CSNbbs

Originally posted in the "Is this what you wanted?" thread but I split it by request.

I read recently that Rush Limbaugh has warned Republicans that they were not elected to govern, only to prevent Obama from governing. No surprise there since that's what they've been doing the past 6 years. But now that they have a Senate majority, the rhetoric from McConnell and Rand Paul, at least, has softened.

Obviously health care is a big issue right now. My question for the conservatives is, what do you want or expect the Republican Congress to do:
1. The Limbaugh option: continue to complain about Obamacare, take symbolic votes to repeal it, but not actually propose any serious alternative
2. Try to pass something like Burr-Coburn-Hatch
3. A new, politically viable alternative that hasn't been discussed yet; or revert to the pre-Obamacare status quo
4. Compromise and tweak Obamacare
5. Other (please explain)

I know that 69/70/75 likes the French system. I'm really only interested in things that a Republican Congress might actually pass, which rules that out, on both the grounds of a government option and the word "French."

(11-07-2014 04:06 PM)Gravy Owl Wrote: [ -> ]Originally posted in the "Is this what you wanted?" thread but I split it by request.

I read recently that Rush Limbaugh has warned Republicans that they were not elected to govern, only to prevent Obama from governing. No surprise there since that's what they've been doing the past 6 years. But now that they have a Senate majority, the rhetoric from McConnell and Rand Paul, at least, has softened.

Obviously health care is a big issue right now. My question for the conservatives is, what do you want or expect the Republican Congress to do:
1. The Limbaugh option: continue to complain about Obamacare, take symbolic votes to repeal it, but not actually propose any serious alternative
2. Try to pass something like Burr-Coburn-Hatch
3. A new, politically viable alternative that hasn't been discussed yet; or revert to the pre-Obamacare status quo
4. Compromise and tweak Obamacare
5. Other (please explain)

I think #4. I think we are in the position of a homeowner who has torn out a wall or two and now realizes that what he wanted to do in unfeasible. something has to be done, we can't just leave it in shambles. It may take a while to get to this though.

Your statement about Limbaugh seems odd. I rarely listen to him, and then not for more than 15-20 minutes, but it does not sound like something he would say. do you have a link to the article, or better yet, a link to an actual recording of this?

I don't think you'll see much since Obama can still veto anything that passes his desk. The Supreme Court took the King v. Burwell case today which challenges the tax subsidies for people purchasing policies on the federal exchange. If the Court rules those subsidies are illegal, then it gives the GOP a bargaining chip to play with. Reinstate the subsidies in exchange for getting rid of the medical device tax would be an example. Whatever gets done will not be comprehensive - it will be tweaks around the edges.

(11-07-2014 04:16 PM)OptimisticOwl Wrote: [ -> ]Your statement about Limbaugh seems odd. I rarely listen to him, and then not for more than 15-20 minutes, but it does not sound like something he would say. do you have a link to the article, or better yet, a link to an actual recording of this?

Well, there's this:

http://mediamatters.org/video/2014/11/05...bar/201455

(11-07-2014 04:16 PM)OptimisticOwl Wrote: [ -> ]I think #4. I think we are in the position of a homeowner who has torn out a wall or two and now realizes that what he wanted to do in unfeasible. something has to be done, we can't just leave it in shambles. It may take a while to get to this though.

Thanks for the sincere response. I think that option is going to be politically difficult for them, but we'll see.

FTR my position on Obamacare is and has always been:
1. I don't think it will be as good as its supporters promise
2. I don't think it will be as bad as its detractors insist
3. I think it's probably a mild improvement over the previous policy but it might move us away from a bigger improvement. But I'm not sure the bigger improvement was ever going to come anyway.

Quote:Your statement about Limbaugh seems odd. I rarely listen to him, and then not for more than 15-20 minutes, but it does not sound like something he would say. do you have a link to the article, or better yet, a link to an actual recording of this?

"Not elected to govern" was part of his exact words. I paraphrased the part about Obama to match that -- a bit snarky on my part, sorry, but I don't think it was far from the mark.

link

I also rarely listen to him but from what I have heard, this seems entirely in line with him.

