# Affordable Care Act in US

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swansont    6166

The ACA wasn't just "imperfect" - it just didn't work as claimed at all. If you want to discuss the ACA, please open a thread, because that would pull us OT for sure. Health "insurance" is a mess in the United States, and has been for years, and I don't know if I see a very good solution.

OK, you've got your thread. Now, let's have some facts to back this claim up.

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rangerx    61

Universal healthcare in any country isn't perfect either, but they prevail. It cannot begin from a defeatist position.

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Phi for All    4741

I'm a proponent of using Medicare as a universal insurance pool, but I thought the ACA was much more successful than most give it credit for. Good article here: http://www.cbpp.org/research/health/census-data-show-historic-coverage-gains-in-2014

The uninsured rate fell sharply from 13.3 percent in 2013 to 10.4 percent in 2014 and the number of uninsured Americans dropped from 41.8 million to 33.0 million, Census Bureau data based on the Current Population Survey (CPS) show.[1] (See Figure 1.) These are by far the largest single-year reductions on record in data back to 1987.
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KipIngram    129

Well, I wasn't just particularly chomping at the bit to discuss this; I just felt that the other thread had drifted OT and didn't want to contribute that more of the same. But I feel like it would be lame not to post something given that the thread is here now. I did find this:

which cites this Brookings study that I'd also run across earlier in my search:

Both of these take the position that the in the immediate aftermath of the introduction of the ACA private industry health insurance premiums rose faster than pre-existing models predicted otherwise.

This CNN article discusses some of the reasons why merely "enrolling people into something called health insurance" doesn't really constitute success:

http://www.cnn.com/2015/03/04/opinion/atlas-obamacare-poor-middle-class/

The core problem is that most of the increased enrollment comes in through Medicaid, and that many doctors are refusing to take new Medicaid patients. I haven't followed this angle up yet, but it also cites a study stating that many Medicaid patients suffer worse outcomes than private insurance patients. It also cites the Congressional Budget Office as projecting that ten million Americans will be forced off of their insurance programs of choice as a result of the program. That was something I wasn't even aware of earlier today that I'll need to peek into further.

The problem with researching this, like so many politically charged issues (like, say, climate change) is that a lot of the information available is politically motivated. I think for every negative review I could find one could find a positive one, along with analyses on both sides showing why the other side's arguments are garbage. I actually intend to read the Brookings study, but it will take a few days.

Please let me digress momentarily and share my own thoughts as to where we've gone wrong with this. Insurance is a very well-defined thing. The idea behind insurance is that you have a group of people some of whom will suffer an extreme cost of some kind, but you have no way of predicting which ones. Each of them pays premiums that represent the average cost across the whole group of all such events (plus a little extra for insurance company profit). Then the insurance brings forth the money for those that actually suffer the event.

Providing that same protection to people who do not pay in that full premium amount is not insurance - it's welfare. I think we have confounded the phrase "health insurance" by turning it into a welfare mechanism. If there are some people who cannot afford health insurance, we could just give them money (a welfare payment) that they could then use to purchase health insurance on the open market. I see no reason it couldn't just be treated as a straight up welfare issue. The government could help people afford it without actually managing it. This would be my general approach to all welfare, by the way - implement it all in one way, via a negative income tax administered by the IRS. Cash money, usable to fund any need, and get rid of the alphabet soup of agencies we have now.

Well, I'll stop there for now. While the "negative" effect of the ACA that would affect me personally in the most adverse way is the driving up of private insurance costs, I recognize that many who value "more people insured" might just not be very bothered by increased private costs. So I will try to look more deeply into the other thread: the premise that just having people on the insurance rolls doesn't necessarily mean that they are better off. I sense that might be a more compelling argument for those focused on the impact of the program on the poor as opposed to the impact on everyone.

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iNow    4502

It should also be noted how many people actively stood in the way of ACA being successful, how many state governors refused Medicaid expansions (out of spite? it sure wasn't a fiscally wise decision...), and how part of the reason so many private insurers are pulling out of the markets is due to the uncertainty the GOP has directly inserted into the future of the program (making it quite hard for a business to commit to the next 1-3 years).

