Obamacare is a triumph of inverted fascism. Forcing people to buy (and taxpayers to subsidize) grossly overpriced, grossly underprotective private insurance may have been the only health-care reform Congress was capable of delivering, but it’s a sad reflection of how far to the right the Democratic Party has moved since the days of FDR and LBJ.

I’m happy for Obamacare’s poster-child beneficiaries — new Medicaid patients, people with pre-existing conditions, people threatened with rescission, young adults on their parents’ policies, and the like. But what the Act gives us on balance is a system that provides coverage ranging from clearly inadequate (bronze) to very good (platinum) to around 91% of the population at a cost of over 20% of GDP. When you compare that to the health-care systems of other developed countries — which provide coverage ranging from very good to excellent to 100% of their populations at an average cost of 10% of GDP (12% of GDP at the high end) — you realize that the American for-profit health sector is siphoning at least an extra trillion dollars a year out of our pockets (20% minus 12%, times our $14.7 trillion GDP). Tune out all of the party-loyalist talking points and it’s hard not to suspect that protecting that $1 trillion skim was the legislation’s core guiding principle all along.

With the Bankruptcy Reform Act of 2005 — passed with the votes of my two “liberal” Democratic senators — it’s harder than ever to get a fresh start by filing for bankruptcy. But given that the only Obamacare policies tens of millions of us will be able to afford are the bronze-level plans with a 60% actuarial value, and given Obamacare’s exceedingly high caps on out-of-pockets, almost as many of us are going to be filing for “medical” bankruptcy as before. (With the advent of Romneycare, the percentage of bankruptcies filed for medically related reasons in Massachusetts dropped an unimpressive 8 percentage points, from ~59% to ~51%.)

Too bad NOM didn’t ask its followers to boycott Microsoft, Apple, and Google instead. That would keep most of them off the Internet…

There are so many potential examples to choose from, but the one Santorum and his followers remind me of most is Francisco Franco’s Falangist Spain.

Nope. Our healthcare-related tax burden is higher than anywhere else except Norway (oil-rich and heavily taxed generally), Switzerland (where ~2/3 of insureds have their premiums subsidized), and Luxembourg (a tiny, ultra-rich international banking haven). In the rest of the First World, healthcare-related taxes go primarily to pay for cost-effective healthcare. In the US, a really big chunk goes to pay for provider “monopoly profits” — our medical prices are much higher than they would be if monopsonistically negotiated by a single bargaining agent, as is generally the case elsewhere — and for the administrative costs and profits of a fragmented, inefficient insurance system dealing with tens of thousands of separate, constantly changing pools of insureds. A single-payer system would eliminate those parasitic drains and allow much more of our already high healthcare-related taxes to go to actual, cost-effective care. See, e.g.:

The questions our healthcare debate ignores
http://www.salon.com/2009/03/09/healthcare_5/

* * *

Although the public share of health expenditure in the United States is much lower than any other OECD country except Mexico,[*] the public expenditure on healthcare is much higher per capita than in most OECD countries. So we pay a lot more in taxes devoted to medical care — not including insurance premiums, co-payments, fees, and other health costs -– than taxpayers in those 27 countries that have universal coverage. Our public expenditure provides coverage only for the elderly and some of the poor (through Medicaid and the SCHIP program for children)[**] while other countries provide universal coverage while spending less.

* * * *

[*] If I’m remembering correctly, I believe the public share of health expenditures might actually be lower in Greece as well (even before the current crisis). However, I don’t recall whether that survey included indirect tax subsidies in public spending.

[**] Actually, our healthcare-related taxes also pay for or subsidize Department of Defense medical care, the Veterans Health Administration, the Indian Health Service, the Federal Employee Health Benefits Program, Tricare, state and local health insurance, employer-paid premiums, and itemized deductions. The point is, we don’t get dependable, lifelong insurance and access to care at no or low out-of-pocket cost in exchange for our very high healthcare-related taxes — unlike the citizens of our peer countries.

Fair enough; no one is saying single-payer is a panacea — just much better for the vast majority of patients than what we have now or what we will have if and when the Affordable Care Act is fully implemented.

I’m curious whether you ran into any fellow patients from Switzerland or France who couldn’t get reasonably prompt, appropriate treatment for your shared condition. I’ve never come across anecdotes about excessive waits in these systems.

