imagine a society without govt...won't happen as long as govt controls schools...

In the words of Sen Ron Johnson, "Layer upon layer of laws, rules and regulations have made our health care-financing system a complex mess, separating patients from direct payment for health care.

As a result, patients neither know nor care what things cost. We have virtually eliminated the power of consumer-driven, free-market discipline from one-sixth of our economy."

Re: “There is no real choice.” That’s 100% because the government does not allow a real free market in medical insurance or any other aspect of the health care system. Imposing tax penalties to force everyone into the dysfunctional health care system is not a solution to this problem, it just makes it worse.

"Suppose a person wants to self-insure?"
It sucks at all those scenarios, including if you want to insure against only certain health perils, have a high deductible, have a maximum limit-- you can't do it. I get a list of 57 plans, and when you drill down they're all following one rules, so there is no real choice. The only choice is which providers they have arrangements with, which they market as a feature, but it's more like a bug. It's difficult or impossible to find straightup insurance against health problems that just makes you whole. There's no more underwriting, no more pricing risk, no more variation in insurance products, but the people in those large insurance buildings need to do something, so they manage contracts with providers.

Suppose a person wants to self-insure? Suppose a person has religious objections to participating in the mainstream healthcare system? Suppose a person prefers alternative practitioners that are not covered by insurance? A person’s health care choices are his or her responsibility, and government has no right to intervene. Today’s dysfunctional health care system is 100% the creation of an overbearing government.

If the "it" is the PPACA, I agree. When I was saying "it" was talking about the mandate. I realize in the last sentence I was confusing as to what I meant by "it".

"But it does have the effect of not roping me into paying for their care."
Nothing could be further from the truth.
It has the effect of forcing you to always pay for their care, just as medicare does. It also eliminates the cost control link between service received and payment for service. This forces medical costs upward exponentially with insurance companies chipping the pot for profits in response to uncontrolled higher and higher costs. Everyone pays regardless of health and medical purveyors are irrationally rewarded for treatments that do no good whatsoever, even when side effects are worse than the original ailments.

"Obamacare forbids insurance companies from varying their rates because of pre-existing conditions"
If everyone paid their own way without gov't interference, it would be like any insurance. Responsible people who don't have enough wealth to cover a peril buy insurance against it. If you don't buy insurance and the peril happens, it's too late to buy insurance; you have to pay for it with your own wealth. If you don't have enough wealth, you cannot pay for it.

Health insurance was complicated because if people didn't insurance against or have money, they always found ways to rope other people into paying. Since health problems are harder to detect than other perils like car accidents, a lot of of effort had to be expended to make sure the peril (sickness) had not already happened.

PPACA comes along and says since in an ideal world everyone would buy it before the peril occurs, let's just make everyone buy it. At that point we can eliminate all the effort expended to make sure sure the peril hasn't already happened, i.e. to make sure people aren't waiting for signs of sickness before buying insurance against sickness.

Many elements of PPACA and even the whole notion of forcing people to buy an insurance product are troubling. But it does have the effect of not roping me into paying for their care.

Since Obamacare forbids insurance companies from varying their rates because of pre-existing conditions, the young and healthy pay a higher rate than they otherwise would, in order to subsidize the medical costs of those less healthy. This feature was deliberately built in to Obamacare in order to provide “affordable” care to the less healthy (and to buy their votes). This is not “making people pay for their own care,” it’s forcing the healthy to pay the inflated medical costs of the less healthy. In no way, shape or form does such coercive legislation belong in a free society.

"The mandate actually implements that, "
How is that? It seems like it's a direct way to make people pay for their own care. A more direct way would be to provide no care for people who do not pay, but I have never seen that in my lifetime.

The mandate actually implements that, by forcing productive and responsible people to pay higher insurance rates in order to subsidize the insurance rates of those less responsible.

"I oppose forcing the productive to pay for the irresponsible"
The mandate decreases that.

"risk can only be identified and evaluated individually - never collectively."
Insurance companies do a good job pricing the risk of accident, unexpected death, fire, etc.

"Does one person have an obligation towards another's welfare ""
I say no. I think it's a good idea for the gov't to help the needy, though, and all the reasons why go beyond this healthcare discussion.

"managing healthcare purchases. This isn't really an independent concern, but merely an outgrowth of both #1 and #2 above."
I agree with what you write about people making their own decisions and accepting the consequences. My use of the phrase "market reforms" was confusing, making you think I want the gov't to manage things. I was saying the opposite.

"We don't need market reforms."
I see how it sounds like I meant gov't fixing the market, but I meant gov't NOT trying to fix the market. My idea if we assume it's politically impossible to touch PPACA, then they could focus on allowing market forces in the areas not currently paid for by insurance. My thought was if that helps people (technically helps them by gov't not "helping") maybe they would be open to changing PPACA.

