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Health Care and a Dirty Word Called “Tax”

There’s a lot we can talk about in response to the U.S. Supreme Court (“SCOTUS”) decision on the Affordable Care Act. It may have created a deep schism in the conservative wing of the Court [Huffington Post]. Its clear from dicta in the various opinions that there are five justices willing to further restrict federal power based on the commerce clause (which bodes ill for a great deal of civil rights legislation) [Opinion on Bloomberg]. But of course the big news is that Roberts’ opinion upheld the individual mandate on the theory that it was an appropriate use of the federal government’s authority to tax.

Cue the conservative shit fit [Washington Examiner, Feministe].

Where I work the response has been no less trollish. (Seriously, sometimes I want to ask my coworkers if they have a Feministe Top Troll plaque in their living rooms.) People are angry. They’re angry that they lost. They’re angry that they are required to purchase health insurance (nevermind that they all have excellent health coverage with a tiny premium mostly paid by our employer). But most of their anger is directed at the idea that they are being taxed. My local rep is even introducing a constitutional amendment to require Congress to label tax bills [Ben Quayle’s Congressional page].

On Friday a coworker flagged me down in the hall to rant about the “tax” and Obama’s purported deceptiveness and to tell me about the Constitutional amendment. I (deciding to act a little trollish myself) asked why she was so concerned given that we have health insurance at work and she has other guaranteed benefits to rely on so the likelihood that she would ever be required to pay the “tax” is somewhere between zero and minus 1 billion. Her response: “Its personal because I don’t want the government thinking it can steal my money.”

Well, its personal for me too. I grew up without medical care even though I was chronically ill. For a years I was denied treatment because of my parents’ religious beliefs and later because we simply couldn’t afford it. Every doctors visit, every recommended test, every prescription was choice between my health and our collective survival. Even when my parent’s scratched their way into the working/middle class my chronic condition meant that we had to choose between my medication and heat or my treatment and the mortgage.

The ACA is not the ideal solution by any stretch. I prefer we just move to a straight up single payer system, but this law for all its flaws is intended to make sure that every person has access to the medical care they require. Making that happen is personal because no one should have to choose between their health and their family’s survival.

For me that is what this debate over “taxes” boils down to. In the starkest terms its a question of whether we as a society believe that holding on to money is more important than someone else’s survival.


38 thoughts on Health Care and a Dirty Word Called “Tax”

  1. Yes. When I was in college, it was Clinton who was trying to get a health-care plan going, and I had to listen to classmates whining about how they wanted to be able to chooooooose their doctor, and what if they didn’t get their choooooiiiiiiice?

    My best friend had been unable to use her left arm because of pain in her elbow for months, but hadn’t been able to see a doctor because she had neither insurance nor money. What kind of choice did she have?

  2. I don’t like the ACA as policy, I’m not a huge fan of the Roberts’ court decision, and yet I am abjectly grateful that I still have health insurance. I turned 22 this April, and I am chronically mentally ill; without health insurance, my life would have been full of many, many more difficult choices — choices like, stay on lithium even though it gives me horrible migraines, because it’s cheap? Switch to the newer drug that I can’t afford, and am getting solely through the charity of my doctor? etc.

    But I don’t think the ACA is good law, and I think the Roberts’ court decision to cut down the Medicaid expansion is going to go a long way to undermine the whole POINT of the law in the first case, namely to expand coverage. I would far have preferred a single-payer system, or failing that, something coherent like Germany’s health insurance system; what we have now are dozens of different gov’t agencies managing different health insurance programs for different classes of people, and because of that incoherence I suspect we’re only going to see a RISE in healthcare overhead costs — the kind of costs Obama told the nation he was trying to address. What good is this law, if twenty or thirty years down the road it has to be gutted because we can’t afford it?

    I’ve been feeling awfully conflicted because as a citizen, I feel I should want “what’s best for my country”, but as an individual, I don’t want to have to choose between medications or student loan payments.

  3. The ACA is not perfect, but it is movement in the right direction. Maybe in another 20 years, we will catch up to some of the plans in other parts of the world. The coverage for pre-existing conditions and children until 26 is huge. And in the end, as you say: “In the starkest terms its a question of whether we as a society believe that holding on to money is more important than someone else’s survival.”

  4. “In the starkest terms its a question of whether we as a society believe that holding on to money is more important than someone else’s survival.”

