Obamacare is a Tax

If you have been following the US health care reform stuff which seems to get labeled Obamacare, you probably already know that some piece of the legislation says that some people must have health insurance and must pay for it out of their pocket or pay a fine for not doing this. (I confess that I have been ignoring most of this but it now gets my attention.)

The US Supreme Court has found this requirement legal by classifing it as a tax. An article in Natural News explains this decision and goes on to say that this sets the way for all sorts of possible taxes.

Regardless of whether you agree with the fundamentals of Obamacare, the fact that the U.S. Supreme Court has now ruled the federal government has the power to tax Americans into mandatory purchases of private industry products means an end to economic freedom in America. Why? Because it hands the federal government the power to force the American people to buy anything the government wants or face tax penalties for refusing to do so. It is the equivalent of announcing a federal monopoly over all private purchasing decisions.

So, what does this have to do with us Gringos living in Nicaragua? For me, I expect nothing as I have Medicare, coverage that I don't want but I expect will keep me out of being subject to this new tax. But, what about others who are under retirement age who have elected to take up residence in Nicaragua or, well, anywhere else outside the US? Are you going to be subject to this tax? Are their options (such as a local medical plan)?

And, if course, the big issue that Natural News points out is that with this Supreme Court decision, it seems the path is now open for us to be taxed for other things we don't use. Of course, being taxed to pay to maintain the bloated government is nothing new but this is very different. It is money for private industry.

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Interrupting our diversion

We have done a good job of covering "everything else". But, as some people might have interest in the actual issue I raised, here is my attempt to summarize the situation.

There are some conditions where an ex-pat may have to pay for health insurance in the US or pay a fine even if they are not in the US. But, the consensus is that they will not have to pay if:

  1. They qualify for the foreign earned income exemption.
  2. They (probably) fill out some paperwork.

While the popular opinion is that this is not a problem, I (still) disagree. In particular, there are US Citizens who don't live in the US but are not working/getting paid under the terms of the foreign earned income exemption, are not covered by any US medical coverage such as Medicare and are not filing any US government-based paperwork. Now, that isn't me but I do know people in that category and I do think it would be nice to offer them some useful advice.

Sort of jumping the gun for Information

RE: Interrupting our diversion Submitted by fyl on Sun, 2012/07/01 - 13:02.

.....But, the consensus is that they will not have to pay if:

1. They qualify for the foreign earned income exemption.

2. They (probably) fill out some paperwork.

While the popular opinion is that this is not a problem, I (still) disagree. In particular, there are US Citizens who don't live in the US but are not working/getting paid under the terms of the foreign earned income exemption, are not covered by any US medical coverage such as Medicare and are not filing any US government-based paperwork.

I gave up my EA business and have not kept up because it is too much work to stay current unless you are earning a lot of money but here are a few general details but not much help. You gotta know that the whole IRS detailed explanation will end up to be many pages & MUCH too long for few paragraphs here.

YMMV but I bet you know as much as anybody.

---First RE Your quote ...earned income exemption... - You know the definition of *earned* income but some here obviously do not - Limited to income like employee salary & wages but NOT business income unless your function was performing personal services. That may be limited to 30% of business income unless investment capitol was not a factor in the business. Thus income from a sole proprietorship or partnership like a restaurant, hostel/hotel, factory, construction etc is generally NOT *earned* and there is no exclusion. In fact you usually gotta file a US tax return even if your had no profit if you think anyone may "drop a dime" on you.

EDIT: An SA probably gets you into the employee category unless it is forced to pay dividends but that is not inexpensive.

---Second RE Your quote - What does your statement "not filing any US government-based paperwork." mean?

---Jumping the gun - The IRS has not ironed out the final details but this is a starting point:

http://www.irs.gov/newsroom/article/0,,id=220809,00.html

This whole thing is gonna be a nightmare before it is over. Google gets a lot of preliminary information and CCH who supplies paid tax interpretation services to professionals has nothing better or final yet.

So you must know as much as anybody right now.

It appears that the family tax could eventually be up to 2.5% of your taxable income but there are a lot of potential ifs, ands, and buts to be worked out about the details, minimums, and exclusions that affect most people here. This is gonna be interesting because apparently the IRS can not use most of the normal means of enforcement & collections.

BTW did everyone here file their Foreign Account Tax Compliance Act (FATCA) Form TD F 90-22.1 by June 30 if they had more than $10K total in foreign bank accounts or 8938 for $50K any time during the year?

Electronic Filing here: http://www.fincen.gov/news_room/nr/html/20110717.html

Um, I didn't have to

"BTW did everyone here file their Foreign Account Tax Compliance Act (FATCA) Form TD F 90-22.1 by June 30 if they had more than $10K total in foreign bank accounts or 8938 for $50K any time during the year?"

One reason I don't have a foreign account here -- taxes are complicated enough as it is (I used electronic filing through one of the tax programs). At one point, I probably did have more than $10K in my bank account. But then, I didn't come down here to evade taxes.

The IRS provides a definition of earned income that includes business income:

http://www.irs.gov/individuals/article/0,,id=176508,00.html

"Earned income includes all the taxable income and wages you get from working. There are two ways to get earned income: You work for someone who pays you or you work in a business you own or run."

Not earned income:

Pay received for work while an inmate in a penal institution Interest and dividends Retirement Income Social security Unemployment benefits, Alimony Child support.

Sound like you're wrong on what an earned income is. My understanding was that what I made as a writer was considered self-employment, subject to self-employment taxes, and then I paid income tax on that. At one point, writers could incorporate and save on taxes by doing that, but I think that loophole has been eliminated.

There's also this:

http://www.irs.gov/businesses/small/international/article/0,,id=97245,00...

...but I'm too poor for that one, too.

Rebecca Brown

You did not read far enough

Um, I didn't have to Submitted by oncidiumfan on Mon, 2012/07/02 - 20:46.

The IRS provides a definition of earned income that includes business income:

http://www.irs.gov/individuals/article/0,,id=176508,00.html

...Sound like you're wrong on what an earned income is.

Nope - You did not read far enough.

Business income is limited as I quote again below

Limited to income like employee salary & wages but NOT business income unless your function was performing personal services. That may be limited to 30% of business income unless investment capitol was not a factor in the business. Thus income from a sole proprietorship or partnership like a restaurant, hostel/hotel, factory, construction etc is generally NOT *earned* and there is no exclusion.

except the last sentence was written too quickly should have added unless your personal services are also an important part of producing the income and then you *do* get the 30% - For example you work your own bakery. But If the business is mostly employee run and managed you are gonna be stuck.