"A starting point might be market reforms aimed only to help people manage their pre-deductible expenses more efficiently."

There are two phrases in this statement which deserve particular attention. The first is "market reforms". The presumed need for a reform to the "market" stem from a progressive mindset. Left to its own designs, the market is the single most efficient method of pairing scarce resources with customer demand. This is because it is the aggregate decision-making of millions of individuals looking out for their own perceived best interests. The notion that this individual self-interest should be overridden by a few elites who want to control that decision-making process is solely for the sake of their own power. It is deceptive both on the sides of the self-appointed elites who think themselves superior in capacity to others and on the sides of the lazy populace who seek to avoid making decisions and facing the consequences.

What should be recognized is that it is only because of the misbegotten assumption of a few elites that they 1) can and 2) should control the decision-making process of others that the market has become distorted in the first place. Thus what is conveniently ignored in the call for "market reforms" is that such are only "necessary" because the market was artificially tampered with in the first place! It is the classic case of claiming that we need to fix a broken clock gear not by removing the spoke wedged in the works but by trying to add on more gears to bypass the problem.

The second phrase of concern is "help people manage". Again, this is the second misbegotten spawn of the elitist mindset that assumes that people are incapable of making decisions in their own interests. Too often elitists deliberately prevaricate by confusing "educational" assistance with actually substituting themselves into the role of agent/decision-maker. They further deceive themselves and those they claim to want to "help" in assuming this role because they in effect deny the individual so misplaced by gaining for themselves the invaluable experience that comes with making decisions and being responsible for the outcomes of those decisions. The attempt by the elitist is couched in terms of "sparing them from negative effects", but in very fact denies them the chance to make good decisions as well as to learn from poor ones. What is even more insidious in this is that all too frequently, the elitist is confronted with the effects of their own poor decision making (which has ruined the lives of others) and then claims that it is not their fault or wasn't their intent or some other form of deflection. They want the power which comes with making decisions, but want to avoid the consequences of actions gone awry. What is incredibly hypocritical about this is that this is the very reason they claim to want to usurp the original decision-making authority in the first place!

No. We don't need market reforms. We need governmental reforms that remove the sticks lodged in the collective gears of the market. We don't need to make decisions for others. We need to offer to truly educate them, but to allow them to face their decisions - and consequences.

You've identified three particular areas of concern and I think each merits its own (minor) discussion.

1. spreading risk
2. helping the poor
3. managing healthcare purchases

1. Risk. There are several grave misconceptions about risk which must be acknowledged and which render this discussion objectively moot. First, risk can only be identified and evaluated individually - never collectively. My fear of heights makes my risk evaluation of skydiving substantially different from someone else. And while actuaries certainly attempt to create risk pools, these are for the effect of managing on the side of the business in aggregate - not the individual policy holder.

Second, risk is ever present in varying degrees and which we do no consciously entertain. We literally risk our lives every day driving to work in the face of the 40,000 vehicular deaths every year (http://www.nsc.org/learn/NSC-Initiati....

Third, reward is rarely considered when evaluating risk in healthcare. It is considered a given that people should always be in good health and that such is a "right". This is simply a mistaken - albeit popular - assumption.

2. Helping others. This actually comprises two questions: 1. Does one person have an obligation towards another's welfare and 2. Assuming Yes to (1) is it permissible to coerce some to provide for others. This is primarily a moral question. Objectivists outright disavow the obligation, thus rendering any answer to #2 irrelevant. Conservatives hold that there may indeed be some obligation, but that the obligation is self-imposed and coercion is not permissible. Progressives hold that there is indeed and obligation and that those in power hold the authority to coerce from some the means of "helping" (really redistributing) to others. Each of these positions is worthy of its own extended discussion.

3. managing healthcare purchases. This isn't really an independent concern, but merely an outgrowth of both #1 and #2 above.

If one ascribes to the moral philosophy of the progressive, then those in authority have a duty and obligation to coerce some into providing for others and that part of that duty and obligation include deciding (on behalf of the coerced) how the coercion is to be enacted and (on behalf of the "needy") how risks are to be assessed and how needs are to be met. The progressive assumes a governmental prerogative of deciding for a host of others how they will assess and deal with risks and rewards.

If one ascribes to the moral philosophy of the conservative, they reject the notion that decisions about risk and reward may be made on behalf of someone else, but take upon themselves to exercise judgement on their own behalf as to how to address the needs. Thus a governmental prerogative is not warranted, but an individual response is.

Objectivists simply take the line that the individual is responsible only to themselves: that both evaluation of risk and reward AND dealing with the consequences of life - whether through choice or chance - are up to the individual to deal with. Neither governmental nor individual response is implied (though an individual may respond).

(more below)

He is in a tough spot. If they shore it up and it works, they ensure continued gov't influence in healthcare. If they shore it up and it fails, they get blamed for breaking it. If they undo it, they create a huge problem for responsible people who happened to get long-term conditions while on PPACA.

