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.

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.

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).

This, to me, is the single most convincing reason for the government to be in charge of health-care, and not the markets. It's always been my assertion that the government needs to be responsible for investments that vest in an amount of time longer than the length of the average career; things like basic science research, retirement benefits, and health care.

I think the failure of the American automotive companies makes this point rather clearly. When automotive execs were faced with a decision in the 60s and 70s to either raise salaries or promise their workers plush retirement benefits, which did they go for? The retirement benefits, of course! Why? Because those execs would likely be long dead and gone before the proverbial shit hit the fan. Ah, but what about the investors? Shouldn't they have demanded long term fiscal responsibility from the executives? Um...why? If you were 20 in 1960 and invested $100 in GM, how many times over would your money have doubled before the trouble began? ...and you'd be 70 now! If you were a prudent investor, you would've moved that money out of stocks and into bonds sometime during the surpluses of the 90s.

In my opinion the government should exist to cover those things the market won't (or to sufficiently incentivize markets to act responsibly enough that they do cover extremely long term investments).

I'd argue that the much maligned concept of "corporate personhood" is designed to solve the problem of individuals having short (and finite) time horizons for making cost/benefit calculations.

Similarly, patent law offers a tradeoff between unfettered innovation monopoly by offering a limited, short-term monopoly on exploiting new ideas. Consider briefly the FDA approval process and a profit-seeking scientist developing a pharmaceutical. The scientist has a 20 year time horizon to maximize profits, so she has a huge incentive to do R&D and to launch the product. Meanwhile the FDA regulator collects the same salary whether he approves or delays approval of a drug, yet he stands to be fired and disgraced if the drug he approved causes harm. If he's overly cautious in order to keep his job, society suffers profoundly.

If you claim that government is better than private industry at solving these sorts of problems, you are making the rather strong claim that the incentives of the FDA burocrat are broadly superior to the incentives of the R&D scientist.

It follows that you would believe that if all R&D scientists were paid a fixed salary and stood to gain nothing for finding a breakthrough drug but stood to be humiliated and disgraced if any unforeseen consequences of a discovery occur, society would be significantly better of.

I think that's a fairly sweeping claim to make, and I'm curious if you could elaborate.

Also, with respect to the automotive pensions, I think you'd be well advised to review this history of the PBGC (pension benefit guarantee corporation). It is a government entity tasked with offering pension insurance for workers in the event that the firm fails. Surprisingly, both unions AND corporate interests lobbied congress to decrease the premiums firms would pay into the PBGC. The result is that the PBGC is not actuarially sound and that if a few major US firms failed the PBGC would go belly up.

Why did this happen? Corporate interests understand that once the government provides a safety net, so long as they were compliant they have nothing to lose (plus, if the firm failed then it's game over anyway). Unions focused on increasing the current allocation of benefits and didn't worry about the future... after all they "won" improved pensions for workers and were pleased when firms could dedicate the extra cash (saved by having artificially low risk premiums) to other forms of compensation, etc. So in this case the government clearly acts on the whim of interested parties and utterly fails to protect citizens (even though doing so is a trivial matter of actuarial calculations and collection of a premium!).

So I would be curious to read your elaboration based on these points of rebuttal.

I make personal decisions based on the effect those decisions will have in my lifetime. I make family decisions based on the effect those decisions will have in my or my children's lifetimes. Presumably, a corporation should make decisions based on the effect they will have in the corporations lifetime which should, because it's a corporation, be regarded as unbounded.

The problem is that responsibility is a slippery thing with respect to corporations. If the CEO makes a decision which will result in disaster in 100 years, is the CEO responsible when that disaster occurs? or will the CEO be dead? So then the shareholders should be responsible, right? except how many current shareholders will still be shareholders in 100 years? Sure, stocks take the future into account in the price, but how far into the future? At some point, the "outlook is hazy" and stocks put decreasing emphasis on outcomes the further into the future those outcomes will be realized. So who is responsible?

My premise is that, if left to market forces alone, no one is responsible! That means that market economics, alone, cannot make wise 100 year decisions. Ah, but what about states? A state whose corporations have all made bad long-term decisions is not going to last very long, so that over a long enough time scale there will be an evolution toward states which can force responsibility for long term decisions onto someone. I would argue that this is at least partly the reason for the rise in representative forms of government: when the governing responsibility is amortized over the entire population, decisions will likely be made with an eye to at least two lifetimes (the classic "won't somebody think of the children", or "our children will have to pay off our debt").

The bottom line is that sometimes governments have to make decisions that seem at odds with the markets, because they must be responsible for the long-term consequences in a way that corporations are not.

Let's take your R&D scientist, and I'll turn the problem on its head: Given that I have 20 years in which to recoup my expenses, why would I study diseases of the poor or cure short term illnesses? The poor can't pay much for my pills, and a pill to cure pneumonia will only make money for a week or two per person. So what do we end up with? Statins! Lot's and lots of statins! High cholesterol is a disease of the rich, and once you start on statins you have to keep taking statins the rest of your life.