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KipIngram    129

I would imagine for some it could have been spite, while for others simply a reflection of belief. Some people just believe that the role of government should be minimalist. I share that belief, while still wanting to show compassion for the less fortunate of us - I straddle that fence the way I mentioned above, by supporting the idea that the government can redistribute wealth to assist the needy without having to get involved with every single detail of how the economy works.

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iNow    4502
Posted (edited)

You believe tens of thousands of people (Edit: it's actually millions across states) should be sick and just die when they don't have to; when the rest of us can simply pitch in an extra buck or two a year to assist and offer them and their families some help. Got it.

We're talking about Medicaid here, not "every single detail of how the economy works."

Edited by iNow

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KipIngram    129

I didn't say that, at all. My point was simply that one way of helping people have health insurance is to help them have the money with which to buy it. If something I said up there implied that I approve of Medicaid patients having worse outcomes than private insurance patients it wasn't in any way meant to. I was just noting that as a point I saw leveled against the ACA when I was searching.

By assisting via cash payments to cover premiums you turn every patient into a private insurance patient, so there wouldn't be a question of "private insurance vs. Medicaid" any more - it would all be private insurance.

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iNow    4502

Private insurance is more expensive. They have smaller risk pools and lower negotiation leverage on prices. The stipends you suggest can't cover most healthcare coverage needs, and Medicaid consistent outperforms private insurance in terms of costs to patient.

http://kff.org/report-section/medicaid-spending-growth-compared-to-other-payers-issue-brief/

A number of methodologically rigorous studies have demonstrated that Medicaid coverage helps to improve receipt of preventive health care, access to care, and out-of-pocket spending burdens and other financial outcomes.4,5,6,7,8

(...)

In addition, recent evidence suggests that Medicaid coverage has long-term positive effects. Expansions of Medicaid eligibility for pregnant women increased economic opportunity of their children when they reached adulthood through increased rates of high school and college completion and higher incomes.16,17,18 In addition, children who gained eligibility for Medicaid paid more in cumulative taxes by age 28 compared to similar children who did not gain Medicaid coverage, such that the government is estimated to recoup 56 cents of each dollar spent on Medicaid during childhood by the time the children reach age 60.

(...)

Spending per enrollee is lower for Medicaid compared to private insurance after controlling for differences in socio-demographic and health characteristics between the two groups.

(...)

total health care spending would increase nearly 26 percent, from $5,671 per person per year to$7,126, if a typical low-income Medicaid adult were covered by private health insurance for a full year

(...)

We find that the evidence suggests that Medicaid has constrained costs as well as, or better than, Medicare and private insurance. The relevant studies are summarized in Table 2.

(...)

Overall, the literature shows that per capita spending in the Medicaid program is lower compared to private insurers after adjusting for the greater health needs of Medicaid enrollees; Medicaid spending growth has been primarily driven by rising Medicaid enrollment; spending growth per enrollee in Medicaid has been low compared to other payers

Medicaid can be improved, but it's wrong to suggest it offers worse outcomes than would the high-deductible catastrophic care only crap at least 1 in 5 Americans could afford with stipends.

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CharonY    1590

Well, I wasn't just particularly chomping at the bit to discuss this; I just felt that the other thread had drifted OT and didn't want to contribute that more of the same. But I feel like it would be lame not to post something given that the thread is here now. I did find this:

which cites this Brookings study that I'd also run across earlier in my search:

Both of these take the position that the in the immediate aftermath of the introduction of the ACA private industry health insurance premiums rose faster than pre-existing models predicted otherwise.

This CNN article discusses some of the reasons why merely "enrolling people into something called health insurance" doesn't really constitute success:

http://www.cnn.com/2015/03/04/opinion/atlas-obamacare-poor-middle-class/

With regard to the premium increase, later studies, including those from the brookings institution found that without ACA, the premiums were likely to be higher :

Since the Affordable Care Act’s (ACA) health insurance marketplaces first took effect in 2014, news story after story has focused on premium increases for certain plans, in certain cities, or for certain individuals. Based on preliminary reports, premiums now appear set to rise by a substantial amount in 2017.