    Just to get this out of the way, I favor a single-payer system over the ACA, and the ACA over nothing. But strictly speaking, we make choices like this all the time. It is highly taboo to say “I value this $30 billion more than a human life”, but that’s the unavoidable implication of any realistic set of policy positions. If human lives were really priceless, we would set a national speed limit of 5mph, spend 100% of GDP on healthcare, ban sharp knives, &c. The fact that we don’t means that we’re willing to say “I value not having to live inside a hamster ball more than the marginal lives that would save.”

    We should argue for universal health care on grounds of outcomes and efficiency, not by daring opponents to break taboos that we all implicitly break anyway.

  5. It is highly taboo to say “I value this $30 billion more than a human life”, but that’s the unavoidable implication of any realistic set of policy positions.

    I disagree. The problem here isn’t that “I value $30 billion more than a human life.” It’s “I value control over money that I believe I earned completely by my own efforts over the lives of other people in my society.”

    My objection isn’t to pragmatism, its to the idea that taxes are somehow stealing your cash to save other people who have no right to it.

  6. If human lives were really priceless, we would set a national speed limit of 5mph, spend 100% of GDP on healthcare, ban sharp knives, &c.

    I see this kind of argument made a lot, and I just don’t buy it. To respond to your examples, a 5mph speed-limit and a ban on knives would be ignored, forcing police to waste time enforcing them that is taken away from other crimes, and to insure the health and well-being of its citizens the government needs to spend money on things besides healthcare. Government spending may not be seen as merely a means to the end of ensuring the safety and happiness of its citizens, but it should be.

  7. I live with a single payer system here in Canada and like it a LOT. But like the ACA, it wasn’t born in its present form and it needs regular attention and adjustments. I remember when Medicare was passed in the US. It wasn’t in the form it is now. Adjustments have been made regularly.
    The United States was NEVER going from nothing to single payer in one step. I lived in the US for sixty years and I’m sure of that. Yhe ACA is definitely a rough beast but getting it passed is the unavoidable first step toward ongoing improvements.

    What is shameful is that the best the US could get right now is the ACA. Meawhile, INDIA with 1.2 BILLION people, including hundreds of millions of the very poor, has declared itself on the road to universal medical care. They expect to be there in a decade.

  8. It’s “I value control over money that I believe I earned completely by my own efforts over the lives of other people in my society.”

    Ok, but the question of whether taxation is just at all is a separate question from:

    a question of whether we as a society believe that holding on to money is more important than someone else’s survival

    Whether opponents of the ACA really are motivated by the belief that their wealth is wholly self-made is another question. I don’t know how much that theory has going for it relative to a null hypothesis like “most opponents are motivated by some mixture of partisanship, inertia, and ignorance of the law’s actual provisions.” I guess I’m just a little less comfortable psychologizing people who disagree with me, even when I think the correctness of my own position (i.e. universal, single-payer health care) is obvious.

    By the way, the argument that taxation is just because you wouldn’t have been able to generate the wealth without the state in the first place is called the Institutional Dependency Argument (IDA). I used to think the IDA was a very strong argument, but now I’m not so sure. The argument would also seem to conclude that the state is entitled to interfere in your personal life however it wants to, because you probably wouldn’t have had a personal life of such generally good quality without the trappings of a modern civilization in the first place.* On average, you wouldn’t even exist! But no one believes that this could possibly be true: even if state-sponsored research and education resulted in a doctor saving a kidney I otherwise would not have, or a website connecting me to a boyfriend that I otherwise would not have, surely the state cannot expropriate my kidney or my boyfriend. There are just certain spheres of human affairs where any interference from the state is intolerable, even if the state is somehow indirectly responsible for our enjoying that state of affairs to begin with.

    I’m not suggesting that the government start harvesting kidneys or repealing the tax code, but I do want to point out that the fact that the IDA seems horrific in this case implies that it can’t be the reason that we think taxation is just in the first place.

  9. We live in a society that has deemed it unacceptable to have people dying in the streets for lack of access to healthcare. Because that is all we can agree on, care is delivered in the least effective and most expensive manner possible.

    Nobody screams about requiring individuals to purchase auto insurance. It is commonly understood and accepted that if you cause an accident, you will likely be financially responsible for damages and/or injuries suffered by another party and that the associated costs will be greater than what you probably have in your bank account at any given time. Nobody is saying you have to protect yourself, but you do have an obligation not to take risks on a stranger’s behalf.