What don't we have? Antibiotics! In fact, most people don't talk about it, but there is a looming antibiotic crisis on the horizon. I've spoken with an expert on the appearance of antibiotic resistance who has studied MRSA and VRSA, and he gives us 20 years until we're basically out of effective antibiotics. You don't have to take my word for it, though...just look at the timeline for the discovery of new antibiotics, and how much it slows down there toward the end: http://en.wikipedia.org/wiki/Timeline_of_antibiotics.

So what of the FDA bureaucrat? It's a straw man unless you can tell me the name of the person responsible for approving thalidomide for use as an anti-morning-sickness treatment. The individual bureaucrats have little to no incentive to not simply "follow the science", but as a society we have every incentive to have a safety net that keeps us from having to support a generation of armless individuals.

This is already getting a bit long, but as for the PBGC? Well, so what? Everyone lobbies the government and gets to give less money to the government and put more money in their pockets. That's a government failure if ever I've seen one. Of course, its not surprising given how close we've allowed corporate interests and government to get.

I was discussing this just the other day with a friend, and if it were up to me to fix the government, you know what I'd do? Every federal politician is set for life! Food, housing, vacations anywhere you like...it's yours! The taxpayer cost for the number of politicians that affect our lives with their decisions would be negligible, but it would effectively remove any and all impact that special interests could have on politicians. Also, if you knew that, when you went into the voting booth, you'd be rewarding someone with a lifetime free pass...well, I bet you'd think about that choice a bit harder than you do now, right?

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?

Not only do I not want senior citizens starving and dying in the streets, I want to be sure that a senior citizen 50 years from now won't starve or die in the streets.

Consider what congress has done to social security benefits over the past few decades. Right now the social security retirement age is OLDER than the average lifespan of African American men. Why are you defending this approach?

People work hard for years and plan for retirement only to have the social security retirement age increased. If a private firm did this the CEO would end up in jail. Why are you defending this racket?

If you're going to take by force 12.5% of someone's lifetime earnings (all most middle class people can afford to put away for retirement), you'd damn well better live up to the promise you made to him about what he'll get and when.

You seem to think that taxes == good social programs. On the contrary, the current budget is full of unsustainable things that only exist to give a handout to one special interest group or another... everyone knows they aren't sustainable and that they exploit those paying in now, but there is a collective action problem (which, incidentally, you are helping to perpetuate).

I've paid lots of money into social security... where has it gone? To fund the war in Iraq. Where will it be when I retire? By that time Soscial Security will probably have been cancelled or merged into the general budget or turned into a welfare program. I really don't understand why you would defend a regressive tax that allows congress to avoid having to be accountable for what it spends.

U.S. Teens Trail Peers Around World on Math-Science Test http://www.washingtonpost.com/wp-dyn/content/article/2007/12...

U.S. prison population dwarfs that of other nations http://www.nytimes.com/2008/04/23/world/americas/23iht-23pri...

Lehman Cooked The Books Prior To Collapse; Geithner And NY Fed Implicated http://thelibertyguardian.com/2010/03/lehman-cooked-the-book...

Let's face it; our government is setup to help the big corporations.

People love Medicare. It helps keep old sick people from financial ruin. That's a good thing.

Lots of banks have failed in the last few years, but government-run programs (FDIC, mostly) keep the fallout from damaging citizens.

The United States is home to many world-class research institutions, many of which receive government grants.

Bernie Madoff was running a huge ponzi scheme to defraud investors, but was eventually caught, by the government, and sent to prison.

The military and US AID have helped save lives and assist in reconstruction of post-earthquake Haiti.

FAA regulators have made air travel extremely safe.

NHTSA and other regulators have improved the safety of cars and saved countless lives.

The Parks department has conserved millions of acres of winderness for people to enjoy for generations.

The Endangered Species Act has literally saved species from disappearing from the planet.

The National Science Foundation helps fund RadioLab, the best thing on the radio.

If GM and Chrysler had been allowed to fail the PBGC would have been wiped out.

Fannie and Freddie were wiped out and would incidentally have failed due to investor flight in the early 2000s if they had submitted financials to investors like other firms (meanwhile the CEOs got very rich). BTW off the books entities are what everyone hated about Enron... our GSEs are the exact same scheme.

Bernie Madoff's daughter was married to a SEC official and in spite of being reported to the SEC multiple times over the years his fund was not investigated. Only the biggest financial crisis since the great depression made his scheme unsustainable, at which point the fraud was obvious, and he was used as a scapegoat for the crisis itself... as if his fund caused it!

Some of the items on your list are good services that are provided by government... but if you look at the government budget they make up (at best) a few percent.

The fact that government can provide multiple valuable services for just a fraction of overall budget each isn't proof of anything. There's a very trendy and shallow mindset these days that government is absolutely terrible at absolutely everything. The truth is more nuanced than that.

This is inevitable for social security, and I'm thinking the gold-plated public pensions (and many private ones) will follow suit.

http://www.azcentral.com/arizonarepublic/news/articles/2010/...

I think it's a very smart move: lets them avoid 'Big Design up Front' and the associated bickering + reification.