--- http://www.irs.gov/businesses/small/international/article/0,,id=96811,00...

--- IRS Pub 54 - Chapter 4 - Income from a sole proprietorship or partnership - http://www.irs.gov/publications/p54/ch04.html

--- http://www.irs.gov/pub/irs-pdf/i2555.pdf : Instructions for form Form 2555 line 20

If you are a writer and did not put much capitol into the business you should get the full exclusion. Of course the IRS is not gonna come here and audit a small business so eventually they probably will have to take your word for it.

I just spent 2 & 1/2 years in an audit and appeals thrash before they saw things my way so I don't take the 30% to avoid any more attention.

BTW - For a foreign business there is no Section 179 and you are stuck with straight line depreciation so that can be a big disadvantage too.

But you can take 100% of your losses against taxable retirement income including taxable IRA & 401K withdrawals so even a bad business is not a total loss.

This discussion is not off topic because fyl was right *Romneycare is a Tax* & will be partly based upon taxable income. (Obama liked so well he copied it instead of thinking for himself if he even can)

I think that's for certain businesses..

...where the owner is an silent partner who contributes capital but not personal service to the company. You're putting money into it, but you're not actually managing it, or you're not managing it full time. So more like return on investment, even if not incorporated, than like a potter making pots and selling them, where there might be capital investments, but without the potter's own personal labor, there's nothing earned. The situation you're talking about would be if someone hire a manager and a bunch of potters and expected a return on investment without day to day service to the entity he created.

One does not really want to crash a major source of investment capital during a recession.

If I paid someone else to writer my books, then I would be in your situation where I was capitalizing someone else rather than doing things myself.

Seems reasonable to me that if people are investing money in companies they don't personally run, they don't get to claim return on investment as earned income. If they're also managing the company on a day to day basis, that looks like it would be different.

Rebecca Brown

You are close to right

YES no participation - no earned income & One LAST comment!!

---An investor comes to Nicaragua and puts 1 Mil in a bank at 5% interest and earns $50,000 investment income which is NOT earned income and thus receives no exemption as you know.

If they're also managing the company on a day to day basis, that looks like it would be different.

If he starts & works a business this limit to the earned income exemption makes logical sense as do most IRS laws because they are geared to enforcing the law in special situations against schemers and following is an explanation the principle with an overly simplified example.

---Ah the same investor says I will outsmart the IRS and start a business with that 1 Mil to get earned income and thus the exemption. So the investor buys 1 Mill worth of shoes and opens a shoe store in Managua with a simple business plan to mark up the shoes 5% plus his expenses and works the store full time as the only employee and sells all the shoes that year and earns his $50,000.

Now he has $50,000 earned income - WRONG.

The 1 mil capital investment is an important part of producing income and thus his earned income is equal to the value of the services he (Or Al Bundy) would be paid for managing the store & selling the shoes (OR 30% of the $50,000 maximum) - Only A few thousand $ may qualify for the earned income exemption since wages in Nicaragua are pretty low..

The same principle *generally* applies many other types of businesses if 1 Mil was all a "capital investment that is an important part of producing income". but the value of the services and thus the % earned income might be different but still 30% maximum.

There is another catch - The whole $50,000 shoe store income (or maybe the non deferred part I don't remember) will usually be classified as income from a business or profession and thus subject to self employment FICA of about 15% tax but a tax deferred savings plan may be also available.

$50,000 Bank interest does not have this problem so things are not as simple as they might seem.

This is why a person might hire a tax guy CPA or EA as well as to is to argue the value of the investors' services or that that part of the 1 mill was not an investment but something else and a few other potential business issues.

The reference material available to them (Paid Manuals or Paid subscription) will usually have many examples to make it easier but I no longer have access to any of that info but the basic principle explanations above are close enough.

I'm rather painfully familiar with self-employment taxes

Before tax software, they were such a hassle that at one point, I was offering myself to a commune which would take all my income from writing and apply it to the communal income and handle the taxes themselves and simply give me work credits for the days I did work that sold.

$50,000 Bank interest has to be reported to the IRS regardless of where the bank is these days.

Rebecca Brown

Yes but you missed the whole issue

You completely missed the issue!

----That $50,000 Schedule C Income from a business or profession pays Self Employment tax of about 13% = $6,500 (depending upon stimulus reductions) in addition to tax on most of that income (Maybe $45,000) which is non deferred and thus is also taxed as income.

----The $50,000 Bank interest is only taxed as income!

EDIT - Sorry I mis-read your communal income explanation so my reply was wrong.

Reference your

"communal income and handle the taxes themselves and simply give me work credits for the days I did work"

may have worked for you if they were legally your employer and collected the SE taxes as well as the W4 withholding from you, paid their share of the SE tax, and filed all the required reporting paperwork including W2s

Plus then you have to file the potentially risky "Home office deduction" paperwork instead of schedule C to receive your expense deductions.

The commune (as are most modern communes) was

incorporated as a secular monastery. One commune in Tennessee had a lawyer member who found the most useful laws that could be modified for communes and they turned out to be the laws governing monasteries. The members turn over all assets to the commune and the commune is owned collectively under a charter (articles of incorporation or by-laws may be the correct technical term) which forbids giving any profit from selling the commune to any surviving members beyond a couple thousand to help them relocate. The people working with this had a fairly good understanding of the issues that had broken up communes in the past (every building at Twin Oaks, the current longest lasting commune, is named for failed past communes).

One of the biggies was the commune's property and industries being so successful that selling the commune off would make the residents serious money, which is what happened to Oneida (silversmithing was their industry). Twin Oaks has a physical plant that's been estimated to be worth $10 million -- tofus factory, full woodworking factory and hammock making facilities, several dormitory buildings, a full sized commercial kitchen, a small dairy, and a wide range of hobby grade equipment for photography, woodworking gear, plus at least 160 acres of mixed agricultural land, pasture, and woodlots, and a fleet of various vehicles, worked by around 100 members. Acorn, the smaller commune in the county, had a little under 100 acres and a very successful seed company, Southern Exposure Seed Exchange, with maybe 12 to 16 members, including a couple of guys who had their hearts broken at Twin Oaks.

If the commune dismantles itself, the bulk of any money beyond the equivalent of $2,000 in 1967 currency would go to either another commune in the commune's umbrella organization or to the umbrella organization, which covers maybe a dozen US communes. The umbrella organization also organized a catastrophic insurance fund for all the communes, and the individual communes made their own arrangements for non-catastrophic coverage.