When you evaluate delays in other countries, remember to take into account how well their systems are funded, as well as how many subspecialists they have in your area of need. (Countries with smaller populations often have a disproportionately smaller number of subspecialists than we do.) Consider also how long your wait would have been in the US if you had not been able to afford your subsidized pre-existing condition plan. From what I’ve read, that seems to be the case for many patients with pre-existing conditions. Would you have qualified for your state’s Medicaid program? Would you have been able to find a surgeon and facility willing to treat you at Medicaid rates?

I’d also be interested to learn how the cost of your insurance and out-of-pockets compared to those of patients in other countries who did manage to get treated in time. (And of course, I’m interested in hearing about how happy their are with their medical outcomes.)

I’m glad you and other patients in your situation have reaped significant benefits from PPACA. However, I believe that all of us, including you, would have done better under Expanded and Improved Medicare For All (HR676). Barring a huge initial backlog of untreated patients, you would likely have gotten your treatment just as promptly; with a universal provider pool being paid uniform rates, you would have had your pick of any hospital and doctor that had an open slot; and it would have cost you nothing out of pocket. And I would have been happy to help pay for your treatment through my health insurance taxes, because I know I would still be coming out ahead.

I am not a lawyer and I know nothing about Commerce Clause jurisprudence. But since constitutional law is the intersection of law and politics, I’m going to go ahead and give my two cents’ worth on the individual mandate anyway:

I think an individual mandate to purchase a private product or service could arguably be a defensible exercise of federal commerce power if the product or service were so tightly regulated and price-controlled, and its benefits so egalitarian, and its cost so fairly apportioned as to make it functionally indistinguishable from a tax-funded, government-provided product or service. Switzerland’s highly regulated, highly subsidized, highly egalitarian, nonprofit multipayer system — which has an individual mandate and only costs 12% of GDP* — would probably qualify. I suspect Japan’s multipayer system might qualify as well (individual mandate, ~8.5% of GDP, great outcomes). The Patient Protection and Affordable Care Act of 2010 (PPACA), with its widely divergent benefits packages, its non-universality, its total lack of price controls, and its staggering cost (>20% of GDP) doesn’t even come close. In the context of PPACA, the individual mandate amounts to the federal government pimping out the citizenry to a predatory, parastic industry to have even more blood sucked out of them. (It will bleed fewer individual patients to death, true, given that PPACA’s other provisions curb some of the most egregious insurance company abuses, but it will definitely suck more blood out of them in the aggregate.)

I don’t mind being required to pay my fair share for an efficient, equitable healthcare system, but I object to being pimped out to Big Health. I’m firmly with the single-payer doctors on this one.

*If you exclude the small, ultra-wealthy tax haven of Luxembourg, Switzerland has the second most expensive healthcare system in the world. It covers 99.5% of the population, costs 1/3 less than ours, and gets among the best medical outcomes in the world. If Swiss insurance companies could negotiate fees and prices on a national instead of cantonal level, it would be even less expensive, but then Swiss pharmaceutical companies and doctors would get mad…

Why the selective focus on increased nominal taxes, without looking at the countervailing savings? Under “Expanded and Improved Medicare For All” (HR676), these would include:

* Lower medical prices, via monopsonistic bargaining (e.g., 40%-50% savings on patented prescription drugs)

* Dramatically less administrative overhead (a savings estimated at $400 billion a year)

* Elimination of provider-side conflicts of interest (e.g., unnecessary referrals by physicians to diagnostic and treatment centers in which they have a financial interest, estimated to be responsible for 50% of Medicare billings in some locales)

* Elimination of the hidden healthcare-tax burden of Medicaid, the Veterans Health Administration, Tricare, the Federal Employee Health Benefits Program, state and local health insurance programs, the Indian Health Service, employer-paid premiums, and itemized medical deductions

* Avoidance of costly urgent and remedial care through the provision of timely preventive and maintenance care

… and last but not least …

* Elimination of all health insurance premiums, deductibles, and copays

Back in 2008, the Commonwealth Fund published an economic analysis of various healthcare bills that were in Congress in 2007. The single-payer bills were the *only* ones projected to achieve 100% coverage while causing total healthcare expenditures to *go down*. The decrease wasn’t dramatic, but it was a step in the right direction, in contrast to all of the other approaches. (The CBO projects that under the ACA our aggregate healthcare expenditures will increase by at least 2% of GDP by 2019.)