Is that the long-term political trend? More steely-eyed fiscal realism each year? Is our society today braver at telling organized lobbies (including suffering or fearful people), "no, that sounds nice but costs a lot more than the proven benefits", than it was a generation ago?

In Washington, they call it "privatizing" and run you out of town.

http://www.newsweek.com/id/224020

A lot of doctors don't want anything to do with medicare patients because they are often breakeven at best and in many cases a net loss. They are many times required to care for these patients in order to maintain hospital accreditation programs that allow them to look attractive to patients with insurance (where the hospital actually makes some profit).

It is good to pay attention to healthcare availability, but no sustainable solution can ignore the cost side. Excess litigation has played a significant role in the massive overinflation of healthcare costs. Flooding hospitals with patients with government insurance - likely to be net-negative income for hospitals - is going to destroy the healthcare system faster than it fixes it.

The classic answers are to either increase FICA taxes or cut benefit levels... which seems idiotic, when the obvious solution (to me) is to just raise the eligibility age. Part of the problem is that people are living longer, and are mostly healthy and able to work longer, so raise the retirement age.

You're right about the demographics, but I'm not sure this part is correct. Yes people are living longer, but it seems that a great deal of that is that when a 70 year old contracts condition A which used to be fatal, we can now often keep them alive at great expense until they die at 80 of condition B. It doesn't mean they'd be effective workers at 70.

My "obvious" solution is to focus on curing aging, which is generally the fundamental cause of both A and B. Until that happens, means-test benefits. Warren Buffett doesn't need to be getting checks from the government.

The primary increases in longevity over the past century have come from increasing survival into adulthood. If, instead of considering longevity at birth, you look at longevity at 35 (that is, how long you can expect to live if you've already made it to 35), the increases are a lot less dramatic. Furthermore, if you look at the records for "oldest living person", that number effectively hasn't moved in the last 200 years, and is stuck somewhere between 110 and 120, which should give you a pretty good idea of where the upper limit is.

Sure, with improvements in medicine, we can keep people productive into their 70s and 80s when they used to spend their last decade or so as invalids. The future of medicine looks like this: you're healthy and active into old age, then you hit the floor. No long suffering, no being bed ridden...but you still hit the floor at some point.

Entertaining the notion that we could live forever if only we spent enough on medical technology is one of the main reasons that we're in the situation we're in. You are not immortal. You will die.

Spot on.

I keep saying that but that's not a very popular point of view here.

HN is rife with 'uploaders' too, people that think that within their lifetime they'll be uploading themselves in to a computer so they'll be immortal.

I really don't get how people can delude themselves like that, given 0 evidence some enormous extrapolation gets made which then attracts a lot of followers.

The human body is a machine. It is a very complex and intricate machine, but a machine it is nonetheless. Yes, we do not yet have the understanding. Yes, we do not yet have the necessary tools. But we will have them one day.

It is a machine, and any machine can be fixed with the right knowledge and tools, and it would seem quite foolish to claim otherwise.

It would seem equally foolish, of course, to plan one's life around the very uncertain wager that these technologies will be acquired by humankind within one's lifetime. No disagreement from me on that one.

Now, you might say that any machine is a collection of chemical and physical processes. Fine. If you want to perpetuate a machine analogy, consider this: the camshaft in your car is subject to chemical wear through oxidation, etc. Eventually, the gear teeth will wear out, and it will need to be replaced wholesale. Fine, you say, we'll make replacement parts. But what about the brain? You can replace any arbitrarily large set of components in a car's engine and still call it the same engine, but do you think that holds true for humans as well? And even, say, we figure out how to preserve the human brain (or even, gasp upload it)...problem solved, right? Nope, sorry again. "You" are not your brain. "You" are an emergent property of your entire body. Your brain without your body is as much "you" as your body without your brain is...

Bottom line: study some biology. It's not as simple as the "easy A" course you took in high school or college led you to believe.

We'll only have them one day if they're not beyond the limits of our understanding. Given that our understanding has limits, this is far from certain.

That is a pretty big assumption to make. If you are saying that our understanding is limited at this point in time, then I'd agree. Barring loss of data/memory, our understanding will always be limited now compared to our understanding in the future.

But if you are claiming there is some fundamental upper bound to our understanding, and that a complete functional understanding of the human body is beyond that upper bound, then I have to ask what motivates that claim.

Not to put too fine a point on it, but that kind of thinking is what supports flawed pseudoscience like "intelligent design" (not claiming you support that, and really not trying to open that can of worms; just drawing a parallel). Sure, if you assume that our understanding is already at some kind of limit, and then show something we can't explain, it follows naturally that it must have supernatural origins. If, on the other hand, you realize that our inability to explain something is most likely just a function of time (eventually we'll learn enough that we will be able to explain it), then the argument seems absurd.

I'm claiming the first conjunct. I don't know whether or not a complete functional understanding of the human body is beyond our understanding.

I don't see why a claim that our understanding has certain fundamental limits should need to be justified. Rather, the opposite claim seems to require justification. If you look at any other animal on earth, this is obvious. Why should we be the only animal without limits?