What these individual data points miss, however, is that average premiums in the individual market actually dropped significantly upon implementation of the ACA, according to our new analysis, even while consumers got better coverage. In other words, people are getting more for less under the ACA.

With regard to public health effects there are papers indicating improvement in health equity, and general increase in coverage (see e.g. Courtemanche et al. J Policy Anal Manage 2017).

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swansont    6166

Well, I wasn't just particularly chomping at the bit to discuss this; I just felt that the other thread had drifted OT and didn't want to contribute that more of the same. But I feel like it would be lame not to post something given that the thread is here now. I did find this:

which cites this Brookings study that I'd also run across earlier in my search:

Both of these take the position that the in the immediate aftermath of the introduction of the ACA private industry health insurance premiums rose faster than pre-existing models predicted otherwise.

The abstract says that it looked at 11 states: 5 in which the state did nothing (no exchanges, no medicaid expansion) and 6 in which the state exchanges suffered severe glitches. It also only looked at the first half of 2014.

The premium rises were lower under Obama than under Bush

There's another study that shows that premiums fell after the ACA was adopted

They also note that plans cover more costs than they did, on average, before the ACA took effect.

it also cites a study stating that many Medicaid patients suffer worse outcomes than private insurance patients.

But that's the wrong metric, to compare medicaid with private insurance. These people had no insurance. Are they better off than they were?

Please let me digress momentarily and share my own thoughts as to where we've gone wrong with this. Insurance is a very well-defined thing. The idea behind insurance is that you have a group of people some of whom will suffer an extreme cost of some kind, but you have no way of predicting which ones. Each of them pays premiums that represent the average cost across the whole group of all such events (plus a little extra for insurance company profit). Then the insurance brings forth the money for those that actually suffer the event.

Providing that same protection to people who do not pay in that full premium amount is not insurance - it's welfare. I think we have confounded the phrase "health insurance" by turning it into a welfare mechanism. If there are some people who cannot afford health insurance, we could just give them money (a welfare payment) that they could then use to purchase health insurance on the open market. I see no reason it couldn't just be treated as a straight up welfare issue. The government could help people afford it without actually managing it. This would be my general approach to all welfare, by the way - implement it all in one way, via a negative income tax administered by the IRS. Cash money, usable to fund any need, and get rid of the alphabet soup of agencies we have now.

Well, I'll stop there for now. While the "negative" effect of the ACA that would affect me personally in the most adverse way is the driving up of private insurance costs, I recognize that many who value "more people insured" might just not be very bothered by increased private costs. So I will try to look more deeply into the other thread: the premise that just having people on the insurance rolls doesn't necessarily mean that they are better off. I sense that might be a more compelling argument for those focused on the impact of the program on the poor as opposed to the impact on everyone.

When you don't like a benefit that someone gets from government, it's welfare. That's a sure-fire way to get people riled up. But it's just playing on the emotion that welfare is bad, which is something you have not established.

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KipIngram    129

So, +1 on Kaiser Family link - I kicked the tires there and they seem extremely well thought of as far as being unbiased. One thing that makes all of this more difficult than it should be is the inflated costs (the many dollars per Tylenol pill and things like that you find in hospitals). Any sort of comprehensive solution should address that as well - if the whole business wasn't outrageously expensive (except where it should be - I don't claim that every treatment should be cheap) then it would be a lot easier to consider various options.

http://kff.org/report-section/medicaid-spending-growth-compared-to-other-payers-issue-brief/

pegs the cost of private insurance vs. Medicaid at 18%. That's a difference, but it doesn't seem like a difference that completely rules out consideration of a fully privatized system. I thought perhaps you were talking about a 2x or 3x difference or something like that. I noted earlier that many doctors refuse to take new Medicaid patients, so we're clearly giving something up for that savings. We save some money, but in doing so we create a "caste system" within the population.

By the way, I don't want to come off as promoting the nobility of private health insurance companies. I think, by and large, they're greedy corporations like most other corporations. It's been my experience that they will dodge paying out any way they can. That is an area where close government oversight is in order, in my opinion. Promises should be kept, just like in any form of business relationship. That includes both 1) keeping to the letter of the agreement, and 2) not "stacking" the agreement with so much legalese that there's a way to wiggle off using technicalities. The insurer / insured relationship is one where one side has mighty legal resources and the other does not - I'm all for government oversight to ensure the little people don't get stomped on. Ditto for government oversight of cost-gouging at hospitals.