(11-07-2014 04:06 PM)Gravy Owl Wrote: [ -> ]Originally posted in the "Is this what you wanted?" thread but I split it by request.
I read recently that Rush Limbaugh has warned Republicans that they were not elected to govern, only to prevent Obama from governing. No surprise there since that's what they've been doing the past 6 years. But now that they have a Senate majority, the rhetoric from McConnell and Rand Paul, at least, has softened.
Obviously health care is a big issue right now. My question for the conservatives is, what do you want or expect the Republican Congress to do:
1. The Limbaugh option: continue to complain about Obamacare, take symbolic votes to repeal it, but not actually propose any serious alternative
2. Try to pass something like Burr-Coburn-Hatch
3. A new, politically viable alternative that hasn't been discussed yet; or revert to the pre-Obamacare status quo
4. Compromise and tweak Obamacare
5. Other (please explain)
I know that 69/70/75 likes the French system. I'm really only interested in things that a Republican Congress might actually pass, which rules that out, on both the grounds of a government option and the word "French."

6. Bismarck system, based on the French or Dutch models, which seem to be the best two. Dutch has been rated slightly higher in more recent studies, but it's also a much smaller system, and almost all the metrics that have ever been used in analyses of health care systems appear to contain latent biases in favor of smaller systems.

Yes, you ruled that out of your question. I'm ruling it back in. I think the grounds on which you ruled it out are intellectually dishonest.

(11-07-2014 04:38 PM)Owl 69/70/75 Wrote: [ -> ]Considering that the Heritage proposal was an adaptation of the German system, and the French and German systems are first cousins, that seems a pretty ridiculous assertion to make. A republican congress might not pass it, but they'd be more inclined to do that than to tweak Obamacare, which is conceptually flawed.

One easy way to avoid having to discuss the merits of a Bismarck system is to reject it out of hand. I would hope your comments do not mean that you are resorting to such an intellectually dishonest position.

(11-07-2014 04:42 PM)Owl 69/70/75 Wrote: [ -> ]6. Bismarck system, based on the French or Dutch models, which seem to be the best two.

Yes, you ruled that out of your question. I'm ruling it back in.

Well, I'm certainly not opposed to it as a policy. On the contrary, I think that's a better basic approach than either Obamacare or the pre-Obamacare U.S. policy. (Whether I would support any specific policy would, of course, depend on the details.)

I just don't think there's any chance at all of this incoming Congress to even take it up for a vote.

The Heritage proposal was made 25 years ago and has not been brought up for a vote. In the meantime, Heritage have abandoned that plan, the danger of Republican primaries has increased, and the word "France" has become naughtier.

I don't think Obamacare compromise is especially likely either, but a couple of prominent Republicans are talking about it.

I would be happy to be proven wrong.

(11-07-2014 04:42 PM)Owl 69/70/75 Wrote: [ -> ]I think the grounds on which you ruled it out are intellectually dishonest.

Let me put it this way. Write a letter to Sens. Cornyn and Cruz, your Rep, and my Rep (McCaul) recommending a policy based on some combination of the systems that are working in France, Netherlands, and Germany, and I will co-sign it.

I don't see the President accepting any Obamacare tweaking. It's his signature achievement.

The future of Healthcare in the US lies in some sort of single payor system. Logically, it would be an expansion of Medicare. Funded by a combination of employee/ employer taxes, expansion of the existing Medicare tax, and individual premiums. And cost controls/ rationing... Fairly stringently.. To keep everything afloat.

(11-07-2014 05:55 PM)Gravy Owl Wrote: [ -> ]

(11-07-2014 04:42 PM)Owl 69/70/75 Wrote: [ -> ]I think the grounds on which you ruled it out are intellectually dishonest.

Let me put it this way. Write a letter to Sens. Cornyn and Cruz, your Rep, and my Rep (McCaul) recommending a policy based on some combination of the systems that are working in France, Netherlands, and Germany, and I will co-sign it.

I think you missed my point. Whether republicans would or would not do something is irrelevant to a discussion of whether it is a good idea. And for you to demand that others select from a list of options that is obviously incomplete because you have unilaterally ruled out options on the grounds that in your opinion republicans wouldn't pursue them is where I have a problem.

Perhaps the problem is that while I'm conservative I'm not republican, so I refuse to allow my thinking to be bound by what republicans might do, and even less by what you tell me republicans might do. To me, conservatism means favoring things that have worked over things that haven't. Bismarck has, Obamacare hasn't--and IMO won't because it can't. Republicans ought to push Bismarck--as should democrats. Whether either one will or not remains to be seen.