This is not to suggest that what we happen to know right now is the upper limit, just that there is an upper limit.

>not claiming you support [intelligent design], and really not trying to open that can of worms

Oh please, this issue has nothing at all to do with ID.

> it follows naturally that it must have supernatural origins.

Or, more plausibly, that it has natural origins which are too complex for us to understand.

Why not? It may be difficult, but aging is a collection of physical processes, and physical processes can be modified with sufficiently advanced technology.

Sure, with improvements in medicine, we can keep people productive into their 70s and 80s when they used to spend their last decade or so as invalids. The future of medicine looks like this: you're healthy and active into old age, then you hit the floor.

That's exactly my point. Medicine today consists largely of playing whack-a-mole with diseases whose underlying cause is aging. That's expensive and produces continuously decreasing benefits. We haven't failed to cure aging; we haven't even tried.

I don't really have the inclination to get into a detailed technical argument but I don't think these sweeping claims that aging is "not going to be cured. PERIOD. FULL STOP!" are credible in the least. The human body is a machine that can be repaired like any other, given the technology and understanding. It might not be in my lifetime, but I can't think of any reason why perfect anti-aging technology would not be available eventually. And if you're going to make broad claims to the contrary, you'll need to back them up.

Cardiovascular disease is mostly caused by carbohydrate consumption and inactivity. The Feds subsidize these, and health care "reform" will make the problem worse.

I think that implicit in your expression of dissent to what I initially wrote is belief in the fallacy of "good fats".

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

Do you have any data to back up your assertion ?

According to http://www.cepr.net/documents/publications/small-business-20... "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)."

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.

One interpretation of the data presented here is that self-employment and small-business employment may be a less important indicator of entrepreneurship than we have long thought. Another reading of the data, however, is that the United States has something to learn from the experience of other advanced economies, which appear to have had much better luck promoting and sustaining small-business employment.

The self-employment rates in Figure 1 are particularly high in Greece (35.9 percent), Italy (26.4), Portugal (24.2), and several other countries where agriculture is still an important part of national employment.

    Country selfemployed export import   net
    ========================================
    Greece      35.9%     $27     $82   $-55 (ouch)
    Italy       26.4%    $369    $358   $+11
    Portugal    24.2%     $58     $88   $-30
    Spain       17.7%    $216    $293   $-77
    Germany     12.0%  $1,187  $1,022   $+65
    Netherlands 12.4%    $398    $359   $+39
    
    EU           ~13%* $1,952  $1,690  $+262
    US           7.2%    $995  $1,445  $-450

So within the EU there doesn't seem to be a positive correlation between net income of a country and self employment (or if there is one it's negative), except maybe that self employment is higher in the EU than in the US and net income of the EU is positive whereas net income of the US is negative (Anyone want to make a table of the full data set? Export and import can be found on wikipedia and self employment in the PDF posted above).

Offtopic: While browsing wikipedia I found this: External debt of Luxembourg is 4,973.68% of GDP (not kidding). Is this something to be very scared about if you live in Luxembourg, or is it not a big problem? Can somebody with a understanding of the matter explain this? :) Edit: Oh I think I get it: it's the amount they borrow, not the net amount of lending/borrowing.

in other words, its the ability to be entrepreneur and not have boot anchors placed in you path. having many small shops making products by hand is not what creates wealth

All this borrowing makes it inevitable that the US consumes more than it produces. It must import as much goods and labor as it borrows, just as you would if you borrowed a large sum of money.

You spend that money to get things from other people or to get their labor. And you will have to pay them back eventually, which is when you will produce more than you consume.

So, while the US may produce more new business and more wealth than other systems, there is also another thing happening at the same time. Namely, all of the borrowing done to create houses and government services we really cannot afford and probably don't need anyway.

For what it's worth it seems to me like the abstract ideological debate between state and private control tends to be vibrant in The States and therefore breeds more "ideological" positions.

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

A convenience store owner in Germany whose father and grandfather owned and worked in the same store can't be put into the same category as a 25 year old who quits his job to found a groundbreaking internet technology company.

Both count as small businesses. One is changing the world, the other one is not.

from http://dictionary.reference.com/browse/entrepreneur

I'd said that the founder of any small business is definitely an entrepreneur.

I wonder why does the US have such a high reputation in entrepreneurship. Is it because we have a higher concentration of high tech start-ups (unverified), which generate more buzz in the media?

* Because it's much harder to fire employees in EU, which makes employing people much riskier.

* Because the rules for employing people (working hours, vacation, etc) are much stricter.

* Because entrepreneurship is stigmatized in EU.

* Because insolvency in the EU involves years of trusteeship and significant legal hardship.

* Because selling in the EU and elsewhere abroad involves more border crossings and different regulatory regimes.

* Because taxes in EU are spectacularly high, not just for the top earners but all the way down through the middle class.

You could fix all of these today (bk reform is apparently a major theme in Europe) and it might still be a generation before the region becomes competitive with the US.

I remember a joke I heard a few years ago about how by law German offices must have windows and German garages must not have windows, so you can't ever start a company in your garage.