    Health insurance really isn’t any different. The cost of providing indigent care is passed along to others. This burden is greatest on those who are self-pay and are least able to afford it. (If you’re fortunate enough to have good health insurance, check out the “contractual adjustments” on your next medical bill.)

    The ACA is far from perfect, but it is the first meaningful step in any direction in a long, long time.

  10. a 5mph speed-limit and a ban on knives would be ignored

    Yes, precisely because we value all the other things we could do with our time more than we value the marginal reduction in mortality. If we did not value human life infinitely, we would have no problem with compliance. Which means that the value of human life in this sense is not infinite.

    You can measure these things indirectly by asking people questions like “how much would you be willing to pay for a traffic light that reduces fatal accidents by .01/yr, relative to the other projects you could fund with that money?” or better yet looking at wage premiums for hazardous occupations vis-a-vis comparable non-hazardous occupations. An overview of the issues is here.

    to insure the health and well-being of its citizens the government needs to spend money on things besides healthcare.

    Right– there are components to well-being besides merely being alive, which will sometimes mean that we will pursue those other components at the cost of marginal spending on health care.

    It’s not a controversial point; in fact it’s perfectly obvious until you put it into terms like “money is more important than someone else’s survival.” Which is why it’s an unconvincing argument, because we all implicitly agree, in a sense, that money is sometimes more important than someone else’s survival. We just don’t like to put it that way.

  11. Ok, but the question of whether taxation is just at all is a separate question from:

    No. The key part of the phrase you’re ignoring is the “holding on to” If you’d like you can add a “money people feel they are entitled to” to the end, but that was implied by the context, i.e., people think the government is somehow stealing their money.

    That isn’t psychologizing anyone. Its listening to the words they say.

  12. Maybe I’m confused but I don’t see how your arguments support the individual mandate. Poor people are already covered in theory. Making some self-employed guy who makes $50k a year purchase insurance isn’t going to change that.

    I’m not saying all aspects of the ACA are bad policy, or that forcing the aforementioned self-employed guy isn’t good policy because it spreads risk and eliminates the free rider problems in health insurance. I just don’t think “everyone deserves health care” is an argument for the individual mandate. Pre-ACA, everyone who could not afford health insurance and who had no job provided by the government ha access to Medicaid; wealthier people had the choice to buy insurance or not. Post-ACA, the only thing that’s changed is people who can afford it can no longer choose not to purchase health insurance (at least without paying a penalty).

    As a side note, one valid criticism of the individual mandate is that it is regressive. People have to purchase similarly-priced policies regardless of income, and the penalty-tax is also regressive.

  13. Kristen,

    The debate over the ACA hinges on whether it’s ok for the state to assess a tax penalty if you don’t purchase health insurance. I don’t have a problem with this. But you write that opponents “believe that holding on to money is more important than someone else’s survival” as if it were just self-evidently crazy. My point is that everyone believes, for some values of “money” and “someone else’s survival” that holding onto money is more important than someone else’s survival, so that can’t be the crux of the argument. The question is: well, how much money, and how much survival? If the plan were, for example, to spend trillions of dollars to prolong the lives of terminally ill 90 year olds by a matter of days, most people would quietly agree that that’s a bad deal. As it happens, I think the deal on the ACA is an ok deal (although not the best one), but it’s not crazy for someone to ask whether the given marginal tax increase is worth the given marginal health care spending. You can just reply: well yes, in this case it is.

    Obviously you want to hit the point where the marginal tax increase just matches the benefit from the marginal spending, and we can debate where that is. I’m just pointing out that everyone in the debate has some idea about how to make that tradeoff, and it doesn’t make sense to accuse one’s opponents of being willing to trade tax decreases off against healthcare spending, when all of us are making that decision somehow.

    people think the government is somehow stealing their money.

    Maybe I’m misreading you? I don’t think we’d want to say that no one is ever entitled to object to any tax increases or uses of public funds: if the state levied a tax hike to fund a new bomber, I’d be pretty pissed. I think we can handle opponents objecting to a specific policy without claiming that they must object in principle to taxation.

    I dunno, maybe you’ve run into people who have unsupportable beliefs about the state and taxation that fuel their opposition to the ACA. I’m sure they’re out there. I’d just rather focus on the stronger arguments against it than weak ones, even if just on the general principle of not wanting to get stomped in public debate.