Modern communes are rather legally sophisticated creatures. They're legally collectively owned under some fairly interesting by-laws.

So, I would have been a secular monk/nun with no vows of celibacy, and the commune would have taken care of my money and fed me, housed me, and provided me with a small allowance and something like six weeks vacation a year. The taxes that applied would be similar to those of a monastery.

What some people were doing was working the 40 hr a week minimum on the commune and going to a nearby library to do their own private work, which the commune would agree didn't belong to it (and get no home office deductions because).

Twin Oaks had a range of people there, at least one nurse, and between the several communes under the umbrella organization, doctors, lawyers, and programmers.

I'm curious now how they will deal with Obama's health care program, if Peachpit, their catastrophic health insurance fund, will be adequate for the purposes of the bill. Whatever, they're very resourceful folks.

One of the Twin Oaks founders was a very bright and very disaffected working class woman who at the end of her life said that she had intended to create an institution which would have allowed working class people to have pooled their resources and live as well as middle class people in terms of the things they collectively owned (hobby facilities, access to land). Instead it became a refuge for middle class people (I wasn't the only one at Acorn with a Columbia University degree).

Ultimately, Acorn and I decided I wouldn't be a good fit, but I still have a lot of respect and interest in what they and Twin Oaks continue to do, and one of the things is that they're both surviving and apparently doing well. Twin Oaks solved a number of problems that brought down earlier communes and also outlasted a couple of attempts to take it over, one by anarchists and the other by some Indian religious cult.

Be curious if what they discovered would work with North Americans and Europeans would work with Nicaraguans. The anarchists argued that the commune was too attached to the market capitalism world and the workers were alienated from their work for the market (hammock making). Once they failed to take over Twin Oaks, they started their own commune on land someone's uncle owned and donated to the cause, and it lasted two months.

The take home is that even something like a mostly egalitarian organization needs structure, by-laws, and a way to fire people who don't work out, but that working out those issues wasn't impossible. The utterly complete freedom thing doesn't work -- I met one of Twin Oak's Planners and she bitched about how in the outside work, if she did this job, she'd be getting a private car and more money and a secretary. Getting people to serve as Planners was difficult. She said she had to make decisions that caused her friends to be mad at her. She had been elected for the job after some time being the hammock factory manager (I don't know if this was before or after the anarchists and that's another position that's decided by concensus).

The folks at Twin Oaks reminded me of the old school Philadelphia Quakers. An interesting place in terms of the problems they'd solved in a different way than the US typical. All very much left of center.

My writing income these days varies from $12.50 to $780 a year (had to file the Social Security paperwork on it yesterday). Maybe in a good year, enough to live like a poor Nica.

Rebecca Brown

I would guess

that virtually none of the NL members are covered under the earned income exemption!

"You can avoid reality, but you cannot avoid the consequences of avoiding reality." Ayn Rand

I would guess you are wrong

I don't know if they are using it, but I do know some NL members who would qualify. Besides people born in the US or to US parents, we also need to consider naturalized US citizens. I know quite a few (just living here, not all NL members) who are Nicaragua/USA dual nationals.

Would need to be out of U.S. for 330 or more days

From: http://www.irs.gov/businesses/small/international/article/0,,id=96968,00...

"Foreign Earned Income Exclusion - Physical Presence Test

You meet the physical presence test if you are physically present in a foreign country or countries 330 full days during a period of 12 consecutive months. The 330 qualifying days do not have to be consecutive. The physical presence test applies to both U.S. citizens and resident aliens...."

Hopefully, this 330-day physical-presence test will be used for Obamacare, too.

There is a possible "gotch" for younger people living off income

People who start businesses here as investor residents are fulfilling both the residency requirement (if they're in Nicaragua for more than 330 days) and the paying or being willing to pay taxes to Nicaragua requirement. They're earning income in Nicaragua legally.

Retirees might have a problem if they're under Medicare age. At the worst for people on SS, that would be a two year gap (can retire at 62, don't qualify for Medicare until 65 absent physical problems). Retirees may be considered long-term visitors rather than actual residents since pensionados can't work in Nicaragua. If you're a 45 year old who decided to spend the rest of your life living off your remittances and don't have insurance, you might be liable. See the IRS or a CPA for details.

Rebecca Brown

I think for this one there are better sources of information

...than the people on this forum. I've had people tell me stuff like I'd have a minimum payment for self-employment taxes -- best to ask question of people who actually might have the answers because they know the system.

If anyone is concerned about this, the really sane thing to do would be to ask either the IRS (which appears to be the entity in charge) or the US Embassy (which can direct the question to the appropriate agency).

I'd simply claim the hardship exemption and get the Feds to pay for the Vivian Pallas coverage, but I really don't think it will come to that.

Rebecca Brown

What Is The "Hardship Exemption" and Why Would U.S. Pay Pallas?

My understanding is that being out of the U.S. for 330 days would likely exempt U.S. citizens from Obamacare penalty, but I'm not familiar with the "hardship exemption" you mentioned or why claiming that hardship exemption would obligate the U.S. government to pay your Vivan Pallas bill?

Can you clarify?

More joking than serious, actually

Everyone here is serving up hysterics over this. I'm simply not going to have any, thanks.

If the US government is going to pay for mine because I'm poor, they should pay for something I can actually use (I'd be exempt because of income and residency in Nicaragua).

Rebecca Brown

fat tax

Owe'bamacare is the biggest fattest tax on the face of the planet! The US Supreme Court said so.

Not exactly

Only the most pathetic of slippery-slope arguments ends up at the "conclusion" that the power to tax Americans into mandatory purchases of private industry products means an end to economic freedom in America. First, there never was economic freedom in America - NEVER, not in the 20th century anyway. And, two, the Federal Government does not have the power to force the American people to buy anything the government wants - or face tax penalties for refusing to do so. This is not the Supreme Court decision; and, in fact, (no U.S. Court decision in the history of the world is that the people must do whatever the government wants.

People have a choice.

There is NOTHING mandatory to purchase about this and nobody is forced to buy anything. People have a choice - Buy the insurance to pay for their health care or or pay the tax penalty to cover their health care.

Thus this "conclusion" provides economic freedom for the American public. The concept of the "individual mandate" is the true American way - Force deadbeats to pay their bills one way or the other instead of freeloading off of the American public.

Now whether Obama should have set up a system similar to single payer system in Canada - My bet is that something proven to work and acceptable to the public would have been much better than the health care system "O" invented. Maybe the system will gradually move toward that as problems are exposed.

