Trying to guess what SCOTUS will do is mostly an exercise in futility, the only certain thing is that the majority opinion will contain some discussion of limitations on the Commerce Clause, because that's clearly what bugs Kennedy the most. If I had to bet, I'd go on total overturn due to lack of severability clause, but I could just as easily see it upheld entirely but with language that imposed some very stern limits on the use of mandatory purchases. Keep in mind the court will not be ruling on Healthcare, it will be ruling on the two separate aspects, whether the federal level has the right to make citizens purchase anything, and if so under what conditions and limitations, and secondly whether the federal can essentially force states to help pay for something they have passed. Legally there is better precedent to allow the second then the first. So, somewhat oversimplified, it comes down to 'Can the federal require individuals purchase something, and if so when?" and 'can the federal require states to fund something, and if so when?' But I want to emphasize that Healthcare itself is something of a secondary issue to this matter, there's really very little doubt how the court would rule on outright socialization of healthcare.

As for what next if it gets overturned, who says there must be a next? Many of us (though not all since the GOP is perhaps even less ideologically unified then the Dems, if better at concealing it) feel that fear has been stoked on Health so much in recent years that the public verges on a state of hysteria about it at all times, and that it is this very mindset which drives higher prices as healthcare providers constantly seek solutions to this that are more tailored to visibility then functionality. Doubling the cost of an effective procedure to drop the risk element from third to fourth sigma, essentially from 1 in 400 to 1 in 16,000 is rarely a logical move but one done routinely to calm the public, and this fear is much more easily stoked when the costs are indirect and intangible, people are much less free with their own money, even if you simply give them the money. So Tort Reform remains one of the big goals of the GOP, but also we want to look at vouchers and/or catastrophic coverage and/or direct government subsidy to certain long term medications. There is also the option of guaranteeing loans for medical treatment.



This in of itself isn't necessarily a bad thing and numbers of this sort tend to be debatable, there are things we'd qualify as healthcare that might not be included in other locations. You've also got at least some element of cost-shifting, the US provides a very large portion of the research and development of new treatments and pays a larger percentage of both the cost to make them in direct fiscal terms as well as in the effective weregeld associated to testing out new procedures and medications. If company X must spend 5 billion to get out a treatment that costs only $100 a person, then they can still profit but charging $110 to a place that will refuse to go higher or even simply 'borrow' all the research, but may make up for that by charging $200 back here. They can also add in lots of secondary cost for litigation, even litigation that might not directly involve them when a doc trying out a newer procedure bungles it. This really has jack to do with who/which country has a better or more efficient approach to medicine and people get wrapped up in comparing what are essentially tangential factors at best.

Those kind of factors are very hard to meaningfully calculate but they can't really be ignored either. We should all keep in mind though that at least part of the ever-rising cost of healthcare comes from new and better stuff, patents expire and procedures improve with practice, if all medical research was suddenly halted, all else being equal medical care cost would begin to ebb down.



The idea that insurance equates to healthcare, while not far from the truth, is fundamentally a flawed concept. For one thing, insurance is by definition a drain on resources at the macro scale. It operates as a lottery or casino. Insurance is very subsidized and insurers are often in a position to bargain down prices, shifting the cost to others, were it not by definition at least 50% of the population would be losing money on it. It also hides direct cost, people who are insured lose much of the cost-benefit mindset that tends to hold prices down. Any national level insurance system is pretty much inarguably foolish. I despise socialism in virtually every respect but it makes far more sense to cut out the middle man by running medicine like we do law enforcement and schools then to simply insure everyone. If you need 1 trillion to pay for everyone's medical care, all things being equal, you'll typically need around 1.2 Trillion to pay for it via insurance, probably even more though because people will generally be more inclined to go in for treatment that they really don't need as much whereas some of that might be offset by preventative medicine, regular check ups and all, make it hard to gauge, there is still no scenario in which adding a middle man in to a unified system will gain a profit. A company, and individual, can benefit from a middle man, if everyone is getting a product they can't. If everyone used a tax attorney we'd simply end up having to raise taxes by the amount those persons were charging.



