’s smallest small-business sectors (as a
proportion of total national employment)."

~~~
jacoblyles
That's certainly an interesting link. I knew that over 99% of US businesses
are considered "small" employing half the population, but I didn't know that
Europe had such a vibrant entrepreneurial society. I'll admit, I'm in middle
of a Programming Languages final so I didn't do a lot of statistical digging
and relied on anecdote instead.

Still the authors of that study do appear to have an ideological axe to grind.
I would be interested in researching the matter further from a less
ideological source. I'm curious why we think of the United States having such
a large share of the world's startups and invention if it isn't true.

~~~
jacoblyles
And it does strike me as weird that I have a lot of friends from third world
countries that come here because they view America as the land of
entrepreneurial opportunity, when this study shows that they would be much
better off in Germany.

~~~
thomasz
There are factors that are equally or even more important, like taxes,
availability of capital, bureaucratic hurdles etc. I once heard from a German
restaurant owner that he fought 12 years to get a permission to put tables in
the garden...

~~~
eru
Another factor might be that it's possible to get accepted as an American in a
few years. In Germany you may be a naturalized citizen on paper--but the real
social acceptance of compatriots runs through bloodlines. (I.e. you have to
look the part, too.)

Not that they won't be nice to you. But your children will stay, say, "Turks"
in the third generation and onwards.

------
aresant
I promise +1 Karma to the first person that puts together an infographic
actually explaining where, exactly, $100 billion a year of tax payer money is
going to go, and what we are going to get in exchange.

I am all for affordable healthcare for everybody, just desperately afraid of
how the gov't typically overspends.

~~~
anonjon
I think the idea that government naturally has to overspend is wrong. It is a
meme that people tend to trot out whenever there is a political discussion
(along with _the other side is bums_ and _politicians are unethical crooks_ ).

In this particular case, the idea is that we pay $100 billion a year of tax
payer money. (For comparison sake, the F-22 program alone cost 65 billion
including development. You could only buy 500 F-22s for $100 billion)

With that 100 billion dollars, we attempt to bring into line the 2.3 trillion
dollars that we spend a year on healthcare. (16% of GDP).

16% of GDP is way more than other western countries spend on healthcare.
[http://en.wikipedia.org/wiki/Health_care_compared#Cross-
coun...](http://en.wikipedia.org/wiki/Health_care_compared#Cross-
country_comparisons)

Other western countries spend about 8-10% GDP on healthcare.

So lets do the math. Lets say we spend tax money on healthcare and we only
manage to get it down 1% from 16% to 15%. That would be a 1/16th reduction on
2.3 trillion dollars... approximately 140 billion dollars. So if we even
manage to knock 1% off of the amount spent on healthcare by doing this, we've
sent 40 billion dollars back to the taxpayers.

If we get more than 1% off of our %GDP towards healthcare, we start making
some serious bucks for Americans. If we got our % spent on HC down to even 10%
we would have made a 540 billion dollar win on this issue.

(Yes, it comes in the form of taxes, but it also means that in the long run
you aren't paying as much for insurance premiums... health insurance premiums
might as well be a tax that doesn't go to the government, as having healthcare
isn't optional if you plan on living for a significant amount of time...)

~~~
richcollins
You are assuming that we would get the same value for the new amount spent.

~~~
anonjon
You are assuming that we are getting anywhere near optimal value from the 2.3
trillion that we already spend. Clearly we do not. Compared to other countries
there has got to be absolutely TONS of wastage.

We die sooner, we spend more of our own money and we spend more government
money.

lose/lose.

~~~
richcollins
I didn't make that assumption at all. I assumed that we will get less value
for our money the less competition and more regulation that there is. Current
regulation already keeps us far from receiving optimal value for our money.

~~~
anonjon
Your assumption is wrong, as clearly indicated by the data. Countries with
less competition and more regulation at least _appear_ to receive closer to
optimal value from their money (in the realm of healthcare).

Healthcare doesn't make sense when viewed as a market economy.

First off, there is a potentially infinite demand for healthcare. (How much
will you pay to live a little longer? As death approaches, the amount you will
pay can be seen as an asymptote towards infinity. You have to be a
particularly well balanced individual for this not to happen.)

Competing for actual finite resources (hospital beds, doctors, nurses,
medications, the drafty-but-fashionable hospital-johnny), with a number of
people who are going to die anyway, but are willing (if not able) to pay non-
finite sums of money, clearly points us towards a conflict. The only
conclusion is for the price of the finite resources to increase indefinitely.

------
defen
So I opposed this bill, but now I have an honest question: Rationally
speaking, shouldn't I cancel my health insurance? I'll pay the fine, which is
way less than my current premiums, and I'll just wait until something goes
wrong to buy insurance, since I can't be turned down.