But back to the point - I found 18% as a cost differential. Do you accept that as roughly right, or do you feel it's much more substantial?

When you don't like a benefit that someone gets from government, it's welfare. That's a sure-fire way to get people riled up. But it's just playing on the emotion that welfare is bad, which is something you have not established.

I don't mean to imply that it's "bad." I generally support a humane, well-executed welfare program. I'm just defining terms - in my mind welfare is anything that transfers economic benefit from one person to another in an income-based way. Insurance premiums transfer economic benefit amongst people in an entirely random way.

I think a single welfare mechanism operated through the tax code would be more efficient and less "exploitable" than one comprised of many many programs such as we have now. I'd prefer such a program even if it was order of 20% more expensive than a set of programs "optimally" managed by the government - I'd be happy to pay my share of the 20% extra. If the 20% is wrong and it would actually be 2X or 3X I'd have to opine again, and I realize that 18% number came up only in the context of health insurance.

I think it's easy to agree that we'd all prefer that any given person not need welfare - that would just mean he or she is doing better in life, right? But in a nation as prosperous as ours I think there is plenty of room for a well-executed safety net to keep people from suffering. Just because I'm generally in favor of free enterprise doesn't mean I lack all compassion.

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dimreepr    614

The problem is in the title "affordable care act" which, politically, suggests that it may not be and would impact on 'my' standard of living.

I wouldn't suggest The UK's NHS is the perfect model, because every man and his dog has some sort of claim on it, but I would suggest it's initial mantra "free healthcare at the point of use" is the way to go, within a strict limit of that mantra.

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HB of CJ    19

It is possible we are missing a very important point. There is not one word written anywhere in the United States Constitution that deals with national mandated health care. None. The Federal Government has no mandate even getting into the insurance business.

The Tenth Amendment even goes further. Pretty pain language of the day which still means what it says. Any such insurance notions must come from the State level, or like said, from the individual respectfully. Either we have a Constitution or we don't. No half ways.

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KipIngram    129

That is true, and is a good point. An income-tax based direct payment of the form I described above would at least "live completely" within the tax code. the 16th amendment is pretty terse - it doesn't really say anything about the redistributive nature of the tax code it authorizes.

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dimreepr    614

How is health care not equal to infrastructure, at a base level?

Every society needs people more than it needs roads.

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KipIngram    129

By that argument practically anything can be considered infrastructure. Food distribution, communication networks, etc. I'm not really taking a yea or nay position on the permissibility of such things - just noting that you're opening a very open-ended door with that argument.

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dimreepr    614

By that argument practically anything can be considered infrastructure. Food distribution, communication networks, etc. I'm not really taking a yea or nay position on the permissibility of such things - just noting that you're opening a very open-ended door with that argument.

Not really, what's the point of roads without the people that traverse them?

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John Cuthber    3181

It is possible we are missing a very important point. There is not one word written anywhere in the United States Constitution that deals with national mandated health care. None. The Federal Government has no mandate even getting into the insurance business.

The Tenth Amendment even goes further. Pretty pain language of the day which still means what it says. Any such insurance notions must come from the State level, or like said, from the individual respectfully. Either we have a Constitution or we don't. No half ways.

Let's have a look at the 10th amendment.

"The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

So, if the people vote for something it's OK.

The constitution does not stop the people deciding to get the government to insure health care.

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KipIngram    129
Posted (edited)

Not really, what's the point of roads without the people that traverse them?

I'm not sure what you're implying with that - the best I can do interpreting it is that you're saying without health care there will be no people and so roads wouldn't matter. True, but I don't think that there would be no people without government run health care, and I doubt you think that either. Do you really think you can interpret the Constitution in a way that makes health care an authorized government function without having that same interpretation used to cover numerous other things? If it actually said in there that one of the roles of the federal government was to facilitate the availability of health care to citizens, then that would be a slam dunk. But it doesn't - you have to pick some words that are in there and then attach a sufficiently broad interpretation to them to make the notion fly. I think that would let a lot of things in the door.