I was raised by a Christian Scientists….

Doctor and hospital were dirty words in our house. I personally don’t follow the teachings but as the common belief that the US was founded on grounds of religious freedoms, how does this play out for them?

What of people who just have a butt load of cash and pay their own way? Why is that not allowed now ? Why penalize some one by charging them a tax for paying their own bills ?

This whole thing sounds pretty unconstitutional to me .

-Doug ©

If you're not part of the solution, you're part of the precipitate

If you'd actually read....

... at the government's information on this, you'd see that people can be exempt for religious reasons -- membership in Christian Science churches would qualify.

Basically, for people who actually have several million dollars to spare, insurance premiums are pretty minor (I don't think the really rich fail to have insurance -- they rather have more expensive forms of insurance that give them more face time with doctors. Relatively few people have this kind of money (more than simply having several million dollars because serious problems can cause hundreds of thousands in expenses, which vanishingly few people can afford to cover out of pocket.

Here's an easy to understand summary of what's involved if you find IRS PDFs too hard going.

http://articles.cnn.com/2010-03-24/health/health.care.penalties_1_health...

Rebecca Brown

My mother`s last job

was for a company owned by 4 millionaires (2 brothers and their wives) who only kept the business open to keep their medical insurance. They read 3 newspapers everyday and drank a lot of coffee and were waiting for Medicare to kick in so they could stay home. Even the rich can`t afford American medicine.

"You can avoid reality, but you cannot avoid the consequences of avoiding reality." Ayn Rand

Not exactly

People have a choice - Buy the insurance to pay for their health care or or pay the tax penalty to cover their health care.

If the choice was buy the insurance or pay for your own health care, I would agree. But it would seem this is saying "buy something private that we think you need or pay the penalty". There are lots of people, me included, who generally are not interested in what in the US is called mainstream medicine. I understand that sawing off your arm that got crushed in a car accident makes sense but all too many mainstream treatments do not. Or, at least to myself and probably the majority of the people in the world, they do not.

For example, here is a real example. I had a friend who had horrible acne. A mainstream doctor was prescribing antibiotics, for years. She then regularly got yeast infections and such. But, all this treatment was free because it was covered by insurance.

I convinced her to to to a naturapath (maybe offering to pay the cost, I forget). She was prescribed a very inexpensive herbal preparation. Within two weeks her acne was significantly improved and within a few months she had totally clear skin and, of course, no yeast infections.

Yes almost exactly

When an arm gets crushed in a car someone is gonna have to pay BIG TIME to have it fixed and many other problems - cancer - heart disease - etc. are a lot more $$ and they all involve "mainstream treatments". Insurance will pay - Many times the individual will or can not pay and this puts society on the hook.

You want to pick & choose - Everyone out for themselves - A radical change in US government!

Many are not interested in paying Social Security & Medicare taxes but they still have to pay to keep society off the hook if they retire poor.

Many are not interested in Bush's wars but they still have to pay.

Many are not interested in public education & put their kids in private schools and colleges but they still had to pay.

Many single people are not interested in paying twice the taxes as a family of 5 who consume those taxes but they still have to pay.

Many taxpayers are not interested in in paying income taxes for the 50% of people who pay nothing but they still have to pay.

And on & on & on - The US has a democratically elected government (more or less)!

Plus - You know darned good & well that a single "real examplel" anecdotal story does absolutely nothing to prove a generality!

Buy the insurance to pay for their health care or or pay the tax penalty to cover their health care rather than being a potential (unintended or accidental) freeloader is the basis of personal responsibility in my book but to each his own.

Acne tends to be self-limiting

Mostly, if alternative medicine works, it's called medicine. Many things don't get treated appropriately because it's "something women just have" like vaginal infections. I went to a woman doctor in NYC who treated whores, feminists, and people who'd heard about her. She worked with her patients until things were cleared up. Antibiotics also either work or don't work in fairly short order if the dose is correct and if the organism responds to the antibiotic. If someone doesn't respond to antibiotics, more of the same antibiotic is rather not a good idea.

If I'm reading the PDF correctly, you can opt out if you're a Christian Scientist, or have other religious beliefs that go counter to having medical treatments.

Not all mainstream doctors are good, but most herbalists and various and sundry other "alternative medicine" people are out and out quacks (I worked for a chiropractor once). My cousin is furious that her mother tried Christian Science when she had lung cancer -- and died. It's possible she would have died anyway, and people can decide that if they're going to lose a lung and be an invalid, they'd rather die, but, sheesh.

I've had doctors miss things like gallstones, but the prescription the quack made when my mother had them was to drink a lot of olive oil so they'd be expelled. That would have probably cause pancreatis and wouldn't have dealt with her stones since they were about the size of the tip of my index finger, no going out the bile duct. I had gallstones and gallstone attacks for years, and finally had the surgery when I was in a "near emergent situation" to quote my doctor after the fact.

Do standard medical doctors make mistakes and overtreat? Oh, sure, that does happen. Do the alternatives cure people of things like serious systemic infections? No. Some things respond to placebos and somethings, like blood infections, just don't (the Wikipedia article on placebos is interesting).

My impression is that most of the alternative medicine people aren't quite smart enough to do real medical training or evaluate the training they received (with a few exceptions) and are rather full of themselves. Often, their patients want a charismatic healing hand-laying experience. For things that are self-limiting anyway, that's fine. The treatment made the patient more relaxed, maybe more confident, and perhaps more patient about waiting for things to improve (I had a ruptured disc where if I'd had insurance, I would have probably had surgery within the week, but a less aggressive treatment of that worked better long term than people who'd had the surgery and now have more pain. A lot of times, the issue is getting patients to actually be patient, rather than demanding car-repair style fixes (I have a friend now who wants disc surgery now, and his insurance company is willing to pay for yoga and painkillers).

My dad has had pneumonia several times since his 80th birthday. Modern antibiotics have brought him through each time and he's now 90. I can see an argument for not treating pneumonia in people that old, but I think he's rather looking forward to his 91st.

Conventional medicine is like democracy -- everything else is worse. I had a doctor in Fairfax County who was herself a bit of a quack with diets and botox injections, but once we understood each other and what I wouldn't buy, she was actually a good doctor.

I've also turned down some conventional treatments when the doctor didn't see if changes in diet would improve things. And my last blood work before moving here was unexceptional for glucose and cholesterol, apparently having a thyroid problem earlier had caused problems with those. Treating the other things without treating the thyroid problem wasn't the way to go.