~~~
blasdel
The ban on pre-existing condition screening doesn't kick in until ¿2014?

There's a temporary public option for the people who would otherwise still be
fucked until then. I'm not sure if you'll be able to get that on short notice.

~~~
rsheridan6
That's really not very far away. Few young healthy people are going to develop
cancer or something nasty and expensive like that in the next three and a half
years.

~~~
MartinCron
Healthy young people get in horrible car accidents all the time.

~~~
rsheridan6
What percentage of healthy young people get in car accidents that require them
to pay large medical bills, excluding those that are paid by the other
driver's insurance? I doubt it's a very large percentage. The fact that
something happens "all the time" in a nation of 300 million does not mean that
it's likely to happen to you.

~~~
btilly
Wait until you're older. While most young people don't have catastrophic
things happen. But enough do that I have no idea how many apparently healthy
young people I personally know who have contracted cancer, been in accidents,
or otherwise had sudden very large costs.

Let me give a few. A motorcycle accident broke an arm, and the other person
left with no insurance information (my brother's arm is recovered). A propane
accident lead to burns over 30% of his body (my brother-in-law Abe survived
with significant scarring, but it was touch and go for a while). Hodgkin's
lymphoma (killed Mark). A stumble leaving a Halloween part lead to falling
with the corner of the step hitting her backbone (Ardith is partially
paralyzed + has other health problems). Cancer of the small intestine lead to
major surgery and months of chemo (Euna looks like she will survive). A brain
cyst lead to balance problems and could have been lethal had it not been for
expensive brain surgery (I know 2 women this happened to, both are nicely
recovered but one had to never have kids). A jump on a dirt bike went wrong
when there proved to be a mine shaft on the other side of the hill he jumped
over (Matt is now paraplegic). Oh, and then we have depression leading to
suicide attempts (I knew multiple people who succeeded).

Then there is the chronic stuff. I know multiple people with diabetes, several
more with Chrohn's disease. Severe allergies are common and can be expensive.
Schizophrenia hits 1% of the population.

These are just some of the people I _personally_ know that stuff happened to.
Most (luckily) were covered by someone's insurance. But not all.

Yes, you can roll the dice and play roulette. Yes, young people feel immortal.
But stuff goes wrong often enough that you're highly advised not to if you
have a choice. If you pay attention and live a while, you too will collect a
nasty list of sad examples.

~~~
rsheridan6
Most of the things you mentioned, you could see coming quickly enough that you
can get on insurance if they can't deny you because of preexisting conditions.
You'll be able to get insurance _after_ your get cancer come 2014. The
exceptions are the ones involving car wrecks, falls, etc, where you don't have
time to fill out paperwork before racking up a huge bill. Even those can do no
worse than bankrupt you, and immortal 25 year olds are usually also broke 25
year olds.

Not that it's a good thing to go bankrupt, but you're talking about a low
single digit chance of an unfortunate but not disastrous event vs thousands of
dollars a year. Contrast to the old system where you were liable to go
bankrupt AND not get coverage at all with no insurance (for example, see the
immigrants who can't get dialysis who were in the press in the last year).

~~~
btilly
_Most of the things you mentioned, you could see coming quickly enough that
you can get on insurance if they can't deny you because of preexisting
conditions. You'll be able to get insurance after your get cancer come 2014.
The exceptions are the ones involving car wrecks, falls, etc, where you don't
have time to fill out paperwork before racking up a huge bill. Even those can
do no worse than bankrupt you, and immortal 25 year olds are usually also
broke 25 year olds._

Not true. First of all most of the things I mentioned were fast accidents that
gave you no warning. So your most is wrong. But it gets worse than that. I
listed no less than 4 people with cancer. Let's go through them and see what
difference insurance made.

Mark woke up, was not feeling well, then wound up in the ER that night.
Without insurance his family would have been financially hosed. (He wound up
dead within a year anyways.)

Euna brought up stomach trouble at a routine doctor's visit, the doctor
followed up, discovered an aggressive cancer at a fairly early stage. (This
was incredibly lucky for her, if the cancer had been located a few inches
farther away there would have been no symptoms at all.) Without insurance she
would not have had a regular doctor's visit, would be less likely to catch it
in time, and she'd have probably died.