Because universal health care is not a sufficient condition for entrepreneurship, only an important one. I might go so far as to call it semi-necessary, but obviously if you have a spouse with corporate health care (as I do), or are less risk averse, you can make do without universal health care.

Silicon Valley has other things which beat the pants-off of Europe in terms of encouraging entrepreneurship (fewer roadblocks, easier access to capital, easy access to large markets, a culture where entrepreneurs are looked up to)

As I see it, the US spends a fortune on health, and gets a dodgy system. It's not quite the caricature Michael Moore paints, but he doesn't seem too far from the mark. Whether that is funded by companies (health benefits for employees - more red tape than in countries with universal health) or by individuals (which lowers individual risk tolerance) is immaterial. Public health works better than private health, according to all the numbers I've seen.

Too true. One of my favorite infographics regarding health care: http://www.fastcompany.com/blog/cliff-kuang/design-innovatio...

We see doctors less, spend more than twice the average anyway, and have below average life expectancy.

And we have a very different population. Obesity is only the most obvious example. And no, healthcare doesn't address obesity, even if your argument requires that it do so.

And we spend more on end-of-life. Unless govt death panels are going to be more frugal than private ones, that cost-differential will persist.

And we pay for a huge fraction of the world's drug development. Are you planning to cut back there?

Well over $150B of existing medicare/medicaid spending is fraudulent, which is significantly more than the "excess overhead and profits" of private insurance. Will that go up or down?

Also, I agree with the implicit point I think you are making, which is that this reform really does nothing to address these issues. (Although I would also say that I'm fine paying for the drug development. We shouldn't stop doing something that benefits us just because others can take advantage.)

So yeah, I really don't have a rebuttal because I agree with you. I wanted much more out of reform, but at this point I'm happy with anything that might get us a bit closer, especially if it makes it easier to reform in the future (which may be wishful thinking).

And since when does our government really get involved with "financing private ventures"? Banks aren't paying out for insurance (and will probably pay slightly less under this reform), and most VC's will have to pay about 2% more in tax. So maybe 5-10 useless web startups a year won't happen, but I don't think it's going to slow down small businesses at all. Many of the people I know who would start one or join an existing one can't because of health insurance.

We are generally small business friendly (I've had one, my parents have 2 going strong) but I don't expect we are particularly better, in reality, than anyone else :)

Because what makes Silicon Valley is a whole mix of factors? After all, why can't other US states copy Silicon Valley, even though a number of them dearly want to?

This counts for any level of schooling, including University. The number of IT spinoffs from my alma mater in the past decade can be counted on one hand.

Lots of people with health problems and families can't work for startups at the moment who will be able to once this happens. That's why this matters.

I'd say the business regulations are the huge difference between those countries and the US as far as silicon valley goes.

That doesn't exist in Europe. Firstly, there is an economic disadvantage to studying in a different EU country, and most importantly there are cultural and language barriers. Instead of having a concentration of the smartest engineers studying within a couple of colleges, you have smart people being distributed rather sparsely over quite a large area.

i currently work for hp, so i know this story and would like to share it (despite being a bit off-topic): http://www.stanfordalumni.org/news/magazine/1998/julaug/arti...

I do know adults with preexisting conditions will be in some sort of special "temporary pool", whatever that might mean. No clue on the cost.

http://www.csmonitor.com/USA/Politics/2010/0320/Health-care-...

When Obama signs the bill, anybody with a pre-existing condition will be able to a (temporary) national insurance plan for those with high-risk conditions. In 2014, it will become illegal for insurance companies to deny coverage for pre-existing conditions, and that plan will end.

I'm 24 with no health problems. My yearly health expenditures are near zero. My largest expenses are probably biannual teeth cleanings. I really don't need health care.

However if I am hit by a truck I would like to be able to afford someone to set my leg in a cast. So I have true insurance with a high deductible($1500USD/year). This coverage is dirt cheap.

Will I have to pay significantly more in 2014? Why should I have to subsidize fat baby-boomers?

>Why should I have to subsidize fat baby-boomers?

Who you're subsidizing depends on how you think about it. An alternative is to consider that you're subsidizing your future old, unhealthy self. Once you're old and unhealthy, no-one's going to want to sell you a new insurance plan with better coverage. (Ignoring whatever changes the recent bill might bring about.)

Do you think that you'll get back the social security that you're paying today? If not, why do you think that health care will be any different?

By definition, you can't wait until you're at high risk of requiring expensive treatment before you insure for it.

I am because it's another intergeneration transfer system.

> If you enroll in a more comprehensive health insurance plan while you are young and healthy, it will pay for expensive treatment when you are older.

Only if said plan sets aside some of the money that you pay now for your future care or there's some source of money in the future for that care. (You're rejecting the third alternative - that you pay your expected costs as you go.)

SS supposedly promised the former (loans to govt) but it's actually the latter (those loans have to be repaid by future taxpayers).

If you don't expect that future taxpayers will be willing to pay you for what you're paying now in SS taxes, why do you think that they'll be willing to pay for your healthcare?