As for your suggestion, what difference would that make? For the record, I've pretty much already done that, and quite a bit more. I also included Obama, back when he was supposedly asking the people to submit ideas. Obama's response, by the way, has been limited to adding my email to his funding request database, and sharing it with virtually every other democrat candidate.

(11-08-2014 04:15 AM)Owl 69/70/75 Wrote: [ -> ]I think you missed my point. Whether republicans would or would not do something is irrelevant to a discussion of whether it is a good idea. And for you to demand that others select from a list of options that is obviously incomplete because you have unilaterally ruled out options on the grounds that in your opinion republicans wouldn't pursue them is where I have a problem.

Perhaps the problem is that while I'm conservative I'm not republican, so I refuse to allow my thinking to be bound by what republicans might do, and even less by what you tell me republicans might do. To me, conservatism means favoring things that have worked over things that haven't. Bismarck has, Obamacare hasn't--and IMO won't because it can't. Republicans ought to push Bismarck--as should democrats. Whether either one will or not remains to be seen.

As for your suggestion, what difference would that make? For the record, I've pretty much already done that, and quite a bit more. I also included Obama, back when he was supposedly asking the people to submit ideas. Obama's response, by the way, has been limited to adding my email to his funding request database, and sharing it with virtually every other democrat candidate.

Well, maybe my original question was unclear. "Whether Republicans would or would not do something" is exactly what I was trying to ask.

"Favoring things that work over things that haven't" is the sort of thing that every member of Congress (both sides of the aisle) would say about himself. But on anything from transportation to gun control to contraception, when's the last time you heard any Republican politician say, "hey, let's do the thing that works really well in Europe?"

(11-08-2014 02:03 PM)Gravy Owl Wrote: [ -> ]"Favoring things that work over things that haven't" is the sort of thing that every member of Congress (both sides of the aisle) would say about himself. But on anything from transportation to gun control to contraception, when's the last time you heard any Republican politician say, "hey, let's do the thing that works really well in Europe?"

How many times do you hear democrats say, "Hey, let's do something that doesn't work in Europe"? But that's what they favor.

As I said above, I'm not a republican, so whether a republican would do it or not is really of no concern to me. And your stating what republicans would or would not do has even less relevance than what republicans might actually do.you

So why don't you quit creating straw men and discuss the merits of Bismarck v. Obamacare?

(11-08-2014 04:24 PM)Owl 69/70/75 Wrote: [ -> ]How many times do you hear democrats say, "Hey, let's do something that doesn't work in Europe"? But that's what they favor.

As I said above, I'm not a republican, so whether a republican would do it or not is really of no concern to me. And your stating what republicans would or would not do has even less relevance than what republicans might actually do.you

So why don't you quit creating straw men and discuss the merits of Bismarck v. Obamacare?

As I clearly stated in post #7, I prefer Bismarck to Obamacare, so I'm not sure why you're pressing me on that.

I asked the initial question because I'm interested in knowing what those who voted in the new Congress expect those new Congressmen to do. I continue to think that's a reasonable topic for discussion which you are not obligated to participate in.

I am not, however, particularly interested in arguing whether "conservative" is the right label for Congressional Republicans.

Mildly interesting article arguing that Republicans should start actually sending bills to Obama to sign or veto. You know, governing.

http://www.slate.com/articles/news_and_p..._pass.html

The more interesting point is how Republicans think executive orders and other executive actions are an unconstitutional outrage when a Democrat does them, but hunky-dory when Nixon/Reagan/Bush does them. And vice versa for Dems. Maybe by 'interesting' I meant entirely predictable.

And how long until McConnell and Reid swap positions on filibusters?

I don't even criticize them for it, frankly. There's a reason no well functioning modern democracy has a presidential/separation of powers system...

(11-07-2014 04:40 PM)Gravy Owl Wrote: [ -> ]

(11-07-2014 04:16 PM)OptimisticOwl Wrote: [ -> ]I think #4. I think we are in the position of a homeowner who has torn out a wall or two and now realizes that what he wanted to do in unfeasible. something has to be done, we can't just leave it in shambles. It may take a while to get to this though.

Thanks for the sincere response. I think that option is going to be politically difficult for them, but we'll see.
FTR my position on Obamacare is and has always been:
1. I don't think it will be as good as its supporters promise
2. I don't think it will be as bad as its detractors insist
3. I think it's probably a mild improvement over the previous policy but it might move us away from a bigger improvement. But I'm not sure the bigger improvement was ever going to come anyway.