The two with the brain cysts went to the doctor after developing severe
balance problems. Not having insurance would have meant living through that
while going through several weeks of paperwork. What is worse the condition
they both had is one where if you stand up and bend over you can drop dead
instantly. So without insurance a few nasty weeks with instant death quite
likely.

So the likely cost for the cancer cases if you didn't have insurance? Instant
bankruptcy, likely death, possible death, and possible death.

Now that may be bad luck, but those are just a list of people who came to mind
for me in a few minutes of thinking. YMMV but that is not a risk I
particularly desire to go through.

~~~
rsheridan6
Not having insurance is not the same as not getting checkups. It means paying
for them out of pocket, but for a healthy young person that shouldn't be too
expensive. Before the health care bill passed, there were already places like
Hello Health popping up that catered to the uninsured. There will be more of
them if people decide insurance isn't worth buying.

It also doesn't mean not getting treatment, because if you have something like
a brain cyst, the ER can't turn you away.

I also don't see why your friend's family would be financially hosed, assuming
he's over 18.

------
luigi
Another way this bill affects readers of HN: Parents can keep children up to
26 years old on their health insurance. Previously, the age limit was
determined by individual insurance companies or individual states.

~~~
ronnier
I'd be ashamed to be in my 20's and be on my parents insurance plan.

~~~
Xichekolas
So you'd be ashamed to be in grad school? (Or doing a startup right out of
college?)

Often the insurance offered by a parent's plan blows away what can be had
through the University. Of course, you can buy individual insurance fairly
cheaply... unless you aren't in perfect health, or are a girl.

~~~
ronnier
Last year I finished my graduate degree in computer science. I worked a full-
time job while doing that (also during undergrad). I'm actually pretty proud
of it. I finished up grad school with a lot of work experience, zero debt and
had insurance the entire time.

~~~
Xichekolas
And you should be proud of that.

I'm currently a CS grad student, with zero debt, working as a GTA/GRA
(depending on the semester). I get my insurance through the University for an
awesome $94 a semester, but if I were still young enough, I'd definitely opt
for my parents insurance, and I wouldn't be ashamed of it. It would just make
financial sense.

------
hzlz
[I posted this on the other thread, which seems to have been deleted as a
dupe. Sorry if it's against protocol to re-post. But I tried to find both
sides, good-and-bad wrt startups.]

Some discussion of the impact on startups in the thread at
<http://news.ycombinator.com/item?id=1208019>

While it didn't discuss all of these, it seems to me that the things that will
directly impact startuppers:

Pros

\- Community rating, no recision, etc will make it easier for people with pre-
existing conditions to get coverage. For people who have pre-existing
conditions (or who have kids who have pre-existing conditions) and don't have
a spouse at a bigco and want to do startups, it makes it possible.

\- Might also make it easier for bootstrappers to get coverage.

Cons:

\- The new taxes are concentrated on capital gains, so will tax startups and
angel investors most of all. [This bill proposes a 3.8% increase on cap gains.
The administration is also planning to change the regular cap gains from 15 to
20%, so if everything passes the rate will go from 15% to 23.8%, or a 58.6%
increase.]

\- Shifts costs from the older to the younger, so most startups here will pay
more.

\- In realistic scenarios, will probably increase the deficit, affecting
interest rates. But that's long-termand not clear.

Pro or con, depending on what you think:

\- Mandatory coverage will require that you have coverage during a
bootstrapping phase.

A mix of good and bad for startups, depending on where you are in the process.

~~~
jbarciauskas
I've heard this a number of times but not heard it detailed: in what way are
the CBO estimates unrealistic? What more realistic assumptions would you make,
and what is their effect on the deficit?