Yes, I know that boomers are getting away with this. Do you think that later generations will?

No, that's just false. It will pay for your future treatment as long as the insurance company is legally obliged to foot the bill. It has nothing to do with the total amount you pay in -- the whole point of the insurance business is that a company is not guaranteed to make a profit on each individual customer.

If you stopped trying to turn this into a debate over social security, you might be less confused on this point.

> No, that's just false. It will pay for your future treatment as long as the insurance company is legally obliged to foot the bill.

You're assuming that the insurance will have money then. I'm pointing out what it takes to make that assumption true.

The relevant term is "counter-party risk", aka the "blood from a turnip" problem.

> the whole point of the insurance business is that a company is not guaranteed to make a profit on each individual customer.

While that's true, it's also true that the total payout plus expenses must be less than the total premiums plus any investment income. Savings and borrowing allows some time-shifting and smoothing but if payouts are too high relative to revenue, the company goes down, regardless of its obligations.

You believe that today's young will receive care when they're old that costs more than they'll pay then. Where is the extra money coming from? It can't be the extra money that they're being asked to pay now because that money is being spent now on today's old people. So, it can only be from tomorrow's young people.

You don't believe that future generations will pay your SS benefits. Why do you believe that they'll pay for your healthcare?

It's not necessary for everyone to pay in as much as they get out in order for that to be the case.

>You believe that today's young will receive care when they're old that costs more than they'll pay then.

As I've repeatedly said, I believe that some of them will. I.e. those who have unusually severe medical conditions for which it would not be feasible to save.

> You don't believe that future generations will pay your SS benefits.

I wasn't saying anything about future generations paying for anything. Again, this really has nothing to do with social security; you are just confused about this.

You've repeatedly claimed that making young people pay now means that there will be money for them (collectively) when they are old.

Where is the money to care for them (collectively) when they're old coming from? It's not coming from the money that they're paying collectively now - that money is being spent. It's not coming from them (collectively) when they're old. That leaves tomorrow's young.

Today's older folks (collectively) get subsidized-by-young health care. Are tomorrow's older folks going to be able to do the same?

Nope, I didn't say the "collectively" part. I keep explaining this.

>Are tomorrow's older folks going to be able to do the same?

Sure, if the young keep paying. But as I explained, there is no fact of the matter about which young people are subsidizing which old people. One way of looking at it is that young people are subsidizing their older selves, while the current generation of older people are being subsidized by their earlier payments when they were young. There's money going in and money going out, but when it comes to the question of "who's subsidizing whom", it largely depends on how you look at it. It's not as if John Smith's dollar bills are marked so you can see exactly who he's subsidizing.

You didn't use the word collectively, but we are talking about groups and you kept insisting that I was talking about individuals.

> >Are tomorrow's older folks going to be able to do the same?

> Sure, if the young keep paying.

Hold that thought.

> One way of looking at it is that young people are subsidizing their older selves, while the current generation of older people are being subsidized by their earlier payments when they were young.

More money is being spent on old people healthcare than old people are paying for healthcare. From that we know that their heathcare is being subsidized. We also know that young people are paying more for healthcare than they're receiveing AND that the surplus is going to old people healthcare. In other words, young people, as a group, are subsidizing old people, again as a group. (Yes, within each group, some folks are going against the flow.)

Since the young people's surplus is being spent today, it's absurd to say that their surplus is going to their future selves. If it was, there'd be money available when they got old even if tomorrow's young didn't keep paying more than they cost collectively.

> It's not as if John Smith's dollar bills are marked so you can see exactly who he's subsidizing.

I'm not talking about individuals. I'm talking about groups.

However, now that you've said "if the young keep paying", I'll ask how that's any different from social security. (SS payouts aren't strictly determined by contributions - there's a huge "insurance" portion.) Yes, the variance within a group is larger, but both are intergeneration wealth transfers.

If you don't think that tomorrow's young are going to be willing to pay for your generation's SS, what makes you think that they'll be willing to pay for your healthcare? (If you do think that they'll pay for your SS, it's probably reasonable to assume that they'll also pay for your healthcare.)

The cost of the medical treatment? A few thousand for sundry expenses. Australia's Medicare system picked up the tab for virtually all of it. He asked them the face value (hoho!) of the treatments, but no one was really sure how to work it out - it's at least 6 figures. I dread to think what it would have cost in the US...

He didn't lose his house or car. The baby that was born during his treatment didn't bankrupt anyone. He still has a job.

What a chilling example of a socialist government system interfering in his personal life!

I would wait until I was sick or injured, then buy insurance.

If you force insurance companies to always provide insurance, then you have to force everyone else to always buy insurance. Or the math won't work.

Until - I hope - now. It remains to be seen how much hash was made of the bill during the sausage-making process.

Now I understand why you guys on here think this is such a big deal to US startups.

It's easy: Just open an office in Canada.

For what it's worth, "pre-existing medical condition" is the #1 reason why Tarsnap is not a YC company.

Unfortunately it doesn't help much when hiring from the USA - the majority of our company is scattered around the states.