  14. I’m not saying all aspects of the ACA are bad policy, or that forcing the aforementioned self-employed guy isn’t good policy because it spreads risk and eliminates the free rider problems in health insurance.

    1) Risk sharing reduces costs. Which allows more people to obtain coverage.

    2) Its part of an overall plan that subsidizes insurance for lower and middle income families. Without the individual mandate creating lower costs through risk sharing the entire plan fails.

    Pre-ACA, everyone who could not afford health insurance and who had no job provided by the government ha access to Medicaid; wealthier people had the choice to buy insurance or not.

    Not true. There is a large segment of the population that is unable to obtain comprehensive care but do not quality for Medicaid. If you make $50k a year you won’t qualify for medicaid. So, if your husband gets sick and suddenly has $150k in medical bills you may have to make some tough choices. If instead you have access to an exchange where you can get medical insurance for your family at a reduce or subsidized rate then an illness in the family won’t bankrupt you. Like I said, its not the best solution to the problem. But its a step in the right direction and the individual mandate is the only way this program works.

  15. But you write that opponents “believe that holding on to money is more important than someone else’s survival” as if it were just self-evidently crazy.

    Yeah no. First, please don’t use “crazy.” Its ablist. The word you’re searching for is unethical. I believe that prioritizing your control over “your” money over people’s lives in unethical. I think its bound up in the USian fascination with individualism.

    You’re making the argument about the pragmatics of choosing. I’m making an argument about the ethics of why people are making a choice.

  16. Thanks, Kristen. I make exactly two weeks’ wages over the Medicaid limit. Insurance premiums at my age, with a pre-existing condition, are prohibited. I will be paying the tax until I reach Medicare age. Meanwhile, boss man, a strident neocon, deplores Obamacare and claims the prez is the Antichrist, while drawing full medical disability and Medicaid. The true wingnut is a totally federally subsidized creature who wants the poor off government programs so (s)he won’t look lowclass by association.

  17. It is patently untrue that pre-ACA, everyone who was “poor” had access to Medicaid, unless your definition of poor is 1) below the poverty line and 2) in most places, pregnant or with children.

    The Medicaid expansion proposal was important because it would have expanded Medicaid significantly, insuring for the first time poor single men and people with incomes above the poverty line. Many states will still opt in to the Medicaid expansion, but a lot of states with many uninsured people will not; the coverage gap will therefore be extensive, as some people will be considered TOO POOR for the insurance exchanges, and therefore will not be able to purchase subsidized insurance — and ALSO will not be able to get Medicaid.

    Points made about the transitional nature of expanding health care coverage to (hopefully, one day) universal single-payer or coherent coverage are quite good. But I think LuckyLady said it best when she commented,

    We live in a society that has deemed it unacceptable to have people dying in the streets for lack of access to healthcare. Because that is all we can agree on, care is delivered in the least effective and most expensive manner possible.

  18. The Medicaid expansion proposal was important because it would have expanded Medicaid significantly, insuring for the first time poor single men and people with incomes above the poverty line.

    Absolutely.

  19. Nobody screams about requiring individuals to purchase auto insurance. It is commonly understood and accepted that if you cause an accident, you will likely be financially responsible for damages and/or injuries suffered by another party and that the associated costs will be greater than what you probably have in your bank account at any given time. Nobody is saying you have to protect yourself, but you do have an obligation not to take risks on a stranger’s behalf.

    Health insurance really isn’t any different.

    Health insurance is very different. I don’t have auto insurance because I don’t have a car, and I’m certainly not required to purchase one. Healthcare is about MY body and MY health, though; everyone needs access to healthcare, no matter who you are, how old you are, or any other factors about who you are individually. Everyone does not need auto insurance.

  20. (As an addendum to my last comment, I’m happy the ACA was deemed “constitutional,” although I’m peeved it isn’t single-payer, and that many, many people will still fall through the cracks and be left uninsured or fined. It amounts to little more than a corporate handout, with a few great exceptions. Hopefully this will only get better with more expansions and improvements.)

  21. Fair point. Depending upon where you live you might not need to own a car, but the crux of the matter is whether or not we have an obligation to ensure that our choices do not impinge upon others.

  22. I believe that prioritizing your control over “your” money over people’s lives in unethical. I think its bound up in the USian fascination with individualism.