I think the constitutionality of the whole business is a separate thing, though - it's very clear that the federal government has already gone far beyond what would be constitutional in the eyes of a strict interpretation supporter. I guess the response to HB of CJ should be that "that bird has flown" - if you're going to prohibit the government from getting involved with health care based on the Constitution, then you need to also prohibit it from doing a whole bunch of things it's already done. Regardless of one's opinion as to how the Constitution should be interpreted, in point of fact we are operating today with a rather broad interpretation.

Let's have a look at the 10th amendment.

"The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people."

So, if the people vote for something it's OK.

The constitution does not stop the people deciding to get the government to insure health care.

I think that's stating it too strongly. Once again, that argument could be used to justify anything, so we may as well not have a Constitution (beyond its definition of how government officials are selected). You can choose whether to interpret the allowed powers strictly or broadly, but we do generally regard the document as defining the boundaries of government power.

Is your view of the Constitution that it prohibits specific things (e.g., laws creating a "state religion," etc.) and that absolutely anything else is fair game?

My opinion is that one of the purposes of constitutional limitations on government is to protect minorities. That is, it lays out limits on the government such that the government cannot do those things even if a majority of voters wants it to.

Edited by KipIngram

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dimreepr    614

I'm not sure what you're implying with that - the best I can do interpreting it is that you're saying without health care there will be no people and so roads wouldn't matter. True, but I don't think that there would be no people without government run health care, and I doubt you think that either. Do you really think you can interpret the Constitution in a way that makes health care an authorized government function without having that same interpretation used to cover numerous other things? If it actually said in there that one of the roles of the federal government was to facilitate the availability of health care to citizens, then that would be a slam dunk. But it doesn't - you have to pick some words that are in there and then attach a sufficiently broad interpretation to them to make the notion fly. I think that would let a lot of things in the door.

I think the constitutionality of the whole business is a separate thing, though - it's very clear that the federal government has already gone far beyond what would be constitutional in the eyes of a strict interpretation supporter. I guess the response to HB of CJ should be that "that bird has flown" - if you're going to prohibit the government from getting involved with health care based on the Constitution, then you need to also prohibit it from doing a whole bunch of things it's already done. Regardless of one's opinion as to how the Constitution should be interpreted, in point of fact we are operating today with a rather broad interpretation.

The problem with the US constitution is that it's considered, by it's populace, as the final word, despite the amendments.

You do understand what 'amendment' means but refuse to acknowledge that it applies to US/us.

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KipIngram    129

I don't know what I said that implied that. "The Constitution" is the whole thing - amendments included. Changing the document is completely supported within our system - ignoring it is quite different.

Just to keep the various threads in sight here, please recall that I wasn't the one that brought up whether or not federally run health care was constitutional or not. Also, I fully support health care being accessible to everyone, and proposed a way that could be accomplished that clearly is constitutional (poverty remediation via the federal governments power to levy any sort of income tax it wishes). It was proposed that such an approach would be prohibitively expensive, to which I responded with a source estimating that mark-up at 18% - a markup I don't consider "prohibitive." I do not advocate a society in which people are deprived of adequate health care due to income.

I'm currently reading this: http://education.stateuniversity.com/pages/1882/Constitutional-Requirements-Governing-American-Education.html, which analyzes the limitations placed on the federal government in the arena of education. Health care and education strike me as at least reasonably similar "fundamental needs," and neither is mentioned per se in the Constitution itself. So I think it's reasonable to feel that the nature of our "handling" of federal power in these areas should align in some way. The article outlines how, in spite of not having any constitutional power in the area of education, the federal government has still affected influence over the states in a fairly major way.