But every alternative medicine person I've ever met triggered the "con artist here" reaction, including the guy who practices in the cemetery here on Tuesdays and Fridays as a traditional healer. Herbalism as "the people's medicine" is a seriously bad joke most of the time, as the herbs tend to be as expensive as traditional medicine. One herbalist here caused a relapse of a cold I was recovering from -- she'd decided to give me something without asking me if I wanted it. I'd tried it earlier and it made me feel worse so I stopped taking it.

When I had conjunctivitis here, I went to an eye doctor my pharmacist recommended. He prescribed three different eye drops and said if it wasn't significantly improved in a week to come back. It was. I may have been able to have cured it with eyebright, but I didn't have a source of eyebright. There's another eye doctor my pharmacist recommended against. Doctors are like everyone else -- some are honest and some aren't so honest.

Cataract surgery was also one of my better mainstream medical interventions. I can't begin to imagine what kind of goofball alternative cures there might be out there for that.

One of the problems with contemporary HMOs in the US is that they pay doctors extra for prescribing things. The problem in these cases is greedy doctors, not medicine. People should understand what to expect, how to take things like antibiotics, when to look for another doctor.

Rebecca Brown

Yes A Tax On The Patient Instead Of On The Public.

Right now the US has VERY costly "Emergency Hospital Socialized Medicine" and everybody other than the actual patient pays. Obviously the hospital has to pass these costs on to the public. There is no way courts are going to allow hospitals to turn down a patient who needs "emergency" care for his cut finger that might get infected. If the patient were turned down and his finger got infected how many lawyers would be begging to sue and then the public would really pay through the nose?

How could anyone argue with the Obamacare "individual mandate" concept that the patient ought to be forced to chip in a little to cover his own medical expenses? Obviously many people will not carry insurance anyhow just like uninsured motorists but maybe this is a step in the right direction.

Where are the cheering conservatives and people who don't like being taxed to pay the bills for someone too irresponsible to pay his own way? It sounds like some people hate Obama so much thy can't think rationally!

Obviously if the whole thing is not done right then the US can not afford it so the next logical step is to change it until it is practical and affordable. People will probably have to accept limits sooner or later like the care in most other countries and pay out of their own pockets for specialized treatments.

The larger the pool, the less any one person pays

The problem with going straight to single payer is that we have a fairly built-up insurance industry (which didn't exist in contemporary form when the UK and most of Europe started national health after WWII) and a sudden stop to that industry would have economic repercussions considering how many things are capitalized by insurance company investments (http://www.naturalnews.com/028602_health_insurance_fast_food.html for a bit of irony).

The very poor are covered with minimal payments through extended Medicaid. Expats are presumed to have equivalent coverage if they have lived out of the US for 330 (whatever) days. People who spend 4 months a year in the US and the rest of the time outside the US will have to have coverage (people who spend that much time in the US will probably go back to the US for treatment). People with religious exceptions to medical care are also exempt.

Helps to actually read what the law is rather than listen to people who are lying about it to cause hysteria (and yes, some people hate Obama so much they can't think rationally -- see all the Birthers, the people who think Obama is disqualified because slaves couldn't vote (ignoring that voter qualifications were up to states in the 18th and 19th Centuries), and the completely ridiculous claims that Obama is a socialist (most progressives consider Obama to be a fairly decent Republican President except for the drone attacks, which are troubling).

One of the reasons for mandating insurance is that the young often don't have it and small companies often don't provide it (I've worked for a couple of places that didn't offer insurance to employees, including some colleges and a electronic publishing company -- my DC sub-subconstractor jobs did provide it). I've had one part-time job that provided coverage; the rest didn't.

So, transitioning out of private insurance companies to single payer needs to be done gradually, and more young people and people with a collection of part time jobs or people working for small companies that haven't been supplying insurance need to be included in so pool prices go down for everyone (I don't think I had any significant medical bills from 19 to my early 40s, in my 40s, two surgeries and a ruptured cervical disc that almost lead to surgery).

I know a very conservative expat from the UK who has no problem with UK style national health, feels that having health insurance managed outside businesses allows businesses to do what they do best and gets them out of having to secondarily manage their employees' health care, which isn't the employer's area of highest competence.

There's a point when people are dying and need pain relief and comfort rather than aggressive treatments (and the scams around cancer treatment are amazing). If people want to enroll in clinical trials, that's another thing entirely, but they'll be going into that with good information. One Canadian, wife of a fairly well-known SF writer, was complaining that her desired alternative counseling methods were not getting covered by Canadian health care when she had pancreatic cancer. Some of the US right wingers were using her case as an example of what was wrong with Canadian health care. Sorry that she had pancreatic cancer, because that is one of the worst cancers to have. But all the medical profession can do keep the patient comfortable (her argument were that the Zen counseling would keep her comfortable, but I doubt any medical insurance will pay for hired spiritual interventions).

Rebecca Brown

...

There is so much disinformation about Canadian healthcare in the US media. For instance, we're single payer but it's based on each province - mine is OHIP, the Ontario Health Insurance Program. And despite having this insurance, our companies still purchase health coverage for extra things like dental, drugs, eye glasses, chiropractic, and upgraded hospital rooms, which means we still have insurance companies. Smaller companies don't purchase extra coverage but at least everyone has basic healthcare. And then, because, the government is paying, they care more about preventative medicine which makes our healthcare cheaper long-term. It also means they run anti-smoking ads on TV.

Brain surgery is an area frequently cited as to what's wrong with our healthcare because we happen to have a shortage of brain surgeons - go figure. What you don't see are medical emergencies bankrupting families or people putting off life saving treatment because they can't afford it. You go to your doctor or your hospital, flash them your health card, and you get treated without ever seeing a bill. While this new US mandate means more people will have health coverage, it still means you could be arguing with insurance companies while you're sick. In Canada, there isn't much reason to ever talk to your provincial insurance company, however with additional coverage, you still go through the nuisance of submitting receipts and getting reimbursed.

One of my neighbors was treated for pancreatic cancer five years ago and is doing great. Things change quickly in cancer treatments so don't ever give up hope.

Disinformation

Sue is right, during the last election the right had a field day with disinformation. It is always possible to find someone dissatisfied with something and put them on T.V. I read an interesting figure last night, Canada spends 1/4 (proportionately) of what the U.S. currently spends on health care (pre obamacare), and manages to cover every single person in the country. We have no HMO's saying what treatment you get, no doctors doing unnecessary procedures to pad bills, and it has worked for close to 70 years. The United Nations states that health care is a basic human right, like water or freedom of movement or association. I can't believe that half the people in the what is supposed to be the leading country in the world for human rights don't believe this. Hard to have "life, liberty and the pursuit of happiness" when you can lose everything you've worked for having a catastrophic illness or injury.