FTR my positions are
1. It won't be as good as its supporters promise, particularly now that at least one prominent architect and supporter has acknowledged repeatedly that some of those promises were blatant lies.
2. It will be worse than its detractors insist. One of my principal complaints about republicans on this is that they've made issues out of things that aren't the real problems. Palin's "death panels" are a case in point. There are real death panels, they are huge problems, but they aren't the things that Palin was complaining specifically about.
3. It's not a mild improvement, or any improvement. The insurance piece of it will be a zero-sum game, some will come out ahead, others will come out behind, it's just an income redistribution scheme. On the health CARE side--and that's really all that matters because without health care, what good does health insurance do?--reduced reimbursements will mean reduced numbers of providers--there's that pesky supply and demand thingy--and that will mean waiting longer for worse health care. It can't end any other way. It simply cannot. Actually, there is one possibility. When Richard Nixon gave us the 55 mph speed limit, Americans learned how to use CB radios. There is a possibility that through concierge plans and the like, the private sector will create something that functions similarly to a Bismarck system. That would be the only good that can come of this.

(11-07-2014 04:06 PM)Gravy Owl Wrote: [ -> ]3. A new, politically viable alternative that hasn't been discussed yet;

#3. A new idea that has not been discussed:

Actually, there has been for quite a wile, a so-called "Republican alternative plan", the mainstream media has completely ignored it so most people don't even know it exists: http://www.hatch.senate.gov/public/_cach...OPOSAL.pdf

It's only 8 pages, so of course, no respectable Democrat takes it seriously because you can actually read it before you vote on it.

Alternatively, personally, I'd do the following:
Philosophy: "Medical treatment is a service, not an inborn right (neither is car repair service, or any other service for that matter.). There is nothing wrong with it costing money and cost should be a factor in making medical/healthcare/lifestyle choices. Providers deserve to make a living off their service same as any other service-provider does, from the dry-cleaner, to the lawyer. They charge what the market will bear in their area." Also: "It pays (in my system, literally) to keep yourself in good physical shape and eat right when you are able to (before you develop conditions from bad habits/choices.)

1. Make ALL health plans individual, neither company or government-owned. Companies could contribute funding for a business expense tax-deduction, but once they part with the money, it belongs to the individual, fully portable, no more govt or company health-plan "hostages."
2. give every US citizen and registered foreign national visa worker an HSA and attached HDHP. Make it "Chilean-style" separate account- it belongs to each individual citizen, not the government, cannot be borrowed from or IOUed by the govt for any reason; To be used only for healthcare expenses under the old HSA rules (not Obama's gutted ones). They have to fund it unless indigent (see #3 next).
3. fund the HSA portion for low-income people, and give them the ability to use it to pay premiums as well--there's the wealth redistribution that's happening one way (Obamacare) or another (higher premiums and costs for everyone under the old system caused by overuse of services by the uninsured, as well as those who think their company health plans are mostly "free" (they're not))
4. Allow hospitals and doctors to voluntarily treat or turn away non-citizens if they choose without penalty. Allow charities to have non-profit clinics and hospitals, privately funded only (no government grants of any kind) to fund the groups left out like illegals, etc...
5. Require that to be considered a US citizen in the future, at least 1 parent of any newborn MUST be a current US citizen.Else they are citizens of their respective country of origin, and let them pay for it. This will vastly reduce the illegal problem more than anything the Dems will do. It will also quickly start to lower health care costs for everyone, as well as the cost of government in general.
6. Institute loser pays tort-reform for medical malpractice, allowing specifically formed non-profit charities to help fund the indigent cases. I'd even be willing to go so far as to seed those non-profit funds for indigent cases every year so long as lawyer's profits were capped as well for those cases.
8. Make doctors/hospitals/providers post prices so people can know what they're spending up front. Emergencies will happen, but to give one example, you should be able to call for the cheapest ambulance service in your area if you have the time (non-life threatening) and have that info easily available up front to make your decision. If plumbers can provide transparent pricing, so can providers/doctors/hospitals. Price should be in the equation of every healthcare decision. Some will consider it more important than others, but it should be easily available.
8. Get rid of "in network" and "out of network" designations. Instead, every provider is a provider open to every US citizen (since everyone has an HSA, they can all now pay), and everyone can go to whatever doctor or hospital they choose. Hospitals charge what their respective markets will bear. Charities can form hospitals for any straggling indigents, or those who find themselves become indigent due to catastrophic healthcare situations.
9. For catastrophic and chronic expenses, the "insurance" part would kick in after the HSA limit has been spent each year. Premiums would reflect the true cost. Under these options, I could then live with everyone having health "insurance" through everyone having an HSA. The BS "plans" we have now are a rip-off and do little or nothing to help improve healthcare delivery or consumption.
10. Keep the annual rollover for unused HSA funds to incentivize for person to not use more health services than they actually really need. Keep the ability to use unused HSA funds saved $$ for retirement if available after retirement age.