Look, I sense that you and I have fundamental differences in what we see as the appropriate role of government in America. But I really do share many of your ultimate goals - I would like to see poverty addressed, I would like for everyone to have access to health care (and a good primary education), and probably other things we haven't discussed. And even though I believe free enterprise surpasses other economic arrangements in efficiency and productivity, I also recognize that completely unregulated free enterprise tends to concentrate wealth in the hands of a very small number of individuals and business entities. This concentration becomes self-reinforcing, and at that point you have a deck that's stacked in favor of an elite few. I don't support that as a "healthy" culture. I am quite in favor of the government taking steps to prevent that situation. I just believe that it could all be accomplished via an appropriately designed tax code (along with other desirable goals, such as encouraging businesses to employ Americans rather than outsource jobs overseas).

I don't think there's any way to completely avoid some people "having more" than others. Even if you legislate full economic equality, some people will find ways around it, and in particular the very government officials you look to to oversee that system will have temptation to "better themselves" via misapplication of their power. Most fundamentally, though, equal outcome completely removes incentives to produce. I fully support, however, reducing the extremes of that inequity. We don't need to have people that are too poor to have any life other than misery. And we don't need to have "super wealth" such that the top 400 earners in your economy average \$270 million a year in income (I read that figure somewhere a few months ago). We need enough stratification in wealth to preserve work incentives, but in our current culture the bottom is too low and the top is too high.

That's not really ACA related anymore, though my "hopes" for the health care area do mirror that philosophy. I'd be happy to chat about thoughts I've had for using the tax code in these ways in a private conversation if you like, though. Hopefully we could find some areas of agreement and not wind up feeling adversarial toward one another. Though I may have some beliefs about the role of government that differ from yours, I'm really not a "forget the poor - I don't care" person.

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Delta1212    894

The problem with the US constitution is that it's considered, by it's populace, as the final word, despite the amendments.

You do understand what 'amendment' means but refuse to acknowledge that it applies to US/us.

While some people do, in fact, ignore the fact that the document is amendable and treat it like gospel rather than a living document, not everyone who points toConstitutional problems with a given solution is doing that. From a purely practical perspective, the fact is that getting an ammendment through is extremely difficult, especially in a hyper-polarized, extremely partisan political environment.

You need very broad based support within the federal government and across a majority of states to pull that off. Even a complete inversion of the current political status quo that put Democrats in the position that Republicans are in right now in terms of majorities at the level of federal and state governments wouldn't be enough to pull off a healthcare-related ammendment. With the situation the way it currently is, that doesn't even rise to the level of pipe dream.

A better argument in favor of a national healthcare program being allowed under the Constution than saying that it can be amended to allow it is the ruling on Social Security in Helvering v Davis which allows that the government is allowed to establish programs to provide for the general welfare using its taxation power to support them.

The existence of Medicare, which received cover under the same defense outlined in that ruling, provides a blueprint for an expanded program that has a basis in Constitutional law.

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iNow    4502
Posted (edited)

It is possible we are missing a very important point. There is not one word written anywhere in the United States Constitution that deals with national mandated health care. None. The Federal Government has no mandate even getting into the insurance business.

The Tenth Amendment even goes further. Pretty pain language of the day which still means what it says. Any such insurance notions must come from the State level, or like said, from the individual respectfully. Either we have a Constitution or we don't. No half ways.

Given your obvious passion for our constitution (helll, you even capitalize it like one would the term god), I'm surprised you're not more aware of the concept of implied powers, specifically the "general welfare clause" and the "necessary and proper clause" which give elasticity to the constitution and flexibility to the legislature. The founders knew the constitution was not all encompassing so inserted ways for us to address needs of this type.

Plus, as others have already noted, that ship has long ago sailed...

Edited by iNow

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Delta1212    894

Given your obvious passion for our constitution (helll, you even capitalize it like one would the term god), I'm surprised you're not more aware of the concept of implied powers, specifically the "general welfare clause" and the "necessary and proper clause" which give elasticity to the constitution and flexibility to the legislature. The founders knew the constitution was not all encompassing so inserted ways for us to address needs of this type.

Plus, as others have already noted, that ship has long ago sailed...

The Constution is used as a proper name to refer to the founding document if the US governmen.. It is the same difference in capitalization that you get when you refer to the Declaration of Independence, which was a declaration of independence, or the White House, which is a white house.

The United States has a constitution and it is called The Constitution. That's not a religious thing. It's just its name.