It's exactly because so many people are divorced from direct cost of medicine that much of the legal abuse takes place and much of the frankly illogical but crowd-appeasing hoops are taken out to be jumped through. In the US your odds of dying in a car accident alone are up around 4th sigma in a given year (I'm abusing the term a bit here but we are talking about quality control) so some procedure that adds thousands of dollars on to slightly increase odds of survival gets pretty damn silly when the net effect is playing around with odds below people's odds of being killed just driving to the medical center for treatment. Not too mention all the increased risk they or others have, spread out, of driving into work to pay for said treatment. Removed from the limelight and politically-driven hysteria actuaries and analysts can determine what is most cost effective instead of the marketing team, lawyers, and public relations managers. It's very easy for people, especially those spurred on by the 'money is evil' crowd, to forget that at the large scale you really can put a price on a human life, and if you don't you're simply dumping the increased fatalities into something less visible but just as real. That million spent to save the 75 year old came from somewhere afterall, cancer research or NASA or education or the new counter top the Johnson's wanted to buy which didn't have a thousand nicks and cuts in it crawling with bacteria. Not too mention that a very large amount of health ailments, accidents, and bloodshed occur from feelings of depression and anxiety, and distraction often caused by these, lack of direct control or disposable income feeds into that.



A good thing, though who is determining the cost-benefit of a given item can be very important, since people will generally seek to maximize their cost-benefit relationship, even if subconsciously, and 'gets me re-elected' or 'keeps me from getting fired or never promoted' can often produce interesting results. I'm not really in a position to determine how such things effect other countries, for one thing because I'm sure it is very different form place to place, but then I generally do not compare countries at all, since outside of the blisteringly obvious cases (which on inspection sometimes aren't so obvious at all) these sorts of comparisons fall apart into thousands of variables with uncertainty margins far too enormous to permit useful comparison. As an example, Life expectancy is a regular one dragged out to compare, and I think you'd agree that its a flawed metric in most cases for comparison, though Hogberg's analysis can help shed some light on that for anyone reading this who is acquainted with some of the issues involved. Joel and I spent several long posts debating the various flaws of these kind of comparisons, if anyone feels masochistic enough just do an on-site search for "HDI".



Cost-shifting, and generally inevitable when you intrude on a market... not always wrong mind you, or at least not necessarily, but the moment you require a given industry to do something you generate conditions which will tend to generate cost shifting. "You must treat" makes it so, that's not necessarily wrong, we do "You must educate" and "You must prosecute/defend cases" after all, but it does violate market principles and you either must accept that it's a non-free market or carefully isolate the required aspects from the elective. Pro bono work does that for certain areas of the law but we keep it sufficiently isolated that it doesn't screw the market up too badly. It is ultimately subsidized by increasing costs elsewhere but in a fairly well-spread out fashion, and though it is a bit of a handwave a good case could be made that society saves some or all of that cost by reduced incarceration rates, without delving into the morality of either.



I'd have to say that 'less' and 'quality of life' are, from an American perspective, being used backwards in your example. This comes back to personal stake though. I'm not, and neither are most conservatives, proposing that an individual patient should be picking up the entirety of their bill, but we do feel those sort of end of life decisions are best made by the individual and more responsibly made if they have a financial stake in it. Even the very wealthy will often balk at receiving very expensive life-prolonging procedures they genuinely can pay for in favor of leaving more behind to their inheritors, especially if the cost is more than just money but reduced 'quality of life'. Most conservatives are religious after all, especially the elderly, this works strongly against anything viewable as active suicide but generally does favor decisions that have a heightened risk of dying earlier when it takes on the form of a personal sacrifice for God, family, or country. And I'd say, anecdotally, that people looking to their own legacy and own funds are more willing to confront that sort of situation head-on then those who are essentially pulling from a vast pool of mutual resources where they can also, rightly or wrongly but probably rightly, point to many others refusing to make such a sacrifice, 'everybody does it, why shouldn't I?' usually makes for a fairly fast decision making process especially if that person views themselves as having a more legitimate claim to prolonging their life as I'd think most people would.