This was more recently than that

My impression from reading about this three years ago was that if pancreatic cancer was treated very early, things were different, but it's still one of the worst cancers to get, apparently even now.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001283/ for recent information (PubMedHealth). "Ninety-five percent of the people diagnosed with this cancer will not be alive 5 years later." Your friend was one of the fortunate ones.

The flip side of this is that the alternative medicines tend to be really problematic. One of the people I knew in NYC decided to do alternative "healing" for her breast cancer, and died. Another acquaintance went the full tilt medical route and is still living (1986 or 1987 to present). Breast cancer survival rates are higher than that for Stage IV -- and early stages of breast cancers (to IIIA) appear to have a majority survival rate. Also, one study showed that women the doctors rated as difficult patient had higher survival rates.

If I understand correctly, each Canadian province has its own insurance company. The parallel would be each US state having its own insurance company. Three guesses why this would never work in the US (Alabama, South Carolina, and Mississippi for starters). Some states don't contribute their costs in US taxes for what they get from the US. Their upper classes like it that way. I've read that they tend to be conservative states and the more Democratic blue states pay more than their costs in taxes. PolitiFact says this is mostly true: http://www.politifact.com/truth-o-meter/statements/2012/jan/26/blog-post... Original article in Mother Jones, which certainly has its own agenda.

Someone elsewhere said the Canadian program wouldn't scale from 30,000,000 to 300,000,000. Individual states were starting programs not that different from the Canadian one (including Romney's health care program in Massachusetts). No reason why it couldn't scale except for the screwy politics in some of the education-hostile states.

Rebecca Brown

...

It's common knowledge that pancreatic cancer is one of the worst ones, just saying it's not 100% fatal.

Like the US, some Canadian provinces are richer or poorer than others and we have transfer payments from the federal government to even things a little in areas like health care where the federal government negotiates the minimum standard the provincial plans must offer. (I can hear the screams of "socialism" now.) The 13 provincial/territorial plans are described as "interlocking" - not sure exactly what that means but I'm pretty sure the payment process isn't as smooth if you require care in another province.

When it comes to alternative treatments, you can see that some alternative care is becoming mainstream but in a sensible way. It's not like you would take it instead of regular cancer therapy. I think most people go to their doctor first and only seek out the alternatives if the regular care doesn't work. For fyl's friend, my local pharmacist would suggest that a woman supplement her diet with natural yogourt while on antibiotics. 20 years ago, you wouldn't get that advice.

95% fatal is better than 100% fatal

South Carolina's womanizing now ex-governor turned down Federal money for extended unemployment benefits (SC is one of the states that gets more Federal tax dollars than they pay out). Some of our states would be third world countries if they hadn't been forced to stay in the Union.

http://www.youtube.com/watch?v=HhGuXCuDb1U&feature=related If it can be proven to work, it's not alternative medicine, but medicine.

Unfortunately, in the US, people do go to alternative therapies rather than conventional all too often. We have people who refuse to get childhood innoculations and vaccinations and some of the disease that had been eliminated are making a return and even killing kids. Phil would say that the stock was being thinned of the weak or something. As someone who remembers when polio was a real possibility and when the vaccine against it was given at school, by public health folks, to everyone, even in South Carolina, I tend to think people who don't get their children vaccinated and immunized should be arrested for treason, but that's just me.

I suspect people in Canada are more sensible about health care since they're covered regardless. And the quacks aren't as virulent as in the US. I remember when chiropractors claimed they could cure cancer. Desperate people will try anything, and other people don't scruple to take the money. This is about the woman I knew in New York: a cancer patient's discussion of Kathy Acker: http://cancerbitch.blogspot.com/2007/04/visibleinvisible.html Maybe she'd have died even with chemo? Kathy's essay is printed in the comments.

There's a kind of paranoia that seems to believe that the conventional medical people aren't really interested in curing people and the alternative medicine people are. Acker might have stayed with conventional medicine if she'd had insurance (been there with the adjunct jobs with no benefits myself). I had help from the Carnegie Fund for Writers once but she might not have been able to get enough from them to cover chemo, though I think there are some programs for uninsured cancer patients.

With Phil's friend, my guess is that the bacteria had become resistant to the antibiotic and were having a field day, especially with the antibiotic killing any competition. Yogurt might have helped with the yeast infections (or not).

Washing the skin twice a day with something that helps keep the pores open would be useful. http://www.webmd.com/skin-problems-and-treatments/acne/features/acne-tre...

Rebecca Brown

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There are a few people that don't believe in vaccines here but it hasn't caught on large scale. It was because of the connection, real or imagined, to autism. And while that connection hasn't been proven, the US, EU, Canada and a bunch of other countries are phasing out thimersol in children's vaccines.

The American medical association has a long history of disparaging chiropractic but it was because one of the early chiropractic school leaders made wild claims. He's long gone and the AMA has since apologized.

I have worked on the equipment used for radiation therapy and I can tell you that millions and millions of dollars are poured into treatments but little goes into prevention. If a company can't make money on it, they're not interested. Drugs that work are often changed a little and re-patented so the company still has patent protection. Nutrition is ignored despite research (funded by charities) saying 30% of your chance of getting cancer is determined by the food you eat, but food can't be patented. But your doctor is not against you.

A broad spectrum antibiotic kills many types of bacteria (we have 500 species in our digestive tract) and we need the good bacteria to digest some foods and keep the bad bacteria/yeast, etc in check. If the yogourt with acidophilus and bifidus doesn't work, the pharmacy sells medicinal strength bacterial cultures.

I think the autism connection has been disproved.

Some of the anti-vaccine stuff predates that. And the naturopaths were against vaccines before that. It's caught on enough in some communities to have causes recurrences of pertussis, and some dead kids. Seems to be a real problem in the Berkeley area and in parts of the UK, herd immunity issues.

I worked for a quack who was a chiropractor who was selling all sorts of cow slaughter house by-products as RNA supplements for incomplete cerebral lateral dominance and other things. The licensing entity seems not to control such shenanigans (RNA is in anything we eat, if that had anything to do with cerebral hemispheric dominance), at least not in the 1980s in North Carolina. Shrug. I also associate it with a sadistic teacher who believed in it.