Is tarsnap Canadian-founded?

I know two people with Type 1 Diabetes that are basically stuck in their jobs due to their insurance situation. One has a PhD and works in a University lab, which he enjoys, except he had to turn down the opportunity to join a startup because it would've been financially impossible for him.

Yep, type 1 diabetes. I also have autoimmune hypothyroidism, but that's rather insignificant in comparison (one 10 cent pill per day).

Starting a business in the US is overall a lot easier than in Europe, but the advantage would be even greater if entrepreneurs wouldn't have to worry about health coverage.

In case you haven't followed that, the idea is basically to match up people who are looking for private insurance with companies offering policies, but to build in the ability to lump the customers together into ad-hoc risk pools. For the insurer this is the same as taking on, say, a medium-sized company with X employees, which means the terms offered can be far better than traditional individual policies.

Of course, this presumes that private insurers determine premiums in a rational manner, which may not be the case (and if it is not the case, then you're going to pay more no matter what).

My CEO wrote about this last year: http://www.benhuh.com/2009/08/01/the-killer-fear-of-guarante...

Clearly if your startup employer chose to offer you cash instead of a healthcare plan, it did so because it thought you'd value the cash + flexibility more than you'd value the plan.

It's simple for any small business to sign up for a group plan for employees... and it's not the cost that is the issue, it's the perceived value of the service.

For me, what it meant was that I had to make a (relatively small) sacrifice to take a job. For others, it might be the difference between being able to work at a startup or stay with a soul-crushing big company.

It doesn't matter how you break down the compensation into salary and perks.

So while it's true that someone with a preexisting condition might not be able to take a job IF the compensation wasn't high enough, it's irrelevant whether the compensation includes healthcare or if it doesn't.

It's not startups. It's single people making more than $200k or married couples making over $250k.

The latter affects more people than the former.

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

Looking at American policies from an outside perspective, it seems the government is unwilling to be the one that will actually suggest that maybe the answer to many current budget problems is to spend less.

The best most cost effective solution to health care is single payer government operation of the health care system. It's a tried and proven over decades to cut the cost of health care all over the rest of the industrialized world.

For some ludicrous reason, the beloved-by the British UK model of health care is called "communism" if it's even mentioned here

When did Great Britain turn communist? I completely missed that event.

But I don't think this is true of either the European socialist states, or of U.S. liberals. You can cherry pick examples of radical elements, Fox News style, but they aren't the main concern here - economic risk is the big one. A tightly integrated state can operate more efficiently than one that tries to regulate companies from afar, but if it goes down due to a "black swan" event, recovery is going to be more difficult.

Depends a bit on what you mean with efficency.

How many states have gone down? Somalia. That's it.

Now how many corporations have gone down leaving the people who the corporation agreed to provide services to in deep trouble?

It's almost quite literally infinitely more risky to trust a corporation than it is to trust government.

Medicare currently operates on a 3% margin. That is, 97% of funds in the medicare program go toward reimbursing patient care. The vast majority of private health insurers operate on a 20-30% margin. The rest of the money goes towards marketing, sales, and towards profit.

Like it or not, every body is shouldering the cost of uninsured patients. One in 6 Americans don't have health insurance, yet they still consume health care. Who pays for that? Everybody does. Hospitals are under a federal mandate to care for everyone regardless of ability to pay. So, to compensate for their losses on uninsured patients. They artificially inflate the rates they charge everyone else to compensate. So, every time you use the health care system, you are paying for uninsured people's care.

Hospitals that have a disproportionately large share of uninsured and minimally insured patients (e.g. a county hospital, non-profit hospitals in the ghetto, small rural hospitals in farming country) routinely need and receive government subsidies to function. Those hospitals are largely subsidized by special funding bills.

Universal coverage, just means that we are now going to be explicit in determining how we are going to pay for people's health care.

edit: added 3rd paragraph.

The main objective is punishing those that wish to pay for their own care and retain control over it by shifting everyone else's costs to them.

Then once people give up fighting the current and get their care covered by the government, they lose control of what happens and accept lower quality because at least it is free.

Then whatever entity is providing care performs whatever possible procedure and drugs they can get away with, while starving the hell out of any preventive measure may make sense. The money spent follows the lobbying.

but don't worry, it will be years before you fall into this sink hole and your family come and visit you as you go down, so it won't be all bad

15% of medicare spending is lost to fraud apparently. please don't bring these same "efficiency" to the whole system. ugh

on top of this, medicare costs are expected to skyrocket w/ babyboomers starting to retire. one more unsustainable situation brushed under the rug

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...

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...)

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

lose/lose.

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.

If you have a serious health problem ( heart attack, stroke, accident ), you will not have time to fill out all of the paperwork and buy insurance because you will need help immediately.

Also insurance companies will probably have processing times of weeks when onboarding new customers, so you won't be able to just get the flu and then decide to have insurance that month.

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.

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.

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).

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.

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.

A: About $20 per month per person.

You're right this is the biggest risk young people face... the rest of their premium is just going to the old folks and their exploiters.