Also how is it shifting costs from the older to the younger? It seems more
that it is shifting costs from the near-bankrupt uninsured to those who make
significant portions of their income from capital gains, i.e. the wealthy.

~~~
jerf
"in what way are the CBO estimates unrealistic? What more realistic
assumptions would you make, and what is their effect on the deficit?"

The CBO is bound to look at the next ten years of effects. In order to make it
look even remotely palatable, the bill collects four years of revenues before
a significant amount of the benefits kick in. It is difficult to imagine a
reason for this that doesn't involve gaming the CBO's estimates. (It's not as
if our government is all like, "Oh, gosh, we really need to save up some money
before we hand this entitlement out." It wouldn't matter anyhow because that
wouldn't significantly affect the long term viability of this plan; what
matters is steady-state income vs. spending.) Multiplying the estimated cost
by 10/6 is a decent start to get a true view of the costs.

The CBO itself has also called attention to the fact that the scoring of this
bill assumes that the so-called "doc fix", in which the payouts given to
Medicare doctors will be cut in accordance with the law back to a certain rate
unless a bill is passed to prevent this cut. This bill is passed every year,
and there is no reason to believe this Congress will not pass that bill either
(and quite substantial reason to believe it will). You can look around for how
big that is, but it's pretty big.

This bill shifts yet more burden directly onto the States as unfunded
mandates, which are not scored as Federal burden (for instance, "Find" the
second instance of "mandate" in
[http://www.wdef.com/news/reaction_to_healthcare_reform_passa...](http://www.wdef.com/news/reaction_to_healthcare_reform_passage_pours_in/03/2010)
). Nevertheless, not only will we have to pay them, we will have to pay them
in a context where we can't even borrow our way out of it as States ability to
borrow is constrained compared to the Feds. I live in Michigan.... WTF is
Michigan going to do with another few billion in mandates?

The CBO has its scope very tightly defined by law, and it's been getting
increasingly gamed over the years. This completes the gaming. They might as
well disband the office, IMHO, Congress has figured out how to bypass them.

Costs are shifted onto younger people by the mandate for people to purchase
insurance or pay a penalty. Many of today's uninsured are young, healthy, and
uninsured by choice. You may disagree with that choice, but that's beside the
point. The point is that they are not paying into the system. Not all younger
people are affected by this due to some other provisions (nothing says
government at work like taxing with one hand and crediting with the other),
but quite a few are. Coryrc linked this, I'm "borrowing" it:
<http://www.newsweek.com/id/224020>

Incidentally, I give this provision a very high chance of being struck down on
Constitutional grounds, but that of course leaves the entire rest of the bill
in place. The CBO estimate can't assume that will happen, but if it does the
already-screwy revenue numbers just get screwier.

Please carefully read the statements I am making here and note their factual
content. I will not deny I think this bill is an enormous, enormous mistake,
but it is not my opinion that taxes are collected for four years before
benefits are paid out, it is not my opinion that the bill contains unfunded
mandates on States, it is not my opinion that younger people will have to buy
insurance or pay penalties (the reason why is arguably my opinion but
extremely-well founded). It is my opinion the CBO might as well disband. It
isn't my opinion that the insurance mandate is facing a constitutional
challenge, though of course who will win that is currently a matter of
opinion. To the best of my knowledge, these aren't "talking points", these are
simply part of the bill as it stands.

~~~
waterlesscloud
I mostly agree with you, and I do think there's a great deal of gaming going
on in the numbers.

But I also think one reason for having 4 years for the benefits to kick in is
to give the private companies implementing those benefits times to adjust.

Given that concern, it's probably not nearly enough time.

------
dryicerx
A startup/small-business related point on the bill is _"A tax credit becomes
available for some small businesses to help provide coverage for workers."_

Just trying to make the top story in HN at least a tiny bit relevant to HN...

~~~
tptacek
From my casual read, that's for businesses where the average wage is pretty
close to the minimum wage.

~~~
blogimus
Average wages need to be $50,000 or less:

From WSJ:
[http://online.wsj.com/article/SB2000142405274870453490457513...](http://online.wsj.com/article/SB20001424052748704534904575132110999558770.html)

Tax credits for businesses: Businesses with fewer than 25 employees and
average wages of less than $50,000 could qualify for a tax credit of up to 35
percent of the cost of their premiums.

~~~
cloudkj
How does equity figure into the equation? I'm guessing even equity doesn't
matter much for startups, since they'll have very low valuation to begin with
anyways.

------
rajat
Why should the average 20-30+ year old even carry insurance? The penalty is
only $250 a year, rising to $750 in a few years. They can't deny you insurance
based on pre-exiting issues. So why not just pay the penalty, which can be
substantially less than the policy, until you have an issue?

~~~
chancho
$750/year is about the cost of so-called "catastrophic" insurance: high
deductible, low monthly. Worthless for the kind of chronic ailments that old
people suffer, invaluable for things like car accidents or leukemia. Only an
idiot would rather pay the fine than buy this kind of insurance.

~~~
rajat
Catastrophic insurance, with a high deductible, is what I carry. They are
going to be grandfathered, but no new policies of this kind will be allowed
under this law. An all encompassing health insurance, with the kind of
deductible they have legislated, is not cheap.

~~~
chancho
Ah, I wasn't aware. (Shows what I know about this bill.)

While catastrophic insurance is a good deal for young unmarried people, part
of me thinks it's not how health insurance is supposed to work. If you're not
spreading the cost of caring for old/sick people among young/healthy people
then what's the point?