Manipulations can be somewhat dangerous for cervical disc issues (http://www.quackwatch.com/01QuackeryRelatedTopics/chirostroke.html). Not so much for back. Again, given time and exercise, my problem went away.

Some of the foods that can cause some cancers are fairly well-documented: cured meats being the main one, and not eating certain other things. http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Cancer_an... is more or less what I've heard. There's something that Japanese eat a lot of which seems to cause stomach cancer --- lots of salt, perhaps. Biggest thing that causes cancer is smoking and chewing tobacco, but not every smoker gets lung cancer, and my aunt who died of it wasn't a smoker.

Big Pharma is a whole 'nother issue (I have a sister who had close to zero science in college who is a pharmaceutical sales woman). Doctors tend to be far more credulous about the claims that they should be. Human beings being too lazy to read the research critically is always going to be a problem.

Thing is that the herbal stuff and the various dietary supplements the quack I worked for was peddling are even more off the wall.

I've posted this before, I think, but if not:

http://www.informationisbeautiful.net/play/snake-oil-supplements/

It gives links to the studies.

Rebecca Brown

...

Your chiropractor sounds... interesting. For comparison, mine sells things like orthodics and the shoes that fit them.

Our health food stores were originally for people like those with celiac disease or food & environmental sensitivities, but the health food stores were also an outlet for both quacks and researchers trying to reach customers. As the stores have become main stream, there is less of the fringe science (which is easy to find on-line anyway) and more supplements, additive free and organic food. The stores are getting enough business that the major grocery stores and bulk food stores are offering organic sections to compete.

I suspect that your chiropractor faces more penalties

...for out and out scamming. The chiropractor I worked for had won an award from his chiropractic association. One regular medical doctor in NC made a living "diagnosing" multiple sclerosis and prescribing mega-vitamins (the whole family was more than a bit crazy: http://en.wikipedia.org/wiki/Bitter_Blood). The doctor's son was reported for practicing without a license but nothing was ever done about it. The US allows more quackery -- and conventional medicine isn't completely innocent either.

In the US, a podiatrist or sports medicine doctor would be the one to prescribe orthodics.

The US has an excellent model for socialized medicine -- the VA hospitals (my dad uses his local one and is planning to have a really big 91st birth day celebration). Hire people and pay them a salary, don't make their incomes dependent on people getting sick but on staying as well as possible. A friend who grew up as a military brat said that military hospitals were also excellent.

Even here, most supermarkets sell flax seed (and since all that I've bought has been fresh, it's not just selling to the gringos). I've seen some organic produce in La Familia, but don't remember seeing it in Supermercado Guadelupe. The real problem here is adding sugar to about everything. I started making my own fruit and milk ices so I didn't get added sugar. Mangos and bananas are sweet enough.

Rebecca Brown

...

Podiatrist and sports medicine doctors offer orthotics here too. You say the US allows more quackery but others might call it freedom. At the very least it lets them innovate - for good or bad. A single payer systems probably lead to more uniformity of treatment across the population.

They could always build more VA hospitals. The Pentagon is the biggest bureaucracy in the world. It would be nice to see its budget help the US people. Lots of job opportunities in hospitals.

Most of the quacks are about as innovative as a flat tire

I've observed enough of them at close to semi-close range to know that they're not really bright enough to do reality-based research. The innovations tend to come from actual smart people, not people pretending to be smart. Most of the problems with US health care come from the submissiveness of the typical American consumer -- believe anything if it's said authoritatively enough, even if it doesn't make sense and fails to lead to results.

The US hasn't been particularly freer than the European countries in quite some time -- arguably a country that has a Pirate Party is freer than the US.

What people noticed about the northern states in the US in the early 19th Century was that people did different things throughout their lives, and so developed more thinking skills. Samuel Morse lived in a small country village in upstate NY when he worked out Morse code. Edison, who came later, was somewhat the last of the generalist inventors.

Once specialization took over, people would know a lot about one thing and nothing really about things outside their areas of expertise. Perfect dupes for the snake oil sellers.

I worked as a tech writer for the Army's medical training program for a year. Whatever one thinks of war, the military has been funding medical training for kids from pre-med through medical school (and internships, which I think were with the military or with hospitals affiliated with the military). They get a close to free ride in exchange for service for some period of time (entering service with the rank of Captain). Good program -- get doctors from populations that couldn't afford medical school and who might prefer not to start their careers several hundred thousand in debt. A friend of mine who was a military brat said in her experience, the military doctors were very good.

Because of the current wars, fewer medical students were enrolling in the program, because, yeah, being a military doctor now would involve being near or in battle zones.

Rebecca Brown

Numbers from the 1980s

I covered a talk presented at the University of Washington some time in the 1980s about health care in the US vs. Canada. Before that I didn't understand the realities of the Canadian system as well.

A couple of things I remember from that talk were:

  • The overhead for dealing with the money in the US was 25-30%. In Canada it was 5-6% of medical costs. I don't remember for sure but I think this was the doctor end of the costs. That is, the doctor overhead of dealing with the billing and payments.
  • Canada was spending about 50% per capita of what the US was for health care (or, probably more accurately, health care costs including insurance overhead).
  • Doctors don't work for the government. They are private.
  • You must first go to a GP to get referred to a specialist thus eliminating the all too common I specialize in X so that is what you need problem with the US-based system.
  • Prices are negotiated between the insurance company (the provincial government) and the doctors for various types of work. For example, the price for gall bladder removal might be $500. Doctors can then decide if they want to do that work. Clearly, while there is only one price, the fact that there is a supply and demand issue will influence the negoited price.

I have no idea of the numbers of government employees involved in health care related services in Canada vs. the US but expect there are far fewer per capita in Canada than the US.

i am

HI! I am from the Gob't and I am here to help!

"Maybe, just once, someone will call me 'sir' without adding, 'you're making a scene." -Homer J. Simpson

"Hi, I want you to achieve your highest potential on the job..."

...and the rest of the lies people get told by their employers.

Corporations are worse than governments -- I have worked for a government agency in Albany that was motivated, dedicated, and which had a personal interest, though the experiences of one of the staff, in what they were doing. Never found that in private business, it's all about the joy of having willing victims.

Rebecca Brown

I think in theory, there will be ways for the poor to get help

If they want me back in the US collecting more than Social Security, more power to them. My guess is that this won't affect people outside the US who have access to public clinics, but if it does, you mentioned Costa Rican insurance a while back. A number of people on the left aren't particularly happy with this.