Turning to real-world evidence, France has a functional single-payer system* that provides excellent, comprehensive coverage to literally 100% of the population. They spend 11.2% of GDP on healthcare and get better overall outcomes than we do by most key measures. We have a dysfunctional kludge system that provides mediocre-to-adequate coverage to around 80% of the population. We spend 18% of GDP on healthcare and rank close to the bottom on most OECD outcome measures. If we were able to adopt France’s system wholesale, we could theoretically save around $1 trillion a year on healthcare — (18%-11.2%) x $14.7 trillion US GDP — while covering absolutely everyone. I’m not suggesting that Americans could ever be as efficient, cooperative, egalitarian, and community-minded as the French, but they do offer a real-world example of the potential savings (and excellent care) that single-payer can offer.

Anyway, both theoretical projections and real-world evidence suggest that under single-payer, your total healthcare-tax burden is going to be lower than the total healthcare-expenditure burden you’re bearing now.

*For historical reasons, France still uses multiple sector-based insurance funds. Functionally, they operate as a national single-payer system.

I also appreciated the coverage, but is Sky News (a News Corporation venture) the only or best source for live video? (You don’t want us to get Murdoch cooties, do you?)

In a related matter, I’ve taken to calling the NDAA’s indefinite military detention provisions the “Get Julian Assange Act.” If Assange is extradited to Sweden and subsequently disappears, the res may not exactly be ipse loquituring, but it will be looking pretty suspicious. Hopefully, the UK’s Supreme Court will decide not to honor EAWs issued by politically subservient prosecutors and it won’t come to that.

Right — because it’s so much more difficult for mega-corporations and super-rich individuals to co-opt small state governments and play them off against each other in a race to the bottom than to influence the federal government. And it’s so much *easier* for a critical mass of citizens to form the lobbying infrastructure necessary for ensuring *their* voices are heard in the capitols of one-horse states. And of course, independent local investigative journalism is superb and flourishing compared to the national scene.

Let’s go back to the kind of limited federalism we had before we had a fully integrated national economy and a homogenized national culture. No, let’s go back to the Articles of Confederation. In fact, let’s break the country up into a league of independent cities. If we are to believe libertarians, it won’t be like the Middle Ages; it will be like a fairy tale.

Okay, I see where you’re going, Obama, but eligibility at age 67 is just not high enough. Raise it to 69.7 years and we can screw the average African American male out of his Medicare and Social Security benefits 100%! They’ll be chipping in for everyone else’s benefits and getting nothing back, and we won’t have to raise the payroll tax cap on rich guys! Pretty sweet, eh? Eleven-dimension chess, indeed.

I call it “bad cop, worse cop.”

The author hit the nail on the head in identifying voting systems as the core issue. Thanks to exceptionally poor political education and exceptionally effective indoctrination, most Americans don’t realize that our voting system — single-round, first-past-the-post — is the least representative, least democratic, most gameable voting system available. (Are the Canadians beginning to figure this out, I wonder? They use the same system as us, and they just seated a conservative parliamentary majority that 60% of the electorate voted against.)

Our political system has many fundamental flaws — private money in politics and a monolithic news media serving plutocratic interests being the two biggest — but a bad voting system is one of very few that ordinary citizens may actually be able to fix working within the system. All it would take to get the ball rolling would be a grassroots and alternative-media education campaign followed by citizen ballot initiatives in the states that permit them. If a critical mass of such states were to adopt instant-runoff (AKA preferential AKA alternative) voting, perhaps it would build enough pressure at the polls to force legislators in at least some of the non-initiative states to follow suit.

Widepread preferential voting would at least give us a chance to start voting for representatives who aren’t wholly owned sycophants of the corporate and super-rich élite — without the risk of turning the country over to our greatest enemies for years or decades by throwing away our votes on spoilers. And if we succeed in electing enough uncorrupted politicians (and if they stay uncorrupted, which is a very big if), we might even be able to get rid of judges and justices who have turned our democracy into a plutocracy by labeling de facto election-buying, politician-buying, and legislation-buying as constitutionally protected “free speech”….

Final thought: Given that Congress’s approval rating is at around 13%, I have a hard time believing that 65% of Americans still support our “two-party system.” The WSJ and NBC both have a vested interest in perpetuating the current system of contrived political theater and horseraces between two teams owned by the same plutocrats that own them, so I consider this poll suspect and am not disheartened by it. It all depends on what questions you ask, and the questions in this one strike me as being designed to elicit support of the status quo.

On the other hand, with permanent Osterity, it would be smoothies all around. ;-)