The other part of me thinks it's just a handout to the insurance industry and
people such as yourself shouldn't have to pay a dime for someone else's
overpriced cholesterol drugs or 3D ultrasound.

~~~
wisty
Catastrophic insurance is exactly how insurance is meant to work. If you want
to save for medical procedures in your old age, you can get a savers account.

The whole point of insurance is that a big financial hit (caused by your house
burning down, cancer, whatever) causes a non-linear amount of suffering. A few
dollars (paid by 99 lucky healthy people) isn't noticeable, but the one guy
who can now afford his emergency operation is a thousand times happier. Total
cost = 100 _$750. Total happiness = 99_ (-meh) + 1 * (OMG I'll see my
grandchildren!!!).

I don't like the whole "forced savings" thing. If you get to 80, and can't
afford an operation that you probably don't need, and didn't save for it, and
your family won't bail you out ... everyone is mortal.

I guess you could say that people don't have the discipline to save. Fine. Tax
the young, and give cash to old people. But don't treat health insurance as a
pension - why should young people subsidize old people who want expensive (but
most likely useless) operations, but not subsidize old people who can live
with the fact that they are mortal and would rather have few bucks to spend at
the Bingo club?

~~~
foldr
What do you do if you get a serious condition in your 20s? Not particularly
common, but I certainly wouldn't feel good if I wasn't covered for it.

Also, most people literally cannot afford to save up hundreds of thousands of
dollars over their lifetime. Nonetheless, this is what they might end up
having to pay in medical expenses.

I can't see any hint of a practical or sensible option in what you're saying.

~~~
wisty
If you get a serious condition in your 20s, that's what you should be covered
by with cat- insurance.

If everyone needs "hundreds of thousands of dollars over their lifetime" they
are getting too much healthcare. That's my other point - we sink all the money
into more-or-less useless operations on old people who are about to kick the
bucket.

Healthcare is best directed towards younger people, where it can make a
difference. Old people often get stuff that's likely to be net negative (side
effects, complications, etc) because the hospitals want to make money off the
procedures.

~~~
foldr
I guess I'm not understanding what this "catastrophic insurance" is supposed
to be. If it covers any medical condition that you might get in your 20s --
_without_ charging enormous co-pays -- then it seems an awful lot like regular
insurance. I can't see any reason why someone in their 20s would need less
coverage than someone in their 70s. You may be less likely to get sick, but if
you do get sick, you'll want that coverage even more than someone in their 70s
(since you have more to lose).

>If everyone needs "hundreds of thousands of dollars over their lifetime" they
are getting too much healthcare.

Eh? I never suggested that everyone needed to spend that amount. But some
individuals will, and not just for "useless operations." There are plenty of
cancer survivors who are in that degree of debt.

>Healthcare is best directed towards younger people, where it can make a
difference.

I hate how the terms of the debate in America are so selfish. In no other
country is there any perception that the old and the young are somehow
conflicting interest groups in healthcare. The discussion of this issue is a
symptom of the bitterness, cynicism, and (frankly) utter insanity brought
about by decades of buying and selling healthcare as a commodity. I just can't
engage on this point; I'm baffled by it.

------
aresant
An interesting aside - house dems tacked onto this bill an overhaul of student
lending which eliminated $60b of private lending in exchange for a wholly
gov't controlled program:

[http://www.washingtonpost.com/wp-
dyn/content/article/2010/03...](http://www.washingtonpost.com/wp-
dyn/content/article/2010/03/21/AR2010032103548.html)

------
andybak
You've got some incredibly complex proposals being thrown into an incredibly
complicated system (and by that I mean the entirety of the social, political
and economic realm - not just health-care).

The law of unintended consequences is going to play out here massively. Not
only is it an intractable problem to predict the outcome from our perspective
but it will be near-impossible for historians in decades hence to look back
and separate which of their present society's ills were caused by this bill or
by the million other factors that occurred in the intervening years.

------
jacoblyles
It's going to be interesting to see if the Supreme Court finds that the
Constitution allows the Federal government to force people to buy health
insurance. With a 4 liberal, 4 conservative, and 1 swing vote split, they
could go either way.