Personally, I think the whole thing should be single payer -- Costa Rican style or the Canadian system. Nobody has the political clout to going against the insurance agencies, though.

Economic freedom in the US has always been rather a joke. We have a GINI index higher than Nicaragua's now, but still have more raw money.

What Obama's program does is force the insurance companies to put more money into actual health care and less into overhead. The issue here is the cost of checking for compliance. I suspect that having the insurance companies get caught not doing the right thing enough times could lead to single payer. My guess is that they will try everything in their powers to screw things up without ending up losing completely. It will be interesting.

The states have always been able to force people to have car insurance, and even when I parked my car for five months, I still had to pay full insurance until I could verify that the car had not been moved (honor system, I called in the mileage). If that's legal, the other is legal. Only way I could have gotten out of it would have been to surrender the plates and gotten the car re-registered when I was back in the US. I did get a refund after I got back and sold the car (75%), but GEICO had my money to use for the duration. I got a bigger windfall that I hadn't expected from getting back money from my extended warranty (if I ever have another vehicle, it will be Toyota).

It's possible that the Supremes have set things up for future transition to single payer, which would be the ideal way to go.

In case you've never worked for a defense contractor, or sub-contractor, most of the wars make serious money for private enterprise.

Rebecca Brown

Very different game

Car insurance is optional to the extent that you don't have to have a car. And in many states you had the option of posting a bond instead of buying insurance. While eventually we all won't have bodies, we seem to be stuck with them right now. My understanding is that this payment will be required, even if you are not in the US. Let's call it a right of citizenship. That is, of course, why I posted the question here. If the US government was just "taxing" people who lived there, that would be one thing but my understanding is that ex-pats will get this right to a new tax as well.

While Costa Rica is single-payer, it still is optional to join the plan. Just like Nicaragua, you as an individual have options. You are not required to join a plan.

If you're a Nicaraguan, you're paying into INSS unless...

...you and your employer are doing the under the table thing. Just because the law is easy to evade doesn't mean it isn't there and doesn't mean it might not be enforced in the future.

I believe that expatriates are exempt if they are legal residents of the other country or out of the US for more than 330 days a year.

If you are a legal US resident, even if you're not a US citizen, the minimum coverage applies (with the various exemptions spelled out in the IRS code).

PDF from the IRS here: http://www.gpo.gov/fdsys/pkg/USCODE-2010-title26/pdf/USCODE-2010-title26...

Relevant section: 5000A, Paragraph 4. (4) INDIVIDUALS RESIDING OUTSIDE UNITED STATES OR RESIDENTS OF TERRITORIES- Any applicable individual shall be treated as having minimum essential coverage for any month-- `(A) if such month occurs during any period described in subparagraph (A) or (B) of section 911(d)(1) which is applicable to the individual....

Basically, that's the foreign income earned exclusion. My tax home is Nicaragua. I have no US address (as Apple found out).

There are some interesting other exemptions, too.

This is an earlier interpretation of this: http://www.asiasentinel.com/index.php?option=com_content&task=view&id=23...

"But only full-time expatriates are off the hook. To avoid the insurance coverage mandate, an expat must qualify for the IRS' foreign earned income exclusion, the beloved loophole which says that expats do not have to pay federal income taxes on their first $91,500 of overseas income this year. The IRS has tight rules for who qualifies: an expatriate must establish a tax home in the new country and must either be a bona fide resident of the adopted country for an entire tax year or spend a minimum of 330 days per 12-month period outside of the United States. But if that's you, the new law will not obligate you to purchase health insurance."

This is something that probably could be answered fairly quickly by asking the US Embassy to check for accurate information from the government.

Rebecca Brown

Not exactly

You need to be employed to have to pay INSS. And a day laborer (that is, you work but it is on a day-to-day basis) is not required to be enrolled.

As for all the other stuff, it seems you are saying that an ex-pat could be expemt if they do the work to prove it. That sucks.

What work?

"OMG, I have to tell the IRS where I live" sounds rather silly. I've told SS and the IRS where I get mail these days and SS has a copy of my cedula. It's not like this isn't on computers already anyway, what with passports being necessary for entering Nicaragua and the US and the information stored on computers in both countries these days.

If I have to verify this, all I have to do is xerox my cedula and my rent receipts. I don't count that as work. Given that some people might try lying that they were living outside the country to avoid this, asking for minimum proof might be warranted.

There's a marvelous joke making the rounds now that the some Republicans would leave the US to avoid this, but they can't find a modern first world country that doesn't have national health care.

As for the day laborer category, I suspect this loophole that's so frequently abused could be closed, just a matter of priorities and cost of enforcement.

Also, just Googling around, it looks like the Costa Rican insurance policy similar to INSS is mandatory for employers. Again, enforcement can be a problem.

About four friends on Facebook have been posting Rush Limbaugh's treat to move to Costa Rica if this passed.

I wonder, actually, if it isn't a system geared to bring single payer Federal insurance in gradually as the private insurers predictably break the laws, try to defraud the system, and generally decide that they can't really afford to be in the business.

Obama got something passed, if not the sort of comprehensive single payer system that should have been passed. Americans have been voting for a President to do this since Clinton. Kennedy and Johnson had quite a fight on his hands to get Medicare/Medicaid passed (I doubt Kennedy could have gotten it passed; Johnson was a master domestic politician but not particularly good with international issues).

Better than it was. Certainly better than COBRA. But the insurance companies will try to scam it. Hopefully, they'll be busted for that, go broke, and we can move on to single payer.

Rebecca Brown

this should help

http://www.globalsurance.com/blog/the-final-us-health-reform-package-wha...

But what does this all mean for American expatriates living abroad? While some of the healthcare reform bill, such as the increased Medicare payroll taxes, may affect expatriates, in general the mandate for health insurance and the penalties for not obtaining it will not affect them. In the new Internal Revenue Service (IRS) tax code, expatriates are treated as if they have health insurance regardless of whether they do or not. Although in order to be exempted from the insurance mandate, American expatriates must already be eligible for the IRS’ foreign earned income exclusion.

In order to meet the criteria for the exclusion that allows U.S. expats to avoid paying U.S. taxes on their first US$91,500 worth of income, the expatriate must have a tax home (the general area of your main place of business or employment where you happen to be permanently or indefinitely engaged) in a foreign country, as well as be either a legitimate resident in that country, or spend at least 330 days a year outside the United States.

you are right, fyl

Ah, sball

Gets into the meat of it

Yes

All but ignored when I posted it 3 days ago.