    But this is the Peter Singer argument in The Life You Can Save [trigger warning for Peter Singer?] — that everybody living better than the most basic daily subsistence does this. And while I find it appalling to agree with Peter Singer about anything, I do (alas) agree with him about that.

    So I don’t think that the issue is “the government is taking my money”, per se. I think it’s “the government is taking my money and throwing it down a hole”.

    Though, to be sure, it’s kind of an academic distinction. In my experience, people who think this about social programs tend to think that, by definition, what the government does is throw money down a hole.

  23. The thing that I think a lot of people on the left don’t realize about a lot of people on the right is that it isn’t just animus against the poor or women that drives the anger here, thats certainly true in some quarters but not in all, but a general sense that government in general and the federal government in specific has too much power, wastes money, and unnecessarily interferes with people’s lives. Health care is important and I think we’ve proved that the government needed to step in, but I think its downright dangerous for people on the left to plug their ears and ignore the objection to unbridled government power that a pretty significant portion of the country has. Sure, in this case its reflexive and unfounded, but its very difficult to hold your nose and accept the expansion of an organization which is raiding medical marijuana dispensaries, killing people (even American citizens) without trial and outside the context of anything that really resembles war, spying on it’s own citizens, arming drug gangs, and generally fighting tooth and nail against transparency or accountability. The idea that a government like that can force your to buy a service is scary. I think its desperately necessary in this case, but I don’t think its right to discount the fear and indignation people are experiencing because the rage at the ACA isn’t just about the ACA.

  24. Post-ACA, the only thing that’s changed is people who can afford it

    Post-ACA, my monthly premiums for a family of four still cost $1228/month, and our deductibles (in-network) are still $500/person and $1000/family per year. Naturally we do not qualify for Medicaid or for a “break” in the insurance exchanges, although we still struggle to pay this bill every month.

    So “afford” is kind of a funny word.

  25. @William,

    I agree with you about the expansion of federal power in certain instances, but I don’t think that the majority of conservatives are complaining about the ACA because of raids on dispensaries. This isn’t about a principled against an authoritarian government…its a principled stand against distributive justice.

  26. Oh noes taxes, the end of all freedom. America fought a revolutionary war to not need to pay taxes, we fought two world wars without taxes. And now Obama is going to make us pay a tax. Absurd, if we can fight wars without paying taxes we should be able to get healthcare without taxes.

    Okay, so my tax attorney just informed me that its only the rich who don’t pay taxes, and under the new law I’ll have healthcare so I still won’t be taxed. So never mind, its okay if the poor pay taxes, as long as the rich peeps like me don’t. 🙂

  27. Kristen:

    While I think that is likely true for many conservative politicians, and absolutely true for the vast majority of the conservative commentariat, I think its a dangerous underestimation of right-leaning independents to assume that all of the ground-level anger around the ACA comes down to people hating the poor or fear of communism. We live in a country where police shoot dogs as a matter of course, where huge segments of the population feel humiliated and disempowered by security apparatus and regulation, where merely flying across the country means theres a good chance you’ll have to allow someone to touch your genitals. People are pissed. A lot of them lack the political nuance to understand what they’re angry about or how it came to pass and I do think that that is behind much of the angst here.

    Even arguments about “stealing my money” often have a root in the general disgust a lot of people on the right have with government as a basic concept at this point. For a long time I considered myself a conservative, I still have friends amongst those camps, I still read some of the publications and blogs. Theres a saying that moves around the libertarian community: “libertarianism happens to people.” A couple of weeks ago I had to go renew my plates. That meant buying a $75 sticker from the city and a $99 sticker from the state for the privilege to drive to work. I know that that money pays for roads, but that intellectual understanding doesn’t do much when I’m driving over potholes on the way there and about to spend almost $200 to avoid being charged even more and threatened with my car being confiscated. The tax process is not pleasant. In order to even get the sticker, though, I had to take an emissions test. The problem is that the State of Illinois has decided that emissions testing is too expensive, so instead they test the car’s computer to see if anything would be causing too much emissions. Unfortunately for me, the sensors in my car that give that data weren’t working. $800 of repairs later, repairs I had to find the money for because the alternative is an ever increasing burden of tickets and public transportation to my job just flat doesn’t exist, I could finally take the emissions test and buy the stickers. I got an $800 regulatory burden on top of my $200 tax burden. As pissed as I am, I had the money and I was thankful for that and I get why emissions testing is an important thing, but the process made my life more difficult and more expensive than it otherwise would have been. Most people’s interactions with government look like that most of the time. Its not getting saved from terrorists or having some great service brought into your town, its getting felt up by the TSA or yelled at in the DMV or charged a bunch of money you know is going to be spent irresponsibly by people who are almost certainly unaccountable.