One thing's for sure, this bill will be challenged.

~~~
btilly
The court is not all about politics.

The whole thing is about regulating a commercial transaction (buying health
insurance) and taxes (aka fees). Both are areas that there is a _lot_ of
precedent saying that Congress is within its rights.

------
grandalf
We should all be wary of the mandate. The uninsured used to be victims, and
soon they will be criminals.

------
InclinedPlane
Missing in this thread so far is a discussion of whether or not this bill is
even remotely constitutional.

Not only does it seemingly institute a poll tax, it stretches the "commerce
clause" of the constitution beyond all reasonable limits, it violates the 10th
amendment, and article 2 section 8.

But I suppose all of that will become irrelevant in our glorious new future
where the life of every citizen of the US is dependent on the efficiency,
fiscal discipline, and humane kindness of federal and state bureaucracies.
Indeed, this is a future I think we all look forward to, as all of these
glorious institutions have provided a hearteningly robust history exemplifying
all of those qualities to the fullest. Haven't they?

~~~
jrockway
_the life of every citizen of the US is dependent on the efficiency, fiscal
discipline, and humane kindness of federal and state bureaucracies_

How? Get some cash, find a doctor, and give him cash to fix you. Nothing is
stopping you from doing that under the new system.

 _it violates the 10th amendment, and article 2 section 8_

No, it doesn't. You can argue that the 10th amendment didn't go far enough,
but that is orthogonal.

The new healthcare regulations are not unprecedented; consider agencies like
the FAA and the FCC (shouldn't each state regulate their airspace and radio
spectrum), FHA (shouldn't each state build their own expressway system?), etc.
Basically, your argument makes about as much sense as "income tax is illegal",
and regardless of how you feel, the constitutional law is not on your side.

Were you really making so much money on capital gains that this is going to
affect you negatively in any way?

~~~
InclinedPlane
_How? Get some cash, find a doctor, and give him cash to fix you. Nothing is
stopping you from doing that under the new system._

I find it intriguing that your purported solution to the limitations of this
legislation is the very antithesis of the program itself. This seems like a
weakness in the reasoning behind the plan. Not to mention that the problem is
more that the quality of care, at any price, will degrade and that we will all
become less wealthy as our government takes more of our money and spends it
ever less efficiently.

Also, each state does own, build, and operate their own expressway systems.
How exactly do you imagine the FHWA operates? There is not some federal agency
that builds interstates across the nation, ignoring state boundaries. Rather,
the FHWA provides a set of standards, design advice, and substantial federal
funding to local agencies which then make their own decisions on building
their own roads. The US government doesn't own and didn't authorize or oversee
the construction of, say, I-5 or I-95 they merely coordinated with local
governments to do so. This is how a healthy cooperation across local and
federal government works.

Anyone who doesn't recognize that this bill represents an unprecedented leap
in the involvement of the federal government in every individual's business
and livelihood is living in a fantasy world.

 _Were you really making so much money on capital gains that this is going to
affect you negatively in any way?_

This is a specious argument. They came for X, and I did nothing... Principles
matter. Extorting taxes out of others to pay for your own healthcare may seem
just fine and dandy an idea if no one you or I know would pay those taxes, but
it's a bad idea on principle.

To adapt a common phrase, those who sacrifice liberty for universal healthcare
deserve neither.

~~~
jrockway
What liberty is being sacrificed?

(Example: I went to the pharmacy to refill a prescription, but it was a few
days early and my insurance company would not pay. The cost of the drug to the
insurance company is $18 -- I pay $10, they pay $8. Without my insurance,
though, the cost of the drug is $85. That's the free market at work -- liberty
indeed.)

~~~
InclinedPlane
The liberty of doctors and drug makers to set their own prices, the liberty of
individuals to decide their own degree of health insurance coverage. Today we
have precious little of this liberty already (I suspect that you imagine that
square 1, the present situation, is some sort of laissez faire free for all
market economy, but that couldn't be further from the truth), tomorrow we will
have even less.

Given that the US has been the engine of medical advancements in the world for
the past several decades (though you'd expect the EU, with a similar
population and wealth to at least match America's contributions), it seems
that perhaps there is some correlation between the ability to earn a profit on
the sale of new drugs and new treatments and the development of those
treatments.

Now, indeed, this correlation seems to hold in every other industry as well,
and everyone accepts that. We understand that Apple would not spend its
efforts developing the iPad were it not assured of a hefty profit. We
understand that Tesla motors would not have poured the significant amount of
R&D into developing their roadster if they did not expect to make
significantly more in sales.

And yet somehow our reason flies out the window when it comes to medical care,
because we can't imagine the "unfairness" of a system which doesn't cover
everyone exactly 100% equally. Sad to say but the universe is unfair. I
believe that it's important that we ensure that life-saving care is always
available to people regardless of whether they are able to pay or not, but I
do not believe that medical care can or should be "free" or entirely
government subsidized for everyone.

That path is the way not only to the stagnation of medical advances but also
to the ultimate bureaucratization of the medical industry. We can look forward
to more and more people deciding to become software developers, lawyers, or
oil and gas engineers instead of doctors, nurses, or pharmaceutical
researchers. And we can look forward to a system ever more encumbered by red
tape and the inefficiency of bureaucracy at every step. In what fantasy world
could anyone imagine that the results will be any different?

We should rejoice that it's even remotely possible to trade dollars for
health. We should thank all of the people who spent so much effort going
through medical school, nursing school, or acquiring chemistry degrees, and
who spend so much effort keeping up with the state of the industry. If instead
we vilify these folks as extortionists and financial nuisances, if we portray
them as providing services that we DESERVE to receive as a birth right for a
pittance, then we will drive them away. We will end up with fewer and more
mediocre doctors and researchers.

And we will kill the goose that lays the golden eggs.