One key problem is people (including me) want a vehicle to spread the risk of an unforeseen health problem, the same way we use insurance to spread the risk of other perils. That's getting harder to do. It seems like we need to separate the problems of a) spreading risk, b) helping the poor, and c) managing healthcare purchases.

A starting point might be market reforms aimed only to help people manage their pre-deductible expenses more efficiently. If people like the freedom that comes with it, it could be expanded.

"We would be better off if we did not have a central bank at all"
I hope cryptocurrencies will become competition for central banks, so even if central banks remain, it will be harder for them to buy gov't debt w/o causing inflation.

Paul opposed the changes because neither of the last two bills have been anywhere close to a true repeal. They would still leave federal government fingers buried to the elbows in the healthcare pie. I support him on this rejection and him characterizing both bills as basically "Obamacare lite".

And the Federal government can issue additional money without issuing additional debt. Central banks can influence money supply to a limited extent, but their options are constrained by the need to maintain the quality of their balance sheet and to fulfill the various “mandates” that Congress dreams up. We would be better off if we did not have a central bank at all. And it would be easier to keep fiscal policy and monetary policy separate if the government were to begin issuing debt-free money rather continuing to issue interest-paying bonds to “back” our currency.

I don't see anything even remotely in favor of a free market in your post. As an advocate of Ayn Rand's philosophy, I oppose forcing the productive to pay for the irresponsible, either by subsidizing the irresponsible at the point of treatment or by forcing the productive to pay higher insurance rates to subsidize the unwise health choices of the irresponsible. The non-initiation-of-force principle and the individual's right to choose apply to health care as much as any other sphere of human thought and action.

"So you're in favor of keeping the individual mandate"
I think the mandate was one of the best things about PPACA. Before PPACA, people with no money and no insurance would turn up at providers and get care. Responsible people with money and/or insurance carried them-- backdoor socialism.

Even if we denied them care, the underwriting process was somewhat onerous. I spent a lot of time documenting that the time I got muscle relaxants after throwing out my back shoveling snow was really nothing. It makes sense for them to be caution. I knew someone in college whose doctor said something looked serious, so he ought to go take out an insurance policy before running further tests in case it turned out to be expensive to treat. Responsible people would buy insurance (or have money to pay for it) BEFORE they got sick. So PPACA bypasses that entire process and makes everyone buy the insurance, so therefore insurance companies don't need to spend all this time working out whether someone's already sick and fraudulently trying to insure against sickness after the fact. It gets you to the same place we'd be if everyone were responsible and got insurance long before any sign of illness.

On top of all this, technology to predict illness with genetic testing is getting better. So it's becoming less of an insurable peril like lightening striking.

I am hugely in favor of some sort of individual mandate. I was going to be roped into to pay for the irresponsible anyway when they turned up in the ER. So I'm totally in favor of making them pay their own way.

So you're in favor of keeping the individual mandate and forcing younger taxpayers into the same risk pools as older, less healthy ones?

"How hard is it to figure out what will sell, and get it done?"
To save face they should have passed something very similar to PPACA and called it "repeal and replace".
If they actually want reform, I think they should add little market-based provisions:
- Make HSA-compatible plans no longer required to contribute to HSAs.
- Make a contracts for patients to pay for medicine only enforceable if a cost estimate or pricing sheet is provided prior to service.
- Make it easier for providers to operate via telemedicine and provide low-cost service in pharmacies and shopping centers.
- Relax rules on prescribing drugs, so someone who knows what maintenance drugs he takes can choose to buy them without a "med check" visit.
- Make medical expenses an above-the-line deduction so people buying medicine get the same tax treatment as a company buying a health insurance plan.

I'm not sure if they could get all that, but maybe they could get some of it. I wonder how people would react to get a taste of freedom. They would choose whether to treat one kid's rash with the same $10 ointment that worked when another kids had a similar rash two years ago, or whether they should pay $200 to talk to have a local expert look at it. Maybe they decide to go in the middle and have a low-cost doc look at it over an app. They would make all kinds of little decisions like that for themselves. And the money would go into the HSA tax-free, grow tax-free, and come out tax-free, regardless of their insurance policy.

"I used to think Rand Paul was a Libertarian"
I have not followed why Rand Paul opposed the changes, but maybe it's because he thinks the bandaids might work and "save" PPACA from collapse.

I agree that in general libertarians have a hard time making moderate incremental steps. When I mention slowly phasing in modest reductions each year in federal spending, libertarians yell "why modest? Why slowly?" is if a radical decrease were a realistic possibility.

"If there was an up-or-down vote on the "individual mandate" by itself, I think a few Democrats would crack."
I think people know that's like saying you should only buy homeowners insurance after you're house burns down or only buy car insurance after you have accident.