    I think thats a lot of what we’re seeing here, people livid at yet another intrusion into their lives and potential ding on their paycheck, at least as much as animus against the poor. Thats what the ACA looks like, especially if someone doesn’t realize they know someone who is affected or hasn’t seen a horror story first hand, it looks like yet another expensive, inefficient, intrusive shitshow. The left has done a terrible job explaining why that appearance is either inaccurate or the lesser of two evils. The rhetoric has sucked. People are angry and have been given very little to assuage or redirect that anger. When you frame that anger as a “principled stand against distributive justice” you not only unnecessarily kick off the kinds of opportunistic criticisms the hardliners will make about socialism (even when demonstrably wrong, it makes things muddy) but you make an attack that completely forcloses the opportunity to educate or persuade. You’re attacking potential allies and giving gifts to enemies. Worse than that you’re not only doing sweet fuck all to help the ACA, something which should be a first step in the first place, but you’re actively increasing the animus which is leading to a move to repeal the act entirely. Maybe thats good enough for right now, maybe you’re angry enough that you don’t want to do 101 with assholes. I get that, I really do, but it doesn’t amount to much at all when these people are in a voting booth and choosing between a Democrat who they see as the embodiment of everything they hate about government because they’re angry and too lazy to look too hard and a Republican telling a small government lie and campaigning to repeal the ACA. Framing the discussion in terms only likely to be sympathized with or understood by your existing supporters is all but guaranteeing a pyrrhic victory on a vital issue.

  28. The thing about the individual mandate is that it is necessary to the other reforms. If you have a rule that basically says that insurance companies have to sell insurance to anyone who wants it, regardless of pre-existing conditions, you’d have a situation that encouraged people to buy insurance only when they needed it–i.e., when they had a medical condition requiring expensive case. Premiums would either skyrocket or companies would go out of business. The mandate expands the risk pool so that no one can game the system that way. I think Washington State tried the former, and it was a complete failure. The mandate is how you achieve universal coverage. (Single-payer would be better, but I’m not sure we were going to go from pre-ACA to single-payer in one step.)

    And you may have a choice about buying a car, but you may not have a choice about receiving health care. Emergency rooms have to treat everyone. If you are in an accident or otherwise unconscious or unable to validly refuse care, you are going to the ER, where they will treat you. It is not entirely up to you whether you consume health care.

  29. The United States was NEVER going from nothing to single payer in one step.

    Why not? The UK did, right after WWII, when its infrustracture was destroyed and it was in a precarious financial condition and it could barely even feed its citizens. But its leaders knew it was the best thing — and the cheapest thing! — for its citizens, too.

    It’s only the utter failure of American’s leaders to present the facts and the vision necessary to implement single-payer that accounts for the US’s current terrible state of health care.

    1. “Why not? The UK did, right after WWII, when its infrustracture was destroyed and it was in a precarious financial condition and it could barely even feed its citizens. But its leaders knew it was the best thing — and the cheapest thing! — for its citizens, too.”

      At the end of the war, the UK elected a Labour government. The US has never had a labour party, much less one in power. The Labour Party started the NHS — not some “leaders” because the war-time leaders were unceremoniously booted out at the first post-war election.

  30. Thanks Kristen. I am mainly in agreement with this, and I’d like to address some criticisms that have been brought up with regard to the ACA.

    I suspect we’re only going to see a RISE in healthcare overhead costs — the kind of costs Obama told the nation he was trying to address. What good is this law, if twenty or thirty years down the road it has to be gutted because we can’t afford it?