~~~
arethuza
"because we can't imagine the "unfairness" of a system which doesn't cover
everyone exactly 100% equally."

The system in the UK doesn't even pretend to have "100% equality" - if you
want to you can go to private health providers and insurers. Very few people
do though because the socialized care from the NHS is often good enough.

As for complaints about bureaucracy - I'm always amazed at how little
bureaucracy is involved. Only time I can remember signing a form in a hospital
was after my wife had a climbing accident and the hospital wanted to keep her
in longer but she wanted to go home - so we had to sign some disclaimer.

Maybe I am a socialist or something, but I actually really like the idea of
everyone in this country getting pretty decent healthcare that is free at the
point of delivery. Of course, I know that I am taxed for it in various ways -
but for this I am happy to pay.

------
eserorg
Pre-Market U.S. Stock Futures: <http://money.cnn.com/data/premarket/>

~~~
jerf
It will be interesting to see how the markets react to this.

My personal theory, which I haven't seen anyone else state, is that the reason
we heard from the bond raters last week about how the US might lose its AAA
status is an oblique threat to so downgrade our rating if this bill passes.
Even if we merely apply the conservative "three times more than the government
says it will cost" we're stacking on another staggering amount of debt and
entitlement on an economy that can't take it. (Given our current entitlement
loadout _even if_ our economy were to start rebounding tomorrow at record pace
we're _still_ in deep trouble in the not-so-distant future... and that's
before we handed out yet more entitlements.) I'm not ready to "predict" it,
but I wouldn't be surprised we lose it in the near future, as in, single-digit
weeks.

They'll be right, too. An entity deep in debt whose only priority is to pile
it on even deeper is an entity that is not going to be cleaning up its
finances anytime soon. We'll have earned it.

~~~
dennisgorelik
I wish they (President and Congress) closed Iraq's financial black hole first
and only then entered new spending spree. That's what Obama promised during
his presidential campaign. Sigh.

~~~
david927
He found out that it's not a "financial black hole" in any sense of the word.
The opposite, it's an OPEC-killer:

[http://www.foreignpolicy.com/articles/2010/03/17/how_iraqi_o...](http://www.foreignpolicy.com/articles/2010/03/17/how_iraqi_oil_is_changing_the_world)

------
tbrooks
In order to bring down the cost of health care, the government would have to
operate the system more efficiently than the market does. I can't think of
_anything_ the government operates more efficiently than the market does.

~~~
mediaman
I'm generally pro-private sector, but the stats on our health care insurance
system are astounding. The OECD averages (which are primarily statist health
care systems) about 8.9% of GDP spent on health care. The US averages 16%. US
has fewer doctors per capita, lower physician visit frequency, lower life
spans, and more uninsured.

I'll grant you that the private sector is more efficient than the government
sector in the vast majority of cases. The health care insurance system is not
one of them.

~~~
tbrooks
I would argue that government involvement in the private sector is why our
system is broken. I don't mean for this to sound snarky, but what nation runs
a better health care system than the US? The quality (for the cost) of medical
care in the US is far better than any other nation.

Both Canada and Britain have gov't health programs. 25% of the people in
Canada wait 6 months or more for surgery, in Britain that number is higher. In
the US, only 5% wait that long. The waiting time for an MRI in Canada is 10
weeks.

~~~
gnaritas
The waiting time for a large chunk of Americans for all of those procedures is
infinite, because they can't afford them at all. That makes the Canadian and
British system look quite a lot better than ours. America has the best
emergency care system for rich people in the world, but for the average Joe
our healthcare system sucks compared to just about any of those socialized
systems. The idea that America has the best healthcare system in the world is
a joke.

~~~
jcnnghm
And that's too bad. They only people that I've ever met that don't have
insurance have enough money to pay for it, but choose not to. The poor are
already covered by social programs.