I would have loved to have my parent's insurance pick up the tab on that one.

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.

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.

It is a bit shameful to be dependent on one's parents at 26, but because of employer based-benefits and the fact that is it NOT shameful to not yet be locked into a profession at 26 means that family insurance plans are a necessary reality.

The real question is why the system had never evolved to allow affordable family plans rather than employer based benefits. I have some thoughts, but that will make this an even more heated discussion.

During WW2, there were wage controls, but employers needed to attract workers, so Congress gave them this small (at the time) tax break for providing health insurance to workers. (They don't have to pay payroll taxes on that portion of compensation.) Who doesn't want to encourage employers to provide perks to their employees, especially perks that improve their health?

But this has blossomed into a huge market imbalance, where people can't change jobs due to insurance concerns, and buying individual insurance puts you at a huge financial disadvantage compared to employer-provided insurance.

Why did it "blossom"? Why did it not get corrected after WW2? Especially when (forgive my lack of data) I'm sure public data could corroborate that the average time spent in one position/job has decreased steadily since then.

Because health care costs skyrocketed, which led to skyrocketing insurance premiums. Something that was previously 1-2% of compensation is now often >10%.

> Why did it not get corrected after WW2?

It's a rare thing for Congress to pass a bill that reduces complexity... just look at the tax system.

This bill is a case in point. There were numerous way to reduce complexity (and hence costs), but instead they just added more. More complexity isn't always bad, but it's very rarely cheaper.

Ways to reduce complexity: remove the market distorting tax break, regulate insurance at a national instead of state-by-state level, make insurance compulsory, make health insurance actually act like other insurance. (You don't expect your car insurance to pay for oil changes or your homeowner's insurance to pay for smoke detector batteries do you? And in that vein, when was the last time you lost your car insurance because you lost your job?)

The Washington Post covers it here:

http://voices.washingtonpost.com/ezra-klein/2009/05/health_r...

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.

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.

- The first is the "doc fix". Basically, there's a 21% automatic cut in the payments to doctors in Medicare. That would lower the payouts to the point where doctors would often lose money seeing a patient, and doctors would stop seeing Medicare patents. Like with the AMT, each year congress approves a temporary fix. It is likely that, while under CBO rules the score assumes there won't be more temporary fixes, there actually will be.

- There are several areas where the bill promises unspecified future cuts. The CBO numbers takes them at their word. Consensus is that these cuts won't actually happen.

- ~$53B comes from the fact that Social Security will take in more money because more companies will pay people wages so they can buy health care on their own instead of the company paying for it. However, it doesn't count the fact that SS will have to pay out correspondingly more.

- The CBO looks at a 10-year horizon. Most of the costs are scheduled not to start immediately, but to ramp way up later.

There are a bunch of other 'hacks' in the CBO scoring to keep the cost near the promised $900bn. Both sides do it, but they discovered a bunch of new tricks this time around. It means that, going forward, CBO numbers on large bills (from both sides!) are probably worse-than-meaningless.

On the older-to-younger q, it's mostly about how community-rating is implemented.

http://www.nytimes.com/2010/03/21/opinion/21holtz-eakin.html...

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... ). 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.

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.

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

Can you tell me specifically how you think this is interesting to hackers, outside of what it means to startup founders and potential startup founders? Many US bills affect "hackers", that doesn't mean we should discuss them.

From WSJ: http://online.wsj.com/article/SB2000142405274870453490457513...

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.

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.

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?

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.

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.

>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.

Er, what? Insurances isn't about getting one group to pay for another. It's about paying a premium proportional to the calculated risk that the insurance provider will have to pay out on what it insures against. The fact that the premiums paid by lower-risk individuals ends up paying for the car that higher-risk individuals need is incidental.

Of course, if the healthy behave that way, it drives up the premiums for everyone else.

Because an accident or infection can run up $50k in costs before you can even put the paperwork through.

Besides, twentysomethings all* think they're immortal and that nothing bad will happen to them anyway.

*And by all, I mean some.

The bottom line for me is that, if I were a healthy young person, I would not pay for health insurance under this plan. Actually, when I was a young healthy person, I didn't pay for insurance - I went uninsured from when I was off my parents' plan until I was 29. So did lots of others. The case for buying health insurance is now far weaker than it was then.

http://www.washingtonpost.com/wp-dyn/content/article/2010/03...

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.

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

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.

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?

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?

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.

(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.)

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.

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.

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.

http://www.foreignpolicy.com/articles/2010/03/17/how_iraqi_o...

The markets reacted to this long ago, which is why we're not seeing much of a reaction to it now (the market is now up by about the amount it was down when the parent posted that link) - nobody had any real doubt as to whether this would ultimately pass or not, the only question was exactly what provisions would be taken out or put in to ensure that it did.

No comment on our debt problems, however - I'd tend to agree that eventually someone needs to pay the piper, though I think single-digit weeks might be underestimating it.

In the long run, a healthier workforce should increase productivity, and then stocks will go up.

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.

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.

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?

Ezra Klein knows what he's talking about (though he is coming from a pro-reform standpoint).