    I can’t speak to overhead costs in particular, but with respect to overall costs, I believe what Obama meant is that the ACA will slightly slow the increase in the rate of health care inflation compared to the pre-ACA status quo. That’s the conclusion of a 2009 study by the Centers for Medicare and Medicaid Services (CMS). It’s true that with continued unlimited health care cost inflation, we eventually won’t be able to afford universal health care. But the same is true of Medicare and Medicaid, or the provision of health insurance through the private sector without ACA. Regardless of what you think of the expanded coverage mandate in ACA, health care cost inflation will have to come under control and ideally, fall as a percentage of GDP, or we won’t be able to afford it no matter what laws there are. It’s also true that further health care reform will be needed. What ACA gets us, as has been said, is universal coverage, or at least coverage for 33 million additional people. But the need to fundamentally reform the spending incentives that drive health care inflation is still there. That is why I believe we will eventually have to move to single payer. We will have no choice.

    lambda,

    I dunno, maybe you’ve run into people who have unsupportable beliefs about the state and taxation that fuel their opposition to the ACA. I’m sure they’re out there. I’d just rather focus on the stronger arguments against it than weak ones,

    The way I read that anecdote, Kristen’s coworker was someone who was objecting to taxation on principle, and expressed “unsupportable beleifs about the state and taxation.” Kristen was responding to the argument she made, which was a viscerial argument emotionally but a weak argument logically. You’re the one waving you hand and saying “But not everyone who objects to ACA must be against all taxation! There are good arguments out there against it!” Well, sure they are. “Its personal because I don’t want the government thinking it can steal my money” isn’t one. That’s a bad argument against all taxation, not a good argument against ACA, and it certainly has nothing to do with institutional trade-offs.

    Basically I see you taking some arguments for taxation (like the Institutional Dependency Argument) and taking them to extremes — if people’s dependency on the government to enable them to make money justifies taxation, then it must justify Stalinism! Of course not. The IDA works, but it isn’t mean to justify any action the government could possibly take. It’s simply a weight in favor of collective responsibility.

    Overall, I’d say the lesson in this discussion so far is that a lot of the reaction is about emotion and symbolism, how one sees “the government” rather than policy, which is too bad.

  31. It’s only the utter failure of American’s leaders to present the facts and the vision necessary to implement single-payer that accounts for the US’s current terrible state of health care.

    Which is why the US was never going to go from pre-ACA to single-payer. I’m not saying it’s not possible to do so, I’m saying that it was not possible given the condition in the country at the time. We had, at best, leaders who were generally unwilling to lead on this issue or who had consumed the Koolaid of “bipartisanship,” and, at worst, Tea Party people who came to Washington wanting to burn the place down rather than do anything that might improve the material lot of their constituents. Even the usual Republicans had decided that their job was to make Obama a one-term president, rather than, say, to govern the country in a responsible manner. Single payer was not going to happen.

  32. Wow. THey already get taxed, and there is a choice in that: Emigrate! It is not going away.

  33. As I helpfully pointed out to a conservative who was ranting, the “tax” is a fine imposed if you do not buy health insurance and it is much much smaller than the following scenario: refusing to mow your lawn for the entire year at the going fine of $75 per citation, which you can expect at least 2 of per week. Where’s the outrage amongst those championing for the freedom to have long grass?

  34. When you frame that anger as a “principled stand against distributive justice” you not only unnecessarily kick off the kinds of opportunistic criticisms the hardliners will make about socialism (even when demonstrably wrong, it makes things muddy) but you make an attack that completely forcloses the opportunity to educate or persuade.

    Except a great deal of this anger is about distributive justice. Which is why you hear people speaking using rhetoric that decries wealth redistribution. You may see the conservative movement as full of people who are just fed up with the authoritarian nature of government, but the actual human beings who make up the conservative base where I live are making a different argument. And no amount of sugar coating is going to change their mind.

  35. Mmmm. Here in the UK we also have a very different culture. Despite the Americanisation that has been slowly creeping in over the decades, we’re still very European, and Europe as a whole doesn’t have the same cultural dislike for socialism (I had to explain to some friends recently why the accusations of Obama being socialist are supposed to be insults).

    In addition, we’d just come out of a war that had left us so poor, so struggling to survive that the entire country had embraced a cultural shift towards community responsibility – everyone depended on everyone else making sacrifices, going hungry, going without new things and working inhumanely long hours in weapons factories, mines etc to survive, so sharing a tax burden for universal healthcare was a relatively easy sell.

    I love the NHS and neither I nor my partner would be here today without it, but I recognise the massive cultural shift that was required for it to happen the way it did. ACA might not be perfect as a solution, but it’s a positive step and, combined with several other small but significant changes Obama has been making to healthcare, it’s probably the best that could have been fought for at this stage.

    The trick is to keep fighting!

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