There's more, but that's the bulk of how I'd run things if I were DictatorObama.

I'm probably giving Limbaugh way too much credit, but Senators and Representatives AREN'T elected to govern. Only Presidents and Governors are. It IS the representatives job to either help or hinder that governance. Because Republicans often have pointed to Obamas lack of 'Governing' experience, I'm cutting some slack that admittedly may not be earned.

As to healthcare...

You can't solve the supply issue by increasing the demand and lowering the cost. Those things don't move together... but that is what we did.

Whether you 'repeal' Obamacare or not or simply write a new law that renders it moot is a matter of symbolism rather than impact. I think lots of Republicans would prefer to repeal it. I think ALL of them would want to replace it.

McCain actually proposed what was essentially a taxpayer funded $2500 policy for everyone... 5,000 for a family... roughly $200/month in premiums and $400 for a family... with automatic enrollment through your employer or state exchanges. If you don't like that number, come up with a different one... but let the market create policies at that price point.... and people can buy them and the bill essentially goes to the government. I suspect there would be a 'young and single' policy... a young and married policy... a no kids coverage policy and perhaps some others. He also included some HSA expansion. You could go to an HMO and get more things covered or a PPO and get fewer things covered for your $5,000 policy and there would be all sorts of competition at that single price point. Above there, you could always pay more and get more coverage.

That essentially accomplishes the individual mandate, and the government (state or federal) could write it's own 'generic' policy 'costing' $5,000 that covers anyone who doesn't enroll in any other plan, which is essentially medicaid.

Anyone who earns more than 100k is already getting this 5,000 policy because that is about what the tax break for insurance is... so this is essentially 'free' money for everyone who makes less than that, but essentially replaces medicaid with some private choices. It would also cover people with PECs. If we need to, we can adjust medicaid witholding so that the 'taxes' are more straightforward. You can still slant it towards higher earners by making it a sliding scale... whatever we need.

I think the 'standard policy' which the government would enroll everyone in and by which all other would be based would be one with a huge hole in it to discourage bad choices/encourage good ones.... i.e. cover wellness and things like breast cancer, type 1 diabetes, heart disease etc etc with low deductibles... but make deductibles higher for diseases associated with choices... like breaking a leg bungee jumping or liver disease from drinking or most type 2 diabetes. Not no coverage, just a higher deductible/copay. Create an economic incentive to live healthier... take the doctors advice rather than what the ACA does which is discourage the doctor (through reimbursement tied to 'satisfaction') from telling you to exercise more/drink or eat less and instead give you a pill to treat the foot or back pain.

I'd also fund more residency slots to create more MDs. Let the doctors pay/get credit for some of their med school or office expenses by joining these 5k networks. Rather than reduce their reimbursement for those patients, you give them a 10% 'kicker' to their school loans (which is most often a loss of tax revenue from the Medical School slot that otherwise wouldn't exist rather than an actual expense).

Obviously there are a number of moving parts, but the GOOD news is that the ACA has created such massive sticker shock that even if we only go 'back' by 10%, that's still a net positive.

The bottom line is that my suggestion is just far more straightforward and honest in its intentions than the ACA is. I increase supply to meet the increased demand by funding more residency slots and NOT cutting reimbursements. I encourage healthy lifestyles without failing to care for those who need it. I repurpose/reorganize, but don't dismantle or create redundant existing care networks (especially medicaid).

Essentially, everyone who doesn't qualify for Medicare gets a $5k (or whatever we decide) Medicaid policy. If you want more, you pay more. You can also (just as you do with medicare) buy a managed medicaid alternative (hmo) or even a ppo with that same money... or (again, just like medicare) buy a supplement for additional care or opt out completely and take a traditional policy with essentially the same tax credit.