That's a very rough issue to contemplate though, and gets into comparisons and moral dilemmas that few of us feel entirely certain about one way or another, excepting megalomaniacs and self-righteous sorts who really shouldn't be the prime decision makers on such things. Let us instead remember that medicine as a science requires lots of patients in just such borderline cases to continue pursuing improvement. It's tricky to research and develop treatment for something no one seeks. If we banged it into people's heads that receiving organ transplants was wrong for instance - and that is hardly historically unknown - we'd have lost out on lots of major improvements to it and to related fields. The reality is that most transplants, especially excluding relatively recent times, were utter wastes of money compared to what the same funds might have done for others, medically or otherwise. It's a delicate balance, and a very murky and obscure one, probably indeterminable in most cases, where that line has to be drawn between long-term gain and pissing money down the drain to extend someone's life a few months. When it's their money that moral conflict is seriously reduced, of course, but mostly we need to be very cautious about any singular group being the sole decision maker for everyone, or putting such decisions in the hands of those for whom the cost-benefit comparisons might vary significantly from the patient's good, the public good, or the benefit of science and medical research. All three of those have legitimate claim in such decision making, 're-election' or parallel equivalents really should not.



I'd add that long term we want to be very careful using a percentage like that as a real guidance figure, personally I subscribe to a very strong and IMHO very reasonable view that improvements to technology will continue to increase our raw production per person. Fifty years down the road the core basics, like agriculture which used to be the majority of human labor but is now minuscule, could easily require virtually no labor and low capital overhead. In relative terms, 25% of $100,000 is less than 10% of $50,000 when the alternative is 0% of $0. If for instance it cost $20,000 a year to sustain someone in vigorous and youthful health almost indefinitely in places where the GDP/cap was about 50k, that 40% would probably be worth it. Not to get all sci-fi-ey but I don't have a lot of doubt that two otherwise identical cultures and economies, where one had an average age of 35 and the other 40 would see the latter considerably wealthier and more productive, especially if the way that happened was sustained vigor, not just stretching out the period of enfeeblement. And thus far people don't just live longer but effectively age slower as these improvements occur, when viewed as a sort of amalgamation of collected hurts and ailments. A society can fundamentally keep operating as long as everyone has food and shelter and can keep at least some reserve around for other activities, and a society that averages 100k per person is spending 50% of that on medicine it is still better situated then one averaging 50k spending 1%. That's not to embrace waste, ever, but we shouldn't let percent itself be considered the core variable.



Well, personally, I'd would institute a very large tax on any employer-based insurance package, and justify it as the equivalent to making people gamble or paying people in company script like a lot of the old robber barons did. It's fundamentally screwed up, bordering on lord-serf, mentality to have an employer involved in any function related to a person which isn't very closely tied to their job, e.g. insurance for on the job accidents or work-related increased risk of injury or ailment, which generally needn't involve the employee at all. You can shift this into pay raises in a revenue neutral fashion. People really shouldn't use insurance for anything but catastrophe anyway, if various doctors or medical facilities wish to offer some equivalent to coverage, like offering reduced preventative care and check-ups for a legal contract to seek all not emergency medical care through them (like paying your local hospital to treat you unless you get into an accident in a different location) then that's normal business. I'd limit government role to subsidizing catastrophe insurance for the poor, means based, or subsidizing R&D and medicine costs with attached limits in exchange for the subsidy on how much above specific cost of production per unit a company could charge in exchange for funding of both that project and current or future R&D. I might also think it wise to consider some equivalent to student loans in terms of medical procedures, essentially guaranteed low-interest loans as an alternative to insurance, keeping in mind we have bankruptcy laws.

The other two biggies would be to clarify how Eminent Domain functioned on Intellectual Property Rights and then general Tort Reform. Alternative to all of this, we can also consider the possibility of non-monetary payment, like the government requiring those it picked the tab up for rendering a certain amount of community service, which would at least tend to reduce frivolous or hypochondria driven medical treatment and possibly reduce other burdens, we do have a lot of work that can be done (especially when wage is a reduced factor) without need of either lots of physical labor or mental prowess, and some return is better then none. I'd rather have someone who got a $1000 a month in free drugs spending ten hours a week helping check books out at the library then nothing at all, frankly a lot of times it would be better for them too. I think it is almost invariably better for all involved in almost every way for someone to have some stake in the cost, even psychologically for the patient knowing they have at least partially compensated their peers via community service is better than feeling oneself to be a total leech on society or engaging in various mental gymnastics of self-justification. That latter tends to involve pointing a finger of blame at someone that's divisive and often violently so.

So, as always I'm not noted for my brevity, but that's my general flavor of thought on the matter, I don't claim any of those ideas are great, functional, or even practical, but I do see them as proof that alternatives to nationalized or socialized medicine, especially in the form put forth, do exist and should be examined.