~~~
gnaritas
> They only people that I've ever met that don't have insurance have enough
> money to pay for it

Then you haven't met enough people.

> The poor are already covered by social programs.

That's a joke I hope, but it isn't at all true. Social programs tend to only
cover emergency care. If you get cancer and you're poor, you're fucked and
doomed to a slow death because emergency rooms don't do chemotherapy. Anything
that requires treatment but isn't immediately emergency life or death and
you're screwed. Do you actually know many poor people?

------
haupt
What's interesting to me is that the thing passed with absolutely no
Republican support whatsoever.

This insane partisanship cannot last.

~~~
beilabs
As an outsider (Irish) I find it interesting that this occurred. Usually at
least one backbencher in Ireland would support the opposing view based on
their own such morales. Was this down to pressure from their own party, their
constituency or just pure spite to derail something that was not their own
idea in the first place?

I'm not pro/against the issue; I have no stake in US healthcare.

~~~
waterlesscloud
There's also the possibility that they believe it's bad legislation. And the
the democrats voted for it as a partisan measure.

Just throwing that out there.

I've never understood why it's only the opposition that can be partisan and
not the majority.

------
SlyShy
I sometimes wonder if these stories belong here, due to the incendiary
properties and tangential relationship to start-ups. Not that I don't think
Hacker News could handle the discussion more or less maturely.

~~~
curtis
If any such story ever belongs on HN, I think you can make a case that this
story is it.

------
DanielBMarkham
I have been biting my tongue on other venues regarding this bill, which is a
good sign it's probably not a good idea to discuss here.

Having said that, I'll put on my business hat and begin adapting. What's this
mean for my startup?

1) Those of you who say the country is waiting for affordable insurance until
startups take off are smoking crack. It's a great benefit, sure, but young
folks don't need health insurance and startups are lucky to keep the lights
on, much less pay fines to have everybody insured. The process of getting new
employees may greatly be enhanced, but we need a thousand pre-employee
startups for every one looking for employees, so that's where to look for
impact, not with insurance. Not sure there is any impact at all for dirt-poor
young startups. It should be interesting how the income requirements work --
can you get 15K in investments and keep that for operating? Or does that make
you rich enough to start having to pay fines? Having said all of that (which
you might hate), it's a great thing to keep your insurance.

2) Those of you saying that it's the end of Western free civilization are
completely overstating the case as well. It's going to add 16 thousand new IRS
agents, sure, and there will undoubtedly be new regulatory burdens associated
with hiring employees and growing. The key metric to watch here is public
debt. We're in a debt explosion and, to some, this just pours gasoline on the
fire. If that assumption is true, and I believe it is, then watching the
national debt rating could be an early indicator that different business
configurations might be better than locating and operating in the states.
(That doesn't mean you can't start out here, just once in growth mode getting
the hell out of Dodge might be worth it) If the country is going broke, sooner
or later somebody is going to come looking for any profits you might be
making. I'm not saying it is or it isn't. I'm saying that it looks like a
legit concern to me -- you can do the math.

3) Medical and insurance discussions will now become political ones. In other
words, somebody has to say "no" in order for any kind of health service plan
to work without going broke. It used to be those people were the insurance
companies. It was a lot of fun hating the insurance companies. Now that we're
regulating the insurance companies like utilities, however, that person is
going to be some bureaucrat somewhere. Your best access to him, if you have an
employee with a complaint or are looking for some kind of change, is probably
through your Congressman, giving your local Congressional weasel even more
power than he currently has. This means all startups, from dollar one, need to
have some face time with their Congressperson if at all possible. Increasingly
he/she is the guy who influences more and more details of operating --
bandwidth availability, insurance standards (now), investment criteria, etc.

I hope that sounded reasonably neutral. I certainly didn't feel angry while
writing it. While the immediate impacts are very low, over time I think this
is a major change in the country's direction. Small business guys need to pay
attention.

------
abrown28
well... 234 years was a good run.

~~~
marshallp
234 was a good run ... of not being a country civilized enough to look after
it all it's sick

------
patrickgzill
I think the Amish will suddenly start gaining a lot of new, adult members.

This bill is an abomination.

~~~
marshallp
Your thinking on this matter are an abomination

~~~
Locke1689
As an explanation of why you're being downvoted, neither of you are
contributing anything to this discussion -- keep flame wars out of HN, ok?