Some simple math.... we spent 414 billion on Medicaid in 2011... assuming 300mm people, that is $1400 per person... but at least 100mm people don't get ANY Medicaid services (because they have insurance or don't need care)... so there is your premium without any additional costs/taxes. You still need to raise costs for other reasons, but this was the 'math' behind McCain's proposal.

(11-19-2014 02:39 PM)GoodOwl Wrote: [ -> ]

(11-07-2014 04:06 PM)Gravy Owl Wrote: [ -> ]3. A new, politically viable alternative that hasn't been discussed yet;

#3. A new idea that has not been discussed:

Actually, there has been for quite a wile, a so-called "Republican alternative plan", the mainstream media has completely ignored it so most people don't even know it exists: http://www.hatch.senate.gov/public/_cach...OPOSAL.pdf

That's Burr-Coburn-Hatch, which I specifically mentioned as option #2.

The big problem there is limiting the tax exemption at 65%, which I think will be wildly unpopular with just about everybody.

It would have gotten more media attention if the House Republicans had brought it up for a vote, or if any of the Senate sponsors had been up for re-election. I'm not sure that's a coincidence.

As far as your proposal, I disagree with some of the details, but the fundamentals of moving towards HSA+HDHP and pricing visibility is actually a very good idea IMO.

The GOP ran on repealing Obamacare and should try to do so. Sure, he will veto it, but they will have delivered what they promised. Nothing constructive will occur in the next two years given his veto power which his ego will cause him to exercise. More bad Obamacare effects will take place so it will be even more unpopular in 2016.

Then, the GOP Presidential candidate should run on repeal with a market based/Medicaid program to replace it. Get rid of the regulations and taxes and just put $ in folks' pockets to buy their own insurance from national carriers after state line restrictions are removed. And, medicaid can take care of low income earners.

I don't like European approaches because they stifle innovation and do involve rationing and delays. But that is just my opinion. In my lifetime, every major government program has always resulted in unanticipated negative consequences.

(11-20-2014 10:26 AM)NolaOwl Wrote: [ -> ]The GOP ran on repealing Obamacare and should try to do so. Sure, he will veto it, but they will have delivered what they promised. Nothing constructive will occur in the next two years given his veto power which his ego will cause him to exercise. More bad Obamacare effects will take place so it will be even more unpopular in 2016.
Then, the GOP Presidential candidate should run on repeal with a market based/Medicaid program to replace it. Get rid of the regulations and taxes and just put $ in folks' pockets to buy their own insurance from national carriers after state line restrictions are removed. And, medicaid can take care of low income earners.
I don't like European approaches because they stifle innovation and do involve rationing and delays. But that is just my opinion. In my lifetime, every major government program has always resulted in unanticipated negative consequences.

"European approaches" is a bit of a misnomer, because there are various European approaches. Not surprisingly, different approaches produce different results.

There is no true single-payer system in Europe. There are various single-provider systems, which are basically first cousins of single-payer, including UK, Spain, Italy, and the Scandinavian countries. The Scandinavian countries seem to work okay, except that they have massive delays that they can't seem to get a handle around. They are all under about 6 million population too. Anything bigger than that seems to get top heavy with administration and runs into trouble. The UK NHS for example, does a decent job of treating the normal walk-in stuff--broken arm, sinus infection, etc.--but struggles with the big stuff. Between rugby and the oil patch, I have a lot of Brit friends, and I would say a substantial portion of them have taken out a second mortgage to get granny some surgery that NHS wouldn't provide on a timely basis, or they have gone to France or India to get things done for themselves. There is so much going overseas to get advanced care throughout the single-provider countries that "medical tourism" has created near-epidemics of diseases brought back from overseas.

The best European systems, by far and consistently, are the Bismarcks--France, Holland, Switzerland, Germany in particular. Germany was the model for the Heritage plan--mandatory purchases, tax subsidies to offset the cost of cheaper plans, multistate exchanges with the ability for anyone from any state to buy from any state. The differences between "mandate" and "exchange" in these systems from the meaning of the same words in Obamacare should be obvious.

I prefer the French and Dutch versions to the German--and they both tend to be more highly rated in various rankings--but Nola, any of them are pretty close to your stated preference. I think you'd be happy with any of